Physical Treatments Reduce Pain in Children with Tension-Type Headache: A Systematic Review and Meta-Analysis

Aims: To assess the effectiveness of a variety of physical treatments in the management of tension-type headache (TTH) in children. Methods: This review is reported in accordance with the PRISMA guidelines and was registered in the PROSPERO database (CRD42014015290). Randomized and nonrandomized controlled trials that examined the effects of all treatments with a physical component in the management of TTH in children and compared these treatments to a placebo intervention, no intervention, or a controlled comparison intervention were included. The Physiotherapy Evidence Database (PEDro) criteria for bias assessment and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group criteria were used to assess the quality of the body of evidence. The outcome measures were pain, functioning, and quality of life. Only RCTs were included in the meta-analyses. Results: An initial search produced 10,464 published articles. Of these, 17 were relevant trials, including 1,815 participants. The overall GRADE rating of the included studies was moderate, and 11 of the 17 studies could be used in the meta-analyses. The effectiveness of physical treatments in terms of a reduction of pain of 50% or more showed a risk ratio (RR) of 2.37 (95% CI: 1.69 to 3.33). Relaxation training was the most evaluated intervention and proved to be significantly effective (RR: 3.00 [95% CI: 1.94 to 4.63]). In children having TTH combined with temporomandibular disorders, occlusal appliances were effective (RR: 2.58 [95% CI: 1.37 to 4.85]). Conclusion: This review supports the use of physical treatments to reduce pain in children with TTH.

child; headache; meta-analysis; myofascial; pain; systematic review; temporomandibular disorders; therapeutics; therapy; treatment

1. GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2018;17:954–976.

2. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A sys-tematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1789–1858.

3. Wöber-Bingöl C, Wöber C, Uluduz D, et al. The global burden of headache in children and adolescents—Developing a questionnaire for a global study. J Headache Pain 2014;15:86.

4. Ozge A, Termine C, Antonaci F, Natriashvili S, Guidetti V, Wöber- Bingöl C. Overview of diagnosis and management of paediatric headache. Part I: Diagnosis. J Headache Pain 2011;12:13–23.

5. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38:1–211.

6. Svensson P. Muscle pain in the head: Overlap between temporomandibular disorders and tension-type headaches. Curr Opin Neurol 2007;20:320–325.

7. Schmidt-Hansen PT, Svensson P, Jensen TS, Graven-Nielsen T, Bach FW. Patterns of experimentally induced pain in peric-ranial muscles. Cephalalgia 2006;26:568–577.

8. Fisher E, Law E, Palermo TM, Eccleston C. Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2015(3):CD011118.

9. Eccleston C, Palermo TM, Williams AC, et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2014;(5):CD003968.

10. Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis. Cephalalgia 2016;36:474–492.

11. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. J Clin Epidemiol 2009; 62:1006–1012.

12. McGrath PJ, Walco GA, Turk DC, et al. Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations. J Pain 2008;9: 771–783.

13. Furlan AD, Pennick V, Bombardier C, van Tulder M, Editorial Board, Cochrane Back Review Group. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976) 2009;34:1929–1941.

14. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003;83:713–721.

15. Byrt T. How good is that agreement? Epidemiology 1996; 7(5):561.

16. Albers L, Heinen F, Landgraf M, et al. Headache cessation by an educational intervention in grammar schools: A cluster randomized trial. Eur J Neurol 2015;22:270–276, e22.

17. Borusiak P, Biedermann H, Bosserhoff S, Opp J. Lack of efficacy of manual therapy in children and adolescents with suspected cervicogenic headache: Results of a prospective, randomized, placebo-controlled, and blinded trial: Research submission. Headache 2010;50:224–230.

18. Bussone G, Grazzi L, D’Amico D, Leone M, Andrasik F. Biofeedback-assisted relaxation training for young adolescents with tension-type headache: A controlled study. Cephalalgia 1998;18:463–467.

19. Fichtel A, Larsson B. Does relaxation treatment have differential effects on migraine and tension-type headache in adoles-cents? Headache 2001;41:290–296.

20. Fichtel A, Larsson B. Relaxation treatment administered by school nurses to adolescents with recurrent headaches. Headache 2004;44:545–554.

21. Gottschling S, Meyer S, Gribova I, et al. Laser acupuncture in children with headache: A double-blind, randomized, bicenter, placebo-controlled trial. Pain 2008;137:405–412.

22. Koenig J, Oelkers-Ax R, Kaess M, et al. Specific music therapy techniques in the treatment of primary headache disorders in adolescents: A randomized attention-placebo-controlled trial. J Pain 2013;14:1196–1207.

23. Kröner-Herwig B, Mohn U, Pothmann R. Comparison of biofeedback and relaxation in the treatment of pediatric headache and the influence of parent involvement on outcome. Appl Psychophysiol Biofeedback 1998;23:143–157.

24. Larsson B, Melin L. Chronic headaches in adolescents: Treatment in a school setting with relaxation training as compared with information-contact and self-registration. Pain 1986; 25:325–336.

25. Larsson B, Daleflod B, Håkansson L, Melin L. Therapist-assisted versus self-help relaxation treatment of chronic headaches in adolescents: A school-based intervention. J Child Psychol Psychiatry 1987;28:127–136.

26. Larsson B, Melin L, Lamminen M, Ullstedt F. A school-based treatment of chronic headaches in adolescents. J Pediatr Psychol 1987;12:553–566.

27. Larsson B, Carlsson J. A school-based, nurse-administered relaxation training for children with chronic tension-type headache. J Pediatr Psychol 1996;21:603–614.

28. Larsson B, Melin L, Döberl A. Recurrent tension headache in adolescents treated with self-help relaxation training and a muscle relaxant drug. Headache 1990;30:665–671.

29. Tornøe B, Andersen LL, Skotte JH, et al. Specific strength training compared with interdisciplinary counseling for girls with tension-type headache: A randomized controlled trial. J Pain Res 2016;9:257–270.

30. Trautmann E, Kröner-Herwig B. A randomized controlled trial of internet-based self-help training for recurrent headache in childhood and adolescence. Behav Res Ther 2010;48:28–37.

31. Wahlund K, List T, Larsson B. Treatment of temporomandibular disorders among adolescents: A comparison between occlusal appliance, relaxation training, and brief information. Acta Odontol Scand 2003;61:203–211.

32. Bonfert M, Straube A, Schroeder A, Reilich P, Ebinger F, Heinen F. Primary headache in children and adolescents: Update on pharmacotherapy of migraine and tension-type headache. Neuropediatrics 2013;44:3–19.