REVIEW

The effectiveness of spinal manipulation for the treatment

of headache disorders: a systematic review of randomized
clinical trials
JA Astin1 & E Ernst2

1
California Pacific Medical Center Research Institute, USA and 2Department of Complementary Medicine, School of Postgraduate Medicine and Health
Sciences, University of Exeter, Exeter, UK

Astin JA & Ernst E. The effectiveness of spinal manipulation for the treatment of
headache disorders: a systematic review of randomized clinical trials. Cephalalgia 2002;
22:617–623. London. ISSN 0333-1024
To carry out a systematic review of the literature examining the effectiveness of
spinal manipulation for the treatment of headache disorders, computerized literature
searches were carried out in Medline, Embase, Amed and CISCOM. Studies were
included only if they were randomized trials of (any type of) spinal manipulation for
(any type of) headache in human patients in which spinal manipulation was compared
either to no treatment, usual medical care, a ‘sham’ intervention, or to some other
active treatment. Two investigators independently extracted data on study design,
sample size and characteristics, type of intervention, type of control/comparison,
direction and nature of the outcome(s). Methodological quality of the trials was also
assessed using the Jadad scale. Eight trials were identified that met our inclusion
criteria. Three examined tension-type headaches, three migraine, one ‘cervicogenic’
headache, and one ‘spondylogenic’ chronic headache. In two studies, patients
receiving spinal manipulation showed comparable improvements in migraine and
tension headaches compared to drug treatment. In the 4 studies employing some
‘sham’ interventions (e.g. laser light therapy), results were less conclusive with 2
studies showing a benefit for manipulation and 2 studies failing to find such an effect.
Considerable methodological limitations were observed in most trials, the principal
one being inadequate control for nonspecific (placebo) effects. Despite claims that
spinal manipulation is an effective treatment for headache, the data available to date do
not support such definitive conclusions. It is unclear to what extent the observed
treatment effects can be explained by manipulation or by nonspecific factors (e.g. of
personal attention, patient expectation). Whether manipulation produces any long-term
changes in these conditions is also uncertain. Future studies should address these
two crucial questions and overcome the methodological limitations of previous
trials. u Spinal manipulation, chiropractic, headache, migraine
John A Astin, PhD, PO Box 426, Santa Cruz, CA 95061, USA. E-mail:
john@integrativearts.com Received 12 November 2001, accepted 23 May 2002

headache of 2.2% (1). In Western countries, one-year

Introduction
Headache disorders are one of the most common
problems seen in medical practice. Population based
studies suggest one-year prevalence rates for episodic
tension-type headaches of 38.3% and for chronic tension
prevalence rates for migraine range from 10 to 12%
(2). Headache sufferers are also frequent users of
complementary-alternative medicine (CAM) with relax-
ation therapies and chiropractic care being the most
common CAM therapies employed (3). Chiropractors

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618 JA Astin & E Ernst
themselves report high rates of treatment for headache
disorders. A study conducted by the National Board of
Chiropractic Examiners found that most chiropractors
see patients for headaches in their clinical practice on a
daily basis (4).
While there is considerable evidence—based on
meta-analyses and systematic reviews of randomized
controlled trials (5–7 )—that various mind-body/
behavioural strategies (e.g. relaxation and biofeedback)
can be effective treatments for headache disorders, the
evidence for chiropractic spinal manipulation is less
clear. Although nonsystematic reviews (8) have sug-
gested that headache disorders respond well to spinal
manipulation, there have been no systematic reviews
to support these claims. We therefore carried out
such a review, specifically focusing on randomized
controlled trials of spinal manipulation (chiropractic or
otherwise) for the treatment of any type of headache
disorder (e.g. migraine, tension, cervicogenic).
Method
A comprehensive literature search was carried out to
identify randomized controlled trials of spinal manipu-
lation in the treatment of any type of headache. The
MEDLINE, Embase, PSYCHLIT, CAMPAIN, Science
Citation Index, Amed, CISCOM, and Cochrane Library
databases (including the Cochrane Registry of ran-
domized trials) were searched from their inception to
March 2001. We also hand-searched our own files and
the reference sections of identified trials and review
articles for additional studies. Criteria for inclusion were
as follows:
’ Random assignment of human subjects;
’ Comparison of spinal manipulation to either a no
treatment control, ‘sham’ intervention, usual medical
care, and/or some active treatment;
’ Publication in a peer-reviewed journal (i.e. excluding
abstracts, conference proceedings, dissertations).
Dual or overlapping publications were excluded. If such
studies were found, the trial with the larger sample size
was used. No restrictions as to the language of
publication were applied. Data were extracted and
validated independently by both authors according to
predefined criteria (Table 1). The methodological quality
of the trials was assessed using criteria outlined by
Jadad et al. (9).
Results
We identified 9 randomized controlled trials that
examined the efficacy of spinal manipulation for any
headache disorder (10–17). Three studies explored the
effectiveness of spinal manipulation in the treatment
of tension headaches (10–12); three examined the
effectiveness of manipulation for migraine (14–16);
two papers examined spinal manipulation for cervico-
genic headache (13, 18). These two were overlapping
publications (i.e. involved data from the same trial),
therefore we used the latter publication that included
data from 14 additional subjects. One trial was found
for ‘headaches of spinal origin.’ (17 ) Study character-
istics are summarized in Table 1.
Owing to the small number of trials, study hetero-
geneity (particularly in terms of differences in the
nature of the control/comparison conditions), and the
lack of data to calculate effect sizes in a number of trials,
we did not carry out a formal meta-analysis.
Mean sample size across trials was 91 (overall n=760).
Seven trials tested the effectiveness of chiropractic
spinal manipulation while one study (12) examined
osteopathic manipulation. In most instances, spinal
manipulation involved what the authors described as
‘low-amplitude, high velocity thrusts’ in which the
vertebrae were carried ‘beyond the normal physiologic
range of movement without exceeding the boundaries of
anatomic integrity.’ (15). In some studies, practitioners
were instructed to focus their manipulation efforts
on the cervical region of the spine but were free to
manipulate any area of the spine they determined by
palpation to be clinically relevant; in other studies
manipulation occurred only along the cervical region of
the spine. With the one exception of a trial in which the
entire treatment appears to have lasted only 10 min (12),
interventions averaged approximately 6 weeks in length
with an average of 10 treatment sessions.
We assessed methodological quality using the scale
developed by Jadad et al. (9) The mean score across the
8 trials was 2.3 (out of a maximum of 5) suggesting
fairly low quality overall. All studies employed random
assignment of subjects (an inclusion criteria), 3 of 7 trials
described the method of randomization, while 6 of 7
discussed dropouts and withdrawals. In two trials, an
adequate method of allocation concealment was used.
In two trials a power analysis was performed. And in
three trials, the assessors were described as being blind
to the treatment condition.
The nature of the control/comparison groups also
varied considerably across trials. Two studies compared
spinal manipulation to drug therapy (amitriptyline);
three trials attempted to employ a ‘placebo’ or sham
condition (e.g. the use of low power laser treatment
to the cervical spine); and, in two trials the control
consisted of palpation or ‘mobilization’ (small oscillatory
movements) without actual manipulation of the spine.
Despite such efforts to control for nonspecific (placebo)
effects, no trials were scored on the Jadad scale as
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 Table 1 Study outcomes

First author/ Jadad Sample size— Study Control-comparison

year score diagnosis design Intervention condition Primary outcome Main result Comment

Bitterli, 3 n=30 3 parallel Manual therapy ‘Sham’ therapy Pain (Visual No significance between
1977 (17 ) ‘spondylogenic’ groups, open (according to Maigne) (manual therapy by a Analogue Scale) group differences
chronic headache by trained physicians nontrained physician). observed (all groups
—3–4 sessions with If this was unsuccessful showed improvements)
6–7 manipulations after 3 sessions,
for each patient replacement with trained
physician for rest of trial
waiting list with subsequent
active treatment
Boline, 3 n=150 2 parallel Chiropractic spinal Oral amitriptyline Headache pain At 6 weeks both groups Performed intention to

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1995 (10) patients with groups— manipulation, twice weekly daily for 6 weeks intensity, showed improvement but no treat analysis which
tension type observer blind for 6 weeks (sessions were headache between group differences; did not significantly
headache 20 min of short frequency, OTC use, drug control showed more alter results
i3 months and lever, low-amplitude, high SF-36 improvement in headache Chiropractic group
frequency of velocity thrust technique) intensity was seen twice
i1/week At 10 week follow weekly compared
(could also manipulation group showed to only twice during
include migraine significantly better outcomes the entire study period
if diagnosis was on all measures for drug control group.
predominantly Treatment group also
tension type) received heat and
massage prior to
spinal manipulation
Bove, 3 n=75 Single blind Chiropractic manipulation ‘Placebo’ laser and soft Number of headache Both groups showed Used intention to
1998 (11) patients with RCT (with and soft tissue therapy tissue therapy hours per day, improvement at 7 weeks treat analysis
episodic tension- blind evaluator) (8 treatments over 4 weeks, headache intensity, (which was maintained at
type headache 15 min) and use of analgesics follow up) but no between
(5–15 per month) (all based on diaries) group differences
—patients followed
for 19 weeks
Hoyt, 1 n=22 3 armed Osteopathic manipulation Palpatory examination for Electromyographic Manipulation group Total treatment
1979 (12) subjects with randomized involving soft tissue restricted movement but muscle tension evidenced significant appears to have lasted
history of dull, trial and high velocity, no manipulation levels in frontalis post-treatment reduction only 10 min (post
nonthrobbing, evaluator low amplitude procedures Resting in supine position Temperature in in headache pain assessments done
bi-lateral blind aimed at releasing restriction for 10 min dominant hand No changes in other immediately following
headaches Subjective measures short treatment)
Spinal manipulation for the treatment of headache

evaluations of Very small sample size

headache severity in each arm probably
introduces statistical bias
619
 Table 1 (Continued)
620

First author/ Jadad Sample size— Study Control-comparison

year score diagnosis design Intervention condition Primary outcome Main result Comment

Nelson, 3 218 patients 3 parallel Spinal manipulation 14 times Oral amitriptyline therapy Daily headache Reductions in Headache: Manipulation group
1998 (16) with migraine— groups over 8 weeks (no more than Combined manipulation diary—calculated Index scores were had more attention
patients 2 times per week)— and medication a ‘Headache Index’ 49% for drug (14 visits) compared
w/concomitant preceded by 5–10 min of which was weekly 40% manipulation to maximum of 3 visits
tension headache massage and/or trigger sum of headache 41% combined for drug group
JA Astin & E Ernst

were not point therapy pain scores—there at follow up: Combined approach
excluded was a 4-week post 24% drug offered no additional
treatment follow up 42% manipulation benefit
25% combined Manipulation group
compared to medication, experienced relatively
manipulation yielded few side-effects
an effect size of .40 compared with drug
at follow up group
Nilsson, 3 53 cervicogenic 2 parallel Six session of spinal Soft tissue massage Headache diaries— Significant changes Intention to treat
1997 (13) headache groups— manipulation (high velocity/ (deep friction and trigger number and observed for spinal analysis—earlier
sufferers observer blind low amplitude) point) plus laser light intensity of manipulation group publication of this trial
over 3 weeks placebo treatment in headaches and in headache hours/day with 14 fewer subjects
upper cervical region analgesics used and headache intensity failed to find a
Cervical muscle No changes in significant effect
tenderness analgesic use
Parker, 2 85 migraine 3 parallel Chiropractic manipulation Manipulation by Duration of Chiropractic group showed Intention to treat
1978 (14) patients groups by 4 chiropractors physician or migraines and visual improvements in intensity analysis
(2 month treatment phase) physiotherapist analogue scale for of pain scale compared to
‘Mobilization’ by pain intensity other 2 groups
physician or Disability No between group
physiotherapist (all outcomes differences on migraine
(small oscillatory assessed two months duration or disability
movements to joint w/in post treatment)
normal range of motion)
Tuchin, 2 127 volunteers 2 parallel 2 months of high velocity/ ‘Sham’ consisting of Frequency and Compared to controls, Significant reporting
2000 (15) with migraine groups, short amplitude chiropractic detuned interferential duration of episodes, manipulated subjects problems in paper
open 2 : 1 spinal manipulation (max therapy (electrodes pain intensity and showed significant raise questions about
randomization of 16 treatments) placed on patient with disability (post reductions in frequency, validity of results
no current sent) treatment and 2 duration, disability and
month follow up) medication use
(but not pain intensity)

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‘double-blinded.’ We note, however, that because it
is difficult to blind subjects to group assignment in
studies of manipulative therapies, such trials will
frequently receive lower scores on quality rating
inventories such as the Jadad scale.
Among the studies that examined migraine headache,
Nelson et al. (16) found comparable improvements in a
composite headache index between spinal manipulation
(49%), amitriptyline (40%) and the two treatments
combined (41%). (It should be noted, however, that
the manipulation group had 14 visits compared to 3
visits for the medication group). At four week follow
up, there was a non significant trend toward the
manipulation group being more likely to have main-
tained treatment gains compared to the other two
groups (effect size of 0.40; P=0.05) compared to drug
therapy alone.
Parker et al. (14) found significant improvements
in ‘intensity of pain’, but no significant differences in
duration of migraines or disability between chiropractic
spinal manipulation, physical therapy manipulation or a
mobilization ‘placebo’ (all 3 groups showed improve-
ments).
In the most recent study, Tuchin et al. (15) reported
that migraine patients receiving spinal manipulation
experienced significant reductions in headache fre-
quency and duration, disability, and medication use
(but not pain intensity) compared to a ‘placebo’ laser
therapy condition. These effects were maintained at
two-month follow up. There were, however, consider-
able methodological and statistical problems with this
study that call into question the validity of these
findings (see Discussion).
Among trials examining tension headaches, Boline
et al. (10) found comparable improvements between
spinal manipulation and drug therapy (amitriptyline)
at the end of the treatment phase. However, at four-
week postintervention follow-up, the manipulation
group experienced significantly greater improvement
on all outcome measures. Patients in the spinal manipu-
lation group were seen 12 times over six weeks
compared with twice overall for the medication
group.
More recently, Bove and Nilsson (11) found signifi-
cant improvements postintervention and at follow up
(in headache frequency and analgesic use) in both the
manipulation and placebo laser therapy group, but
no intergroup differences were noted. In an earlier,
smaller trial (n=22), subjects receiving osteopathic
spinal manipulation showed significant post treatment
reductions in headache pain compared with a control
group receiving only ‘palpatory’ examination with no
manipulation (12). The treatment in this trial, however,
consisted of only one 10-minute session of manipulation,
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Spinal manipulation for the treatment of headache 621
thus it is difficult to gauge the significance of these
findings.
In a small three-armed trial, Bitterli et al. (17 ) found
no significant between-group differences between
‘manual therapy’ (according to Maigne (19)) performed
by physicians and either ‘sham’ therapy performed by
nonphysicians or waiting list (no treatment) control
among patients with ‘headache of spinal origin’. Finally,
in the one trial examining chiropractic manipulation for
the treatment of cervicogenic headaches, Nilsson et al.
(13) found significant reductions in headache hours
and intensity compared to a ‘placebo’ light control
group. As noted, an earlier publication (containing
14 fewer subjects) (18) failed to find a significant
treatment effect for manipulation. However, the
authors subsequently published the paper in 1997
which included these additional patients and which
did find a significant treatment effect.
Discussion
The relatively small number of randomized trials
identified (n=8) coupled with a high degree of hetero-
geneity and small sample sizes in a number of studies,
makes it difficult to draw definitive conclusions.
Although we included only randomized trials, on
average the methodological quality was fairly low,
which suggests that there may have been significant
bias in a number of the studies. Moreover, the results
of our review might have been influenced by the
phenomenon of positive publication bias.
Looking across all headache categories, we found
that spinal manipulation yielded treatment effects
over and above the respective control groups in 4 of 8
studies. In the two studies that compared manipu-
lation to drug therapy, no intergroup differences were
observed in one study while the other trial found
chiropractic to be superior to drug therapy at follow-up.
In the studies that compared manipulation to a ‘sham’
or placebo intervention (e.g. laser light therapy), results
were again equivocal with 3 of 6 studies showing
significant between group differences.
The most recent of the three migraine trials reported
that chiropractic spinal manipulation was superior to a
sham condition (detuned interferential therapy) in
terms of headache frequency, duration, disability, and
medication use (but not pain intensity) (15). However,
there were significant methodological and reporting
problems in this study that raise questions as to the
validity of the findings. For example, closer analysis
suggests that the authors did not carry out the
appropriate statistical analyses (e.g. they report doing
paired t-tests as well as a ‘Oneway ANOVA’, neither of
which would have been able to adequately test for
622 JA Astin & E Ernst
intergroup differences). Moreover, the figures were
mislabelled in this paper (figure captions did not
match what was described in the text) and no means
or standard deviations were provided (only graphical
representations of some of the purportedly significant
outcomes).
In the earlier trial by Parker (14) that compared
manipulation to a ‘mobilization’ placebo, the manipu-
lation group experienced significant improvements on
one of three measured outcomes (pain intensity). Finally,
in the third and largest of the migraine trials (n=218),
Nelson et al. (16) found no differences between migraine
and amitriptyline therapy although both groups did
demonstrate clinical improvement following treatment.
It is therefore not clear whether or not the observed
effects of spinal manipulation can be attributed to
specific or nonspecific (i.e. placebo) effects.
In the two trials examining chiropractic manipu-
lation for tension headaches, one trial reported that
chiropractic manipulation was no better than a ‘sham’
condition, whereas the other trial found manipulation
to be superior to amitriptyline therapy at follow up (but
not postintervention). Again, the design in this latter
study cannot rule out nonspecific effects.
The one study that examined the effectiveness of
manipulation for cervicogenic headache did find a
significant treatment effect of chiropractic spinal manipu-
lation compared to placebo light therapy suggesting
this therapy may be effective for this particular type
of headache disorder. Although this diagnostic cate-
gory remains controversial (20, 21), cervicogenic head-
aches are, by current definitions, believed to be of neck
(or cervical) origin and therefore theoretically more
amenable to chiropractic (cervical) manipulation than
other headache types (22). It remains, however, for
future research to demonstrate this more definitively.
This raises the question as to the optimal design for
future trials of spinal manipulation for headache. Such
a study should, in our view, have a closely defined
research question. This includes an adequate definition
of the experimental and control conditions, the setting,
and the outcome measure. Studies should be random-
ized to minimize selection bias and its sample sizes
should be based on power calculations. Depending
on the exact research questions, it could be ‘sham’
controlled and patient-blinded. In any case, it should
be evaluator-blind. The test statistics should be pre-
defined and relate to intergroup comparisons rather
than to prepost differences. In view of the oftentimes
emotional discussions in this area, such a study would
benefit from an independent outside monitor. It is
clear that a study of this nature is best designed with
the input of chiropractors, research methodologists
and statisticians. The above data shows that, at present,
a study of this caliber (even though feasible) does not
yet exist.
In conclusion, it is unclear from the findings of this
systematic review whether or not spinal manipulation
is an effective treatment for headache disorders. Meth-
odological limitations coupled with the small number
and considerable heterogeneity of the randomized trials
we were able to identify make it difficult to rule out
nonspecific (placebo) factors as an explanation for the
clinical improvements that were consistently observed
across trials, irrespective of headache category. We
therefore believe that additional, better-designed trials
are required before such treatments can be considered
effective for headache disorders.
Acknowledgements
This work was completed while the first author was at the
Complementary Medicine Program at the University of Maryland
School of Medicine and was supported by a grant from the
National Center for Complementary and Alternative Medicine,
National Institutes of Health (5 PS0AT00084).
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