Contributed by MK Brennan, MS RN LMBT and Jolie Haun, PhD EdS LMT

With the common stressors in daily life, complaints of tension and migraine headaches are not uncommon. This month's Massage Therapy Foundation review shares findings from two studies that suggest massage can provide relief for people suffering from headache pain. The authors of these articles report that episodic tension type headaches impact up to 42% of the population and migraines impact approximately 10%.

Traditionally, tension headaches and migraines have been treated with medications – so much, the term, "medication overuse headache" (MOH) has evolved. MOH refers to headaches that persist despite the regular use of drugs for treatment. Needing an alternative effective treatment for the debilitating pain of headaches, the authors of these articles suggest massage therapy presents a potentially reasonable alternative.

The first study, "Changes in Psychological Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study" by Moraska and Chandler, evaluated a structured massage therapy program, focusing on myofascial trigger points and psychological measures associated with tension-type headaches. Moraska and Chandler noted that there seems to be a cycle of physical pain, decreased productivity and a psychological impact of tension headaches that contribute to stress, anxiety and depression. This theoretical assumption warranted the use of the State-Trait Anxiety Inventory, Beck Depression Inventory, the Perceived Stress Scale and the Daily Stress Inventory to measure participants' outcomes.

Eighteen participants between the ages of 21-65 years were recruited through flyers placed in doctor's offices and advertisements in local newspapers. All of the enrolled participants had episodic or chronic tension headaches. Exclusion criteria included anyone taking anti-depressants or anti-psychotic medications. The 2004 International Headache Society guidelines for episodic or chronic tension-type headaches (TTH) were used in determining the inclusion criteria. An episodic TTH is defined as one that occurs 15 days or less per month. A chronic one occurs 15 or more days in a month. Two participants did not complete participation in the study; one due to a motor vehicle accident and the other because of insufficient headache diaries.

The study was designed to have four 3-week phases: baseline (one 3-week period), massage (two 3-week periods) and follow-up (one 3-week period). In the baseline phase of the study, participants kept a headache diary to assure that they met the guidelines. Guidelines included each headache lasting at least four hours or longer and less than one migraine headache per month. The massage sessions were two 45 minute sessions per week over the two 3-week periods for a total of 12 massages in six weeks. During the week, there was at least a 48 hour span between the massages. Moraska and Chandler reported, "Massage was directed toward soft tissues of the cervical and cranial regions with an emphasis on reducing myofascial trigger point (MTrP) activity." (p.88)

Participants were randomly assigned to one of the six participating massage therapists and remained with that same massage therapist throughout their participation in the study. The therapists were experienced practitioners and received training for the study's massage protocol. In addition, conversation was limited during sessions and the participant's headache history was not discussed with the massage therapist. Study measures were completed by the participants at the start of the study, at 3-week intervals and at the end of the study. Additionally, the Daily Stress Inventory was administered over 7-day periods during baseline and the final week of massage. Psychological measures were administered on days other than when massage was provided in effort to avoid the massage session having influence on the outcomes of those measures.

Moraska and Chandler reported a significant reduction in stress, anxiety and depression for the participants after six weeks of massage, but not at three weeks. Additionally, the frequency, intensity and duration of the participants' headaches were reduced following the 12 massage sessions. Since the authors linked TTH pain with an increase in stress, anxiety and depression, a decrease in the pain through massage treatment may have impacted psychological outcomes. Study limitations include small sample size and a lack of a comparison group, resulting in limited power of results. Though this study clearly has some limitations, findings warrant further examination in a larger sample with a control group. It should also be noted the massage therapists who participated did receive specialized training beyond what a typical massage therapist might have.

The second study was "Reduction of Current Migraine Headache Pain Following Neck Massage and Spinal Manipulation" by Noudeh, Vatankhah and Baradaran. This study focused on reducing the pain intensity of the participants with acute onset migraine headaches. The authors recruited 10 male patients between the ages of 18 and 65 with acute onset of a migraine headache as defined by the International Headache Society diagnostic criteria for Massage Without Aura (MWO) and Massage With Aura (MWA). Potential participants who had secondary cause for the migraine, were not able to complete the data tools, or could not receive massage/manipulation due to skeletal disorders were excluded from the study.

Participants' pain was assessed using the Visual Analog Scale (VAS) with the numerical value of 1 indicating no headache pain and 10 indicating the worst pain possible. The VAS was administered prior to the massage/manipulation intervention. The two-step treatment protocol lasted no more than five minutes. First, massage techniques were applied to the trapezius and supraspinatus muscles, as well as the posterior and lateral neck muscles. Next, skeletal manipulation of the cervical and upper thoracic spine was done. The VAS was administered again after the massage/manipulation session. The authors also asked the participants about possible side effects following the session and their satisfaction with the physical intervention. The participants remained at the clinic (i.e. study site) for an hour after the intervention to assure that the headache did not recur; if it did, an analgesic was offered. Two participants did not remain in the clinic for this period of time; they chose to leave because they said they needed to sleep.

The authors report that 8 out of 10 participants had at least a 50% reduction in their pain level immediately following the massage/manipulation. However within the hour wait period following, three participants did request oral analgesics and one participant was treated with intravenous therapy and intramuscular medication though the authors state that there was no recurrence of the headache for any of the participants. Limitations of this study include the lack of a control group and no way to determine if it was the massage, manipulation or the combination of the two that was responsible for the participants' reduced pain.

Though different in nature, these two studies provide preliminary evidence that massage can be effectively used to treat individuals who suffer from tension and migraine headaches. These studies findings warrant further examination in larger samples to determine if findings can be replicated to support conclusive findings and dosage recommendations.

The convergent data reported in these two studies contribute to the field of massage, providing supportive evidence for the use of massage for a prevalent condition that affects a significant portion of the general population. Since headaches, both acute/chronic TTH and migraines are common, many massage therapists are likely to have clients with these painful and sometimes debilitating conditions. Knowing how massage may impact the pain and the psychological outcomes associated with headaches can be helpful in determining treatment options and providing the best possible care for clients.

To learn more about the effects of massage therapy for conditions such as headaches, migraines and more, you can review the Massage Therapy Foundation article archives, read accepted MTF Research Grant abstracts, or search Pub Med for massage therapy studies.

Sources:

1. Albert Moraska, PhD and Clint Chandler, BS. Changes in Psychological Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study, Journal of Manual & Manipulative Therapy 2009; 17(2): 86–94.
2. Younes Jahangiri Noudeh, MD, Nasibeh Vatankhah, MD, and Hamid R. Baradaran, MD, PhD. Reduction of Current Migraine Headache Pain Following Neck Massage and Spinal Manipulation, International Journal of Therapeutic Massage & Bodywork. 2012; 5(1): 5–13. Published online March 31, 2012.