Effect of Mulligan manual therapy and exercise on headache frequency, intensity, disability, and upper cervical joint hypomobility in people with episodic tension-type headache: a randomized clinical trial.

Tension-type headache is common and often managed with exercise-based physiotherapy, but whether adding a specific manual therapy technique, Mulligan mobilization, helps has been tested mainly in cervicogenic headache rather than tension-type headache. This trial compared exercise alone, exercise plus Mulligan manual therapy, and exercise plus a sham version of the manual therapy, following 99 people with episodic tension-type headache over six months. Headache frequency dropped slightly more in the manual therapy group than in the exercise-only group right after treatment and at three months, and briefly more than the sham group immediately after treatment, but these differences did not meet a clinical threshold the researchers considered meaningful, and by six months no difference remained between any groups. The exercise and sham groups did not differ from each other on any measure.

The authors suggest Mulligan therapy's underlying mechanism may not suit tension-type headache as well as it suits cervicogenic headache, a conclusion drawn from one moderately sized trial with short-lived, clinically uncertain effects.

If you live with tension-type headaches and wonder whether hands-on manual therapy added to exercise helps more than exercise alone, this study offers a cautious answer. Researchers followed 99 people with episodic tension-type headache for six months, comparing three approaches: exercise alone, exercise with a specific joint mobilization technique called Mulligan manual therapy, and exercise with a sham (fake) version of that technique. The group that got the real manual therapy had slightly fewer headache days than the exercise-only group right after treatment and at three months, and briefly fewer than the sham group too, but the researchers say these differences were too small to be considered clinically meaningful.

By six months, the three groups looked similar. Interestingly, exercise alone performed no differently than exercise with sham therapy.

This suggests that for tension-type headache specifically, this manual therapy technique may offer only short-lived and uncertain benefit beyond exercise, based on one trial rather than a larger body of evidence.

This is a summary of research, not medical advice. Talk to your own healthcare provider about anything affecting your care.

This trial addresses whether adding Mulligan manual therapy to exercise improves outcomes in episodic tension-type headache, a question previously studied mainly in cervicogenic headache. Ninety-nine participants were randomized to exercise alone, exercise plus Mulligan manual therapy, or exercise plus sham manual therapy, with outcomes assessed at baseline, 4 weeks, 3 months, and 6 months including headache frequency, intensity, disability, upper cervical rotation range, pressure-pain thresholds, and satisfaction. Headache frequency was statistically significantly lower in the manual therapy group versus exercise alone post-intervention (mean difference -1.0 day) and at 3 months, and versus sham at post-intervention only (mean difference 1.0 day), with similar trends across other outcomes.

However, the authors explicitly state the clinical relevance is unclear because between-group differences did not reach a clinical threshold, and no difference persisted at 6 months. Exercise and exercise-plus-sham did not differ on any outcome, which argues against a simple attention-effect explanation for the sham arm but does not establish that Mulligan manual therapy itself drives meaningful change.

This single trial, with short-term and clinically uncertain effects, informs rather than settles the question of whether this technique has a role in episodic tension-type headache management, and the abstract does not report adverse events.