185 Annales Universitatis Paedagogicae Cracoviensis Studia Naturae, 6: 185–202, 2021, ISSN 2543-8832 DOI: 10.24917/25438832.6.11 Sabina Adamczyk �e Osteopathy Academy, Non-public Continuing Education Institution in Krakow, Szlak St. 65, 31-153 Kraków, Poland; Sabina04@poczta.fm Osteopathic capabilities for headache therapy – a short overview Introduction In order to de�ne a headache, one should take into account, �rst of all, its non-speci�city, expressed in subjective perception. �is symptom is most o�en located throughout the head and felt both on the surface of the face skin – in the orbital-temporal area, and deep inside the skull. It is characterised by di�erent intensity and duration. However, headache is not usually a symptom of severe disease, although cluster headaches can lead to severe systemic disturbances (Stovner et al., 2006; Prusiński, 2012). Headache is the most common phrase searched by patients in the Google browser around the world (Kamiński et al., 2020). It concerns di�erent age groups of society: from children to the elderly (Linet et al., 1989; Lipton, Stewart, 1993; Anttila et al., 2006; Louw, Schmidt, 2015; Mrozkowiak et al., 2018). Research in recent years has shown that over 90% of people experience at least one headache incident each year. Usually, most people experience the so-called random pain, e.g. alcohol syndrome, fatigue, lack of sleep. However, about 15% of people experience more serious ailments in the form of cyclical pains. �ey are characterised by annoyance, but most of all have a negative impact on the quality of life. �ey are a disease phenomenon and may require medical attention. �e most common pains of this type are: tension headaches, migraine and cluster pains (Malec-Milewska, Woroń, 2012; Prusiński, 2012). �e most common form of headache is tension type headache (TTH), a�ecting approximately 30–80% of cases. �ey are o�en called stress or psychogenic pains and arise from increased muscle tension. Patients usually describe TTH as dull, compres- sive, and tightening pains which radiate to the occiput or forehead. �ere is also pain involving the back of the neck. �e cause of TTH is, among others, myofascial pain syndrome (MFPS), which is characterised by the occurrence of non-speci�c muscle S ab in a A da m cz yk 186 pain in the head and neck; o�en it is not strictly associated with headache. MFPS may a�ect up to 55% of head and neck pain patients (Stępień, 2003; Fumal, Schoenem, 2008; Chochowska et al., 2015). Migraine (Lat. migraena) is a type of headache experienced by approximately 15–18% of women and 6–8% of men. It most o�en a�ects young people, under the age of 40, and is usually characterised by unilateral pain lasting from 4 to even 72 hours. Migraines may be accompanied by nausea, vomiting, sensitivity to light, noise, odours and vegetative disorders. In its course, migraine may transform into daily headaches or may coexist with a tension headache (Gervil et al., 1999; Rożniecki et al., 2018). A migraine headache has a speci�c location that usually a�ects the area behind the eyeball, in the forehead, and in the temple. It can have bilateral or alternating symptoms. �is pain is sometimes so strong that it excludes the patient from everyday life. Pain of vascular origin is pulsating with the patient’s heart rate and is o�en shooting or excruciating (Glaubic-Łątka et al., 2004; Wójcik-Drączkowska et al., 2007). �e classic type of migraine is the so-called migraine with aura. Migraine aura is a type of neurological disorder that, in its classic form, a�ects eyesight: it causes visual disturbances – spots in front of the eyes, �ashes of light in the �eld of vision, visual acuity disturbance, and sometimes even loss of vision (Domitrz, 2007; Wójcik-Drączkowska et al., 2007). Cluster headache, otherwise known as Raeder syndrome or histamine headache, formerly known as Horton’s headache syndrome (Lat. cephalea Hortoni), is the most intense headache. It belongs to the group of primary pains, i.e. those that are not caused by any disease (this group also includes migraine). It most o�en occurs in men between 20 and 50 years of age. Its causes are unknown. �is type of pain is described as excru- ciating, burning, glaring, stinging, drilling, and above all, very intense. It is unilateral pain, located within the trigeminal nerve (sensorial innervating the face). �is pain can also appear in the orbital (behind the eyeball) or temporal area, less commonly in the cheek or jaw (Malec-Milewska, Woroń, 2012; Rożniecki et al., 2018). Patients su�ering from chronic headache usually undergo pharmacological treat- ment, which is known to cause many side e�ects over a  prolonged period of time, o�en leading to damage to various internal organs. In recent years, a  phenomenon has been observed that in alternative pain treatment centres, such as physiotherapy, osteopathy or Chinese medicine, patients look for other methods of non-pharmaco- logical treatment (Stovner et al., 2006; Prusiński, 2008; Łukasik, et al., 2012; Vemuri, Got, 2020; Healy et al., 2021). It is, among other, a  consequence of returning to herbalism and alternative medicine, as well as promoting an ecological, healthy and hygienic lifestyle. Osteopathy is one of the branches of medicine focused on the natural treatment of the whole person (Greenman, 2005; Speece et al., 2017). Diagnostics and treatment in this �eld are based primarily on precise palpation, using manual tests and techniques, O steopathic capabilities for headache therapy – a short overview 187 in order to treat the causes of dysfunction and restore the mobility of each body sys- tem. Palpation (Lat. palpatio), is an examination by touch – a diagnostic method that involves touching the size, shape, hardness or location of a speci�c anatomical structure with the �ngers. �is method is used by doctors in examining the chest and abdominal organs, and also to evaluate the heart rate (Bolechowski, 1982; Greenman, 2005; Wong et al., 2014). Osteopathic treatment is based on the interdependence of anatomy and physiology and the perception of each person as a functional unit, capable of recovering on its own, if the structure and physiological functioning of the body are in the right condition (Jäkel, Hauenschild, 2011). In recent years, this type of therapy has been increasingly used to treat pain, and the basic practices in this area have been developed for a long time (Fig. 1. – Appendix 1). Taking up this type of topic in the review aspect was caused by the desire to present other, bene�cial, and still relatively little known methods of �ghting headaches. �e current level of knowledge on this subject requires systematisation, as well as indication of which osteopathic therapies bring patients the best results in pain therapies. Experiments included in the analysis �e bibliography on the e�ects of osteopathic therapies was analysed through search strategies using medical subject headings (MeSH) and key words in the text. �is review is methodically based on the review method used by Jäkel and Hauenschild (2011). �e following databases were searched: JAOA (Journal of the American Os- teopathic Association), Pubmed.gov. Due to the large number of erroneous records, the use of the word “osteopathy” was abandoned in favour of more speci�c phrases, consistent with the chosen topic. �e key words and phrases selected for the search were: “headache osteopathy”, “non-pharmacological migraine treatment”, “tension headache”, “migraine therapy”, “osteopathy and tension headache”. �e “keys words” were used in both Polish and English. A selection was made among the publications from 2005–2020. �e search for given phrases resulted in 220 potential publications, of which 132 were from PubMed and 88 from JAOA. By removing duplicate articles, 180 records were obtained. A�er analysing the abstracts, articles not related to the subject were rejected. Six publications relating to experiments in the �eld of osteopathic headache treatment were included in the further analysis. �ese were Randomized Controlled Trial (RTC) studies and prospective and retrospective comparative studies: Voigt et al. (2011), Rolle et al. (2014), Adragna et al. (2015), Chaibi et al. (2017), D’Ippolito et al. (2017), Gandol� et al. (2018). �eir short description is presented in table 1. S ab in a A da m cz yk 188 Tab. 1. Characteristics of the analysed experiments with the use of osteopathic techniques Research authors Study type Subject of study Voigt et al. (2011) RCT E�cacy of OMT in the treatment of migraine Rolle et al. (2014) RCT Studies on the e�ects of OM� in patients with frequent episodic tension headaches Adragna et al. (2015) Comparative study before and a�er the interven- tion �e in�uence of OMT on pain and quality of life in patients with migraines Chaibi et al. (2017) RCT Adverse Events in CSMT, with single-blind, placebo, and with Randomized Controlled Study for people with migraine D’Ippolito et al. (2017) Prospective and retrospective com- parative studies E�ect of OM� on pain and mood disorders in patients with high-frequency migraine Gandol� et al. (2018) RCT Will myofascial treatment and the use of trigger point therapies reduce pain and pain medication intake in patients undergoing onabotulinumtoxinA injections for chronic migraine? Note: CSMT – Chiropractic Spine Manipulation �erapy; OMT – Osteopathic Manipulative Treatment; OM� – Osteopathic Manipulative �erapy; RCT – Randomized Controlled Trial Types of procedures in analysed osteopathic experiments Voigt et al. (2011) evaluated the e�ectiveness of Osteopathic Manipulative Treatment (OMT), combined with standard care, for women su�ering from migraines, de�ned according to the International Classi�cation of Diseases (ICD-10, G43; migraine with or without aura). �e researchers gathered a clinical group of 42 women, aged 25–65, meeting the de�ned criteria (minimum 3 migraine attacks per month). �irteen wom- en were diagnosed with migraine with aura. �e duration of migraine symptoms ranged from 2 to 45 years; on average 23 years. �e exclusion criteria were as follows: non-medical therapies (e.g. acupuncture, homeopathy) within 8 weeks prior to study initiation, pregnancy, lactation, and neurological diseases (e.g. brain tumours, multiple sclerosis and others). 42 participants were randomly assigned to 2 research groups (21 people each): OMT and control. A  licensed physiotherapist performed osteopathic manipulations of each participant in 5 sessions of 50 minutes over a period of 10 weeks in the OMT group. Osteopathic manipulation involved a variety of techniques at the discretion of the osteopath, tailored to each participant. �e control group did not receive any osteopathic manipulation, sham treatment, or other physical therapy. All women completed standardised health outcomes questionnaires before the study (t1) and 6 months a�er the end of the follow-up (t2). �ese were: Health-Related Quality of Life (HRQoL), Migraine Disability Assessment (MIDAS), Short Form-36 (SF-36) and the German “Pain Questionnaire” (Schmerzfragebogen des Schmerztherapeutischen Kolloquium eV Dr. Lowendorf ). O steopathic capabilities for headache therapy – a short overview 189 �e Italian team of Rolle et al. (2014) conducted a  pilot study on the e�ects of Osteopathic Manipulative �erapy (OM�) in patients with frequent episodic tension headaches. �ey carried out randomized (RCT), with single-blind, and control of placebo. �e inclusion criterion for the study was the diagnosis of a frequent episodic Tension Type Headache (TTH). �e study excluded people: under 18 years or over 65 years of age, taking acute headache medications for 10 or more days a month in the last 3 months, su�ering from pain for less than a year, with mental illnesses and other disorders (e.g. secondary aches of head pains) or with any ongoing prophylaxis during the study period. �is experiment included: a  1-month baseline period, a  1-month treatment period, and a 3-month follow-up period. Patients were randomly assigned (coin toss) to the control or experimental group with OM�. During 4 weekly treat- ment sessions, patients from the experimental group underwent corrective OM� techniques. �ese techniques were not protocol based but were individually tailored for each patient as described by Greenman (2005). Patients in the control group un- derwent a cranial rhythm assessment (sham therapy), considered a placebo – manual techniques were used, but the observed osteopathic disorders were not corrected. At the end of the active treatment period, at 1 and 3 months, patients in both groups were assessed using “Headache Diaries” and the Headache Disability Inventory (HDI). �ese Diaries included: changes in the frequency of headache reported by patients (number of episodes during the period studied), headache intensity (for each episode in the study period; rated from 1 – lowest pain experienced to 5 and above – worst pain ex- perienced), medication use without prescription (total number of drugs used during the period under study). Adragna et al. (2015) conducted an experiment on the e�ects of osteopathic med- icine (OMT) in patients with migraine without aura in the form of a pilot study. �ey examined 8 people: 3 men and 5 women; patients were selected in a private doctor’s o�ce and included in one therapeutic group. �e researchers used four osteopathic treatments in the experiment, carried out over the course of 8 weeks. �e measures of the result were: frequency of attacks, use of analgesics, completed body awareness questionnaires: MIDAS, Headache Impact Test (HIT-6), SF-36 and Body Awareness Questionnaire (BAQ). Experimental data was collected at baseline (t0), 1 month a�er the last treatment (t1), and 3 months a�er the last treatment (t2). From the three months prior to t0 and throughout the study, all participants completed a “Headache Diary” and continued prescribed drug therapy. Chaibi et al. (2017) took up the topic related to the occurrence of adverse events in Chiropractic Spine Manipulation �erapy (CSMT). Investigators conducted a rigorously designed experiment, with single-blind, prospective, randomized clinical trial (RCT), using CSMT in migraineurs to assess Adverse Events (AEs), a�er manual intervention. �ey recruited a group of 97 migraine patients (83 women and 14 men), aged 18 to 70. S ab in a A da m cz yk 190 Participants, who experienced at least 1 migraine attack per month were randomized to the experimental CSMT, placebo (non-speci�c manual touch and non-therapeutic pushing manoeuvre), or control (follow-up medication) groups. Interventions were administered in twelve 15-minute sessions over a period of 3 months. �e researchers compared the AEs of participants who completed the study. �e results were assessed a�er 3, 6 and 12 months. �e initial exclusion criteria were: contraindications for spine manipulation, spinal radiculopathy, pregnancy, depression and CSMT in the last 12 months. During the experiment, the exclusion criteria also included: any other manip- ulative intervention of any physical therapist, or pregnancy. AEs were assessed during 703 sessions (355 in the CSMT groups and 348 in the placebo groups). D’Ippolito et al. (2017) undertook to investigate the e�ect of OM� on pain and mood disorders in patients with high-frequency migraine. �ey reviewed the medical records of patients with this type of diagnosis. �e inclusion criteria for the experiment were as follows: diagnosis according to ICHD-3b (pain: > 8 and < 15 days per month), participation in the OM� program and psychological evaluation, before and a�er the OM� program. Patients with one of the following criteria were excluded: a di�erent diagnosis of ICHD-3b (e.g. tension headache, chronic migraine), somatic or psychiat- ric disorders (e.g. major depression, psychosis) and the presence of musculo-skeletal disorders, temporomandibular diseases, neurological or rheumatic diseases. 11 people participated in the study. Patients included in the experiment were subjected to psycho- logical assessment according to standard psychological assessments. �e following were used to assess the symptoms of depression and anxiety as well as personality patterns: the Hamilton Depression Rating Scale (HDRS), State-Trait Anxiety Inventory (STAI), forms X-1 (state anxiety), and X-2 (trait anxiety) and the Millon Clinical Multiaxial Inventory (MCMI-III) – is only used during the �rst visit. HDI and HIT-6 – used to assess pain and its impact on daily activities. All patients were eligible for osteopathic treatment, but only those who wished to be treated in this way were enrolled in the OM� program. Four 45-minute sessions were conducted over 8 weeks. �ese pro- cedures focused on correcting the dysfunctions identi�ed at the �rst assessment and were performed using myofascial techniques, balanced ligament tension and osteopathy in the cranial �eld. A�er the OM� program, all patients were re-evaluated using the above-mentioned tests. �e last of the analysed experiments by Gandol� et al. (2018) aimed to determine, whether myofascial treatment and trigger point therapy will reduce pain and reduce pain medication intake in patients undergoing onabotulinumtoxinA injections due to chronic, di�cult-to-treat migraine. Adults with persistent migraines took part in the experiment. �is was a single-blind pilot study with two parallel groups (experimental and control). �e osteopathic intervention used here included manipulative treatment, consisting of techniques aimed at improving joint mobility and reducing the sti�ness O steopathic capabilities for headache therapy – a short overview 191 of the so� tissues of the cervico-thoracic spine – the experimental group (12 people). In addition, TENS current-healing treatment with a portable device (Master 932, Elet- tronica Pagani srl, Milan, Italy) was used – control group (10 people). �e frequency and duration of treatment was the same in both groups: 1 session per week for 4 weeks. Non-clinical and demographic data, including personal habits (e.g. co�ee, alcohol and tobacco consumption) were collected during registration using a  questionnaire. An evaluator unaware of treatment allocation recorded the results before treatment (T0), during treatment (T1), and 1 month a�er treatment completion (T2). �e information relating to the detailed characteristics of the individual experiments analysed here related to osteopathic intervention is summarised in table 2. Clinical bene�ts of experiments and their analysis in the light of selected literature An experiment conducted by Voight et al. (2011) found a signi�cant reduction in total MIDAS; the result was statistically signi�cant in the intervention group as compared to the control. �e number of days with migraines that the patients su�ered while per- forming their daily duties and activities decreased, but in both the intervention groups with OMT and the control group, it was statistically insigni�cant. �e intensity of pain and work disorders and the number of days of incapacity for work caused by migraine showed a statistically signi�cant reduction in the intervention group. �e control group had statistically signi�cant declines only in the functioning of the emotional role. Based on the intention-to-treat analysis design, the OMT group experienced signi�cant improvements in vitality, mental health, body pain, and phys- ical role functioning (4 of 8 HRQoL domains); SF-36 showed statistically signi�cant improvement in the intervention group. Overall, this experiment con�rmed the positive e�ects of OMT on migraine headaches in terms of: reduced pain intensity and reduced number of days with migraine and disability, and in part improved HRQoL. Based on “Headache Diaries” and HDI, no adverse events were recorded through- out the study in any of the groups of the experiment conducted by Rolle et al. (2014). �ere was a  signi�cant change in headache frequency in the OM� group (approx- imately 50% reduction from baseline a�er 3 months of follow-up) and an absolute di�erence between the 2 groups at 3 months, with a 33% lower headache frequency in the OM� group. Over-the-counter medication use only decreased in the OM� group at all time points a�er baseline, compared with the mean baseline. Pain intensity also slightly decreased over time in the OM� group (resulting in an approximately 20% reduction from baseline and a�er 3 months of follow-up). �e overall HDI score showed no signi�cant improvement. However, a comparison between the changes in HDI score in the 2 groups revealed a di�erence in time in the OM� group (resulting in an approximately 40% reduction from baseline and a�er 3 months of follow-up). �e S ab in a A da m cz yk 192 Ta b. 2 . B as ic in fo rm at io n ab ou t t he a na ly se d ex pe ri m en ts Ex pe ri m en t Pa tie nt p op ul at io n A ss ig ne d gr ou ps N um be r o f s es si on s/ le ng th o f s es si on Pr ac tit io ne r p ro �l e W ay o f r es ul ts c ol le ct in g Vo ig t e t a l. (2 01 1) W om en w ith m ig ra in es , ag ed 1 8 – 65 ; 1 3 pe rs on s ha d m ig ra in es w ith a ur a C on tr ol g ro up n = 21 N o in te rv en tio n Ph ys io th er ap is t w ith o st eo - pa th ic p ow er s C om pa ri so n of re su lts be tw ee n th e 2 gr ou ps O M T g ro up n = 21 5 se ss io ns o f 5 0 m in ut es fo r 10 w ee ks R ol le e t a l. (2 01 4) Pe op le a ge d 18 – 6 5 w ith fr eq ue nt e pi so di c pa in C on tr ol g ro up n = 19 Sh am th er ap y Q ua li� ed O st eo pa th C om pa ri so n of 2 g ro up s: 1- m on th b as el in e pe ri - od , 1 -m on th tr ea tm en t pe ri od a nd 3 -m on th fo llo w -u p pe ri od O M � g ro up n = 21 4 O M � se ss io ns e ve ry w ee k A dr ag na e t a l. (2 01 5) A du lts w ith m ig ra in es w ith ou t a n au ra O ne th er ap eu tic g ro up n = 8 4 tr ea tm en ts 8 w ee ks Q ua li� ed O st eo pa th C om pa ri so n of re su lts at b as el in e (t 0) , 1 m on th a� er la st tr ea tm en t ( t1 ) an d 3 m on th s a �e r l as t tr ea tm en t ( t2 ) C ha ib i e t a l. (2 01 7) W om en a nd m en su �e ri ng fr om m ig ra in es C on tr ol g ro up n = 27 N o in te rv en tio n N ot sp ec i� ed C om pa ri so n of 3 g ro up s, a� er 3 , 6 a nd 1 2 m on th s of in te rv en tio n pl ac eb o gr ou p n = 35 Sh am th er ap y C SM T g ro up n = 35 12 se ss io ns o f 1 5 m in ut es fo r 3 m on th s D ’Ip po lit o et a l. (2 01 7) A du lts w ith m ig ra in e O ne th er ap eu tic g ro up n = 11 4 se ss io ns o f 4 5 m in ut es fo r 8 w ee ks Q ua li� ed O st eo pa th C om pa ri so n of re su lts be fo re (t 1) a nd a �e r in te rv en tio n (t 2) G an do l� e t a l. (2 01 8) A du lts w ith m ig ra in es , a ge d 18 – 6 5 C on tr ol g ro up n = 10 N er ve st im ul at io n (T EN S) ; 4 se ss io ns fo r 4 w ee ks O st eo pa th d oc to r C om pa ri so n of re su lts be tw ee n th e 2 gr ou ps b e - fo re (t 0) , d ur in g (t 1) a nd a� er tr ea tm en t ( t2 ) O M � g ro up n = 12 1 se ss io n of 3 0 m in ut es p er w ee k fo r 4 w ee ks N ot e: O M T – O st eo pa th ic M an ip ul at iv e Tr ea tm en t; O M � – O st eo pa th ic M an ip ul at iv e � er ap y; C SM T – C hi ro pr ac tic S pi ne M an ip ul at io n � er ap y O steopathic capabilities for headache therapy – a short overview 193 obtained results allowed for the conclusion that OM� is an interesting alternative in TTH therapy. However, it should be remembered that OM� is not recommended for everyone and is not completely devoid of side e�ects (Rajendran et al., 2012), although this experiment did not �nd any. �e results of the experiment of Adragna et al. (2015) showed 100% of somatic dysfunction (SD) in the C1-occipital joint in the �rst session, and only 37% in the same joint in the second session with OMT. A reduction in SD was observed between OMT sessions, showing a signi�cant reduction in total dysfunction a�er the third and fourth sessions. �e musculoskeletal SD improved with the fourth treatment and the craniosa- cral system with the second, third and fourth OMT treatments. Signi�cant changes in the results were observed in the HIT-6 scale in the t2 period, MIDAS in the t1 period and the SF-36 scale in the t1 and t2 periods. �e BAQ, the second MIDAS, and the results of the “Headache Diary”, despite the reduction of migraine attacks and taking medications, did not produce statistically signi�cant results. However, this experiment generally showed that OMT had a positive e�ect in reducing pain and improving the quality of life of migraine patients without aura. �e results of the research team of Chaibi et al. (2017) indicated, that the most com- mon adverse event was local tenderness – 11.3% in the CMST group and 6.9% in the placebo group. Fatigue on the day of intervention was reported by 8.5% of participants in the CSMT group and 1.4% in the placebo group. Adverse events were mild and tran- sient, and no serious and other adverse events were reported. �us, this therapy is safe, provided that people with severe contraindications are initially excluded (Rajendran et al., 2012; Chaibi et al., 2017). D’Ippolito et al. (2017) showed that although the number of migraine attacks per month decreased, this was not considered “clinically signi�cant” because the sample size was small and all patients had the same range of headache attacks (> 8 and < 15 days per month). �e results of the STAI X-2, HIT-6 and HDI questionnaires in the study before treatment (T0) and a�er treatment (T1) showed a statistically signi�cant reduction in means. �e results observed in this small group of patients showed that OM� reduced the HIT-6 scores. �e change in mean STAI X-2 score was not con- sidered “clinically signi�cant” because both the T0 and T1 scores in this test suggested moderate anxiety. �e HDI score showed a statistically signi�cant di�erence between T0 and T1, but it was not considered a “clinically signi�cant improvement” anyway. �ere were no statistically signi�cant changes in the mean HDRS and STAI X-1 scores in the period from T0 to T1. In the case of MCMI-III, the result was inconclusive. However, the analysed retrospective study revealed that patients with high-frequency migraine had statistically signi�cant decreases in HIT-6, STAI X-2 and HDI scores a�er the OM� program. Nevertheless, it is impossible to draw de�nitive conclusions about the causal relationship between OM� and the changes in score and the clinical e�ect of these S ab in a A da m cz yk 194 changes. One reason is the retrospective, non-randomized selection process, and the other is an equally important, small sample size, which has limited both the generaliza- tion of results and the ability to determine the clinical signi�cance of scoring changes. Another limitation was the lack of a control group. �e presence of a control group could alleviate potential confounding factors, such as the mechanism of action of therapeutic touch and interactions between therapist and patient, which may have a positive e�ect on headache (Keller, Bzdek, 1986; Autret et al., 2012). However, this experiment showed that OM� can have a therapeutic e�ect on pain and mood disorders in patients with high-frequency migraine and could be useful as part of a multidisciplinary treatment program (Krause et al., 2017). �e results presented by Gandol� et al. (2018) showed no signi�cant di�erences between the groups in the pre-treatment assessment. �ere were also no signi�cant intergroup di�erences in pain intensity in the analysed period. In the post-treatment evaluation, the total consumption of analgesics and non-steroidal anti-in�ammatory drugs (NSAIDs) was signi�cantly lower in patients treated with osteopathic therapy than in those treated with TENS. �e pressure pain thresholds in the muscles of the upper trapezius, occipital and temporal muscles were signi�cantly lower in patients treated with manipulation than those treated with TENS. �e total consumption of painkillers, NSAIDs and triptans was signi�cantly lower a�er a  series of treatments than before treatment in patients undergoing manipulative treatment. No adverse events were reported during and a�er the experiment. �us, according to the authors of this experiment, manipulative techniques aimed at reducing peripheral nociceptive triggers may be of added value in treating chronic migraine symptoms and reducing the use of reliever medications. �e comparison of all the results obtained in the analysed experiments is summa- rised in table 3. Tab. 3. Main outcomes and e�ects of analysed experiments, in comparison to control patients or baseline results Experiment E�ect/result in comparison to control group and/or baseline results Voight et al. (2011) • statistically signi�cant decrease in the total score in the OTM group; • pain intensity, work disorders, number of days of inability to work due to migraine, showed a statistically signi�cant reduction in the OTM group; in the control group, statistically signi�cant declines in the functioning of the emotional role; • 4 out of 8 spheres tested improved (vitality, mental health, body pain and physical role functioning). Rolle et al. (2014) • the frequency of pain and its intensity have decreased; reducing the amount of medications taken; • HDI has not changed signi�cantly. O steopathic capabilities for headache therapy – a short overview 195 Adragna et al. (2015) • signi�cant changes expressed in reduced pain; • no signi�cant changes in the evaluation of some tests. Chaibi et al. (2017) • local tenderness was greater in the CSMT group than in the placebo group; • greater fatigue on the day of intervention in the CSMT group than in the placebo group; • the adverse events were mild and transient. D’Ippolito et al. (2017) • improvement in general condition but not clinically relevant due to a small sample size. Gandol� et al. (2018) • in the experimental group, there was a reduction in the doses of drugs taken and an improvement in the range of motion, especially in �exion and lateral bend. Note: HDI – Headache Disability Inventory; CSMT – Chiropractic Spine Manipulation �erapy �e method of manual osteopathic therapy considered in all the experiments discussed here belongs to the relatively little-known complementary and alternative medicine treatments, useful in combating pain (Vincent, Furnham, 1997; Vickers, Zollman, 1999). �ere are studies containing descriptions of the necessary, more or less complicated, manual techniques in this �eld. An example is the extensive textbook in this area by Greenman (2005), which, in addition to the basics, comprehensively and transparently presents osteopathic tests, treatment methods, as well as frequent clinical images and accompanying diagnostic and therapeutic methods. Nevertheless, much more popular methods from this group are, for example, acupuncture (e.g. Di- ener et al., 2006; Li et al., 2012; Linde et al., 2015), methods of brain stimulation, such as biofeedback (Nestoriuc et al., 2009) – recently very fashionable, di�erent relaxation methods (Evers et al., 2009), or homeopathy (Ernst, 1999). �eir e�ectiveness has been tested through numerous medical experiments. In the case of osteopathic treatments, there are still few well-planned experiments con�rming the e�ectiveness of this type of therapy. However, randomly selected experiments for this analysis are an example of a keen interest in this subject. On their basis, it can be concluded that in this type of research it is very important to plan them so that the obtained results are as credible as possible, which was especially emphasized by Adragna et al. (2015), Rolle et al. (2014) and D’Ippolito et al. (2017). According to them, an important role is played here, among others, by sample size, presence of a control group, clear exclusion and inclusion criteria – non-standard selection process, OMT tailored to the patient’s needs and a reliable description of the condition before and a�er therapy. As for the selection of appropriate treatments individually for each patient, it usually takes place in the clinical practice of osteopathy, with the use of techniques correcting any observed dysfunctions. �is is because clinical �eld observations suggest that standard osteopathic therapies are less e�ective than those tailored to individual needs (Rolle et al., 2014). �e individual relationship of the patient with the therapist-osteopath S ab in a A da m cz yk 196 is also very important, as mentioned earlier (D’Ippolito et al., 2017). Improving the psychological factors that are believed to aggravate the pain and in�uence the progres- sion of migraine – from episodic to chronic – can be especially important, and a good relationship with the therapist is not neutral in this regard. Considering the overall condition of the patient, OM� may be an interesting treatment option, for example, episodic pain, characterised by several contraindications and side e�ects. �is therapy is especially indicated for patients not adhering to the treatment regimens and with an increased risk of adverse drugs reactions. Manipulation techniques aimed at reducing peripheral nociceptive triggers (pain receptors) may be of great value in the treatment of chronic migraine, especially as their side e�ects are generally minimal or completely unnoticed (Rolle et al., 2014; Chaibi et al., 2017). An interdisciplinary approach, including pharmacological and non-pharma- cological treatment, is also very important (Healy et al., 2021). In this regard, the use of OMT can reduce acute drug intake and muscular-vascular dysfunction in patients with chronic migraine (Gandol� et al., 2018). Manipulative osteopathic treatment, for example in the case of somatic dysfunctions of the thoracic spine, may require an interdisciplinary team of specialists. Without proper treatment, acute somatic dysfunc- tions of the thoracic spine can turn into serious chronic problems. Although the main moderator of treatment is a quali�ed osteopath or physician, a multidisciplinary and holistic approach, requiring the collaboration of several specialists, is currently preferred (Vemuri, Got, 2020). �is model emphasizes a multidisciplinary approach to persistent pain due to its intertwined physical and psychological nature (Parkin-Smith et al., 2015). Certainly, combating headaches also requires this kind of interdisciplinary approach. �e articles analysed here supports the hypothesis that osteopathic manipulation has a therapeutic e�ect on pain and mood disorders in patients with high-frequency migraine and may be useful as part of an interdisciplinary therapeutic program. Many physicians recognise that the traditional methods of pharmacological pain treatment available to date are o�en unsatisfactory and their social and health costs can be high (Jensen, Stovner, 2008). Positive e�ects of OM� on headache control may be due to speci�c neurochemical e�ects, including increases in circulating opioids and serotonin levels, involving the descending serotonergic and noradrenergic pathways (Degenhardt et al., 2007). However, the molecular basis of OM�’s clinical outcomes is largely un- known and more research is needed to address this issue. Conclusion �e experiments presented above con�rm the e�ectiveness of OMT manipulative oste- opathic therapy in the treatment of headaches of various origins. Osteopathic treatment in all its range of possibilities of the techniques used, o�ers great opportunities to re- O steopathic capabilities for headache therapy – a short overview 197 duce pain and improve the well-being of su�erers, especially in migraines and tension headaches. �e analysed results also show that the recommended therapy is a  very good supplement to standard drug therapy, thanks to which the use of large doses of drugs can be signi�cantly reduced. Researchers of these issues also pay attention to the fact that future experiments should be planned with a su�ciently large sample size. In order to improve the quality of good medical practice, they also encourage osteopaths to use systematic assessment of adverse events in selected manipulative therapy and a holistic, interdisciplinary approach to pain management. Con�ict of interest �e author declares no con�ict of interest related to this article. 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Journal of Bodywork and Movement �erapies, 18(2), 165–173. https://doi.org/10.1016/j.jbmt.2013.09.010 O steopathic capabilities for headache therapy – a short overview 201 Appendix 1 Fig. 1. Classical osteopathic practices in the �eld of headache therapy: A – neck ligament relaxation, B – positional relaxation of the sternocleidomastoid muscle and the inclined muscles, C – stretching of the cervico-thoracic fascia, D – relaxation of the broad neck muscle, E – relaxation of the temporal muscle, F – relaxing the masseter muscle (Photo. S. Adamczyk) S ab in a A da m cz yk 202 Osteopatyczne możliwości terapii bólów głowy – krótki przegląd Streszczenie Celem przeprowadzonego tu krótkiego przeglądu było usystematyzowanie, a także wykazanie skuteczności technik osteopatycznych w różnego typu terapiach bólu głowy. Zestawione powyżej eksperymenty potwierdza- ją skuteczność manipulacyjnej terapii osteopatycznej OMT w tym zakresie. Leczenie osteopatyczne w całym swym wachlarzu stosowanych technik, daje ogromne możliwości w redukcji bólu i poprawy samopoczucia osobom cierpiącym, szczególnie na migreny oraz napięciowe bóle głowy. Analizowane wyniki wskazują także, że zalecana terapia stanowi bardzo dobre uzupełnienie standardowej terapii lekowej, dzięki czemu zażywanie dużych dawek leków można znacznie ograniczyć. Badacze tych zagadnień zwracają jednocześnie uwagę na fakt, aby przyszłe eksperymenty były planowane z odpowiednio dużą wielkością próby. W celu poprawienia jakości dobrej praktyki medycznej, zachęcają również osteopatów do stosowania systematycznej oceny zdarzeń niepożądanych w dobranej odpowiednio terapii manipulacyjnej oraz całościowego, interdy- scyplinarnego podejścia do leczenia bólu. Key words: alternative medicine, headaches, Osteopathic Manipulative Treatment, OM� Received: [2021.02.04] Accepted: [2021.04.20]