The most common type of headache facing humans is the tension type headache.

It was named this by the International Headache Society in 1988. The pain felt can radiate from the upper back and neck, base of occiput, ears and above the ears, jaw and above the eyes. Tension type headache is defined as, a common primary headache disorder, characterized by a dull, non-pulsatile, diffuse, band-like (or vice-like) pain of mild to moderate intensity in the head, scalp, or neck. The subtypes are classified by frequency and severity of symptoms. There is no clear cause even though it has been associated with muscle contraction and stress. (1) Tension type headaches affect an estimated 35%- 40% of adults in Western society. They can last from minutes to seven days. The average tension type headache lasts 4-6 hours. However chronic tension type headaches can last 15 days or more per month for a minimum of six months. (2) There are many ideas, which are considered to contribute to tension type headaches. The underlying pathophysiology remains a matter of speculation, with peripheral muscular and CNS components both likely involved. (3) It has been shown that chronic tension type headache is difficult to treat since its etiology is not completely clear. There is a theory that the pain associated with tension type headaches are caused by misinterpretation of information by the brain is perceived as pain. There is evidence that one of the neurotransmitters involved is serotonin. Both spinal manipulative therapy (herinafter referred to as SMT) and the antidepressant drug, amitriptyline, have been studied to learn their effectiveness in the treatment of tension type headache. SMT, in this instance, is defined as inducing movement by applying force to a vertebra. Amitriptyline has been shown to work as serotonin acting at the level of the second order spinothalamic neuron has an antinociceptive effect that diminishes pain sensations. Lower levels of serotonin have the effect of lowering pain threshold. As Amitriptyline is a serotonin agonist, other than acting as an anti-depressant, it inhibits the uptake of serotonin from the neural cleft and enhances the antinociceptive effects of serotonin (4). Side effects of any treatment must always be considered. Once the risk versus reward ratio is considered, a proper decision can be made whether to pursue that treatment. The main side effects of amitriptyline are drowsiness and dry mouth. While these are the main side effects, there is also a plethora of more significant side effects. (5) SMT as the treatment for chronic tension type headaches is directed at the cervical spine. There is a possibility that this treatment results in the reduction of nociceptive stimuli. (6) The main side effects of SMT are mild to moderate pain, disc herniation, and fractures. Though these are the main side effects, many others have been reported. (7) While the effects of amitriptyline have science behind them, SMT is purely theoretical. It has been shown that tension-type headache can be induced by noxiously stimulating structures innervated by cervical nerve roots C1-C3. (8-10) Headache pain may result from a common pathway shared by the trigeminal system and the upper three cervical nerves. Primary afferent nociceptors from these nerves converge upon common second order spinothalamic neurons. This results in cortical pain centers interpretation of stimulation from cervical structures presenting from the areas of the head innervated by the trigeminal system (8). There is a popular and often referenced study by chiropractors on the topic of treatment of

tension type headache in the Journal of Manipulative Physiological Therapy that appears to show that SMT is more effective in the treatment of chronic tension type headaches than amitriptyline. The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline was slightly more effective in reducing pain by the end of the treatment period, but was associated with more side effects. Four weeks after cessation of treatment however, patients who received spinal manipulation experienced a sustained therapeutic benefit in all major outcomes in contrast to the amitriptyline group, who reverted to baseline values. The sustained therapeutic benefit associated with spinal manipulation seemed to result in a decreased need for over-the-counter medication. There is a need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare SMT to an appropriate placebo such as sham manipulation in future clinical trials.(10) This study did in fact show that SMT offered relief to symptoms. However it openly admits that four weeks of therapy is not an indicator of a proven therapy. It is a good place to begin to validate SMT as an effective treatment for tension type headaches and it confirms that amitryptiline is effective in relieving symptoms. Complimenting the study on SMT v. amitryptline for the treatment of chronic tension type headaches in JMP is a study on non- invasive physical treatments for chronic/ recurrent headache. In this study it is stated both that, For prophylactic treatment of CTTH, drug amitriptyline is more effective than spinal manipulation during treatment, but SMT superior in short term after cessation of both treatments (11) and There is no good evidence that SMT is effective in preventing episodic tension type headache. (11) In 2008, a rigorous review of literature was performed. Ten quality articles of evidence were chosen. Based upon patient oriented evidence, which considers reduction of mortality and morbidity, improvement of the symptoms, better quality of life and reduced costs as well as disease oriented evidence comprising intermediate, histopathology, physiologic and other surrogate or potentially useful results for improving the patients quality of life that may or may not reflect the patients actual improvement; there was a recommendation for the use of amitriptyline based on consistent and good quality patient oriented evidence. (12) Typically a study that is designed to see if SMT is (more) effective compared to a modality such as amitriptyline, designed by SMT physicians, is designed to gain more acceptance for SMT. Until more long term quality studies can be completed and published, SMT should not be fully accepted by any physician based on lack of definitive evidence. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headacheBefore any firm conclusions can be drawn, further testing should be done in rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length. (13) Of the two treatments, based on the most recent and properly done research, amitryptline is more effective in the relief of tension type headaches. The risk versus reward regarding side effects of either treatment are arbitrary to the patient and typically negligible if the treatment offers relief. Once more properly done long term studies are completed analyzing the efficacy of SMT as the treatment for tension type headaches, a better assessment can be competed.

Works Cited

(1)International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004: suppl 1)Year introduced: 2006 (1995)

(2) Headache Classification Subcommittee of the International Headache Society (2004). "The International Classification of Headache Disorders: 2nd edition". Cephalalgia 24 (Suppl 1): 9160

(3) "What Is Serotonin? What Does Serotonin Do?." Medical News Today. MediLexicon, Intl., 4 Aug. 2011.

(4) Magni G. The use of antidepressants in the treatment of chronic pain: a review of the current evidence. Drugs 1991; 42:730-48

(5) Healthline. Amitriptyline Oral Hydrochloride Tablet, March 12, 2009 http://www.healthline.com/goldcontent/amitriptyline#page2?brand= Accessed November 17, 2012

(6) Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. [J Manipulative Physiol Ther. 1995]

(7) Adverse effects of spinal manipulation: a systematic review E Ernst J R Soc Med. 2007 July; 100(7): 330338.

(8) Bogduk N, Marsland A. On the concept of occipital headache. J Neurol Neurosurgery Psychiatry 1986;.49:775-8022.

(9) Bovid G, Berg R, Dale LG. Cervicogenic headache: anesthetic blockades of cervical nerves (C2-C5) and facet joint (C2/C3). Pain 1992; 49:315-2023.

(10) Bovim G, Sand T. Cervicogenic headache, migraine without aura and tension-type headache: diagnostic blockade of greater occipital and supra-orbital nerves. Pain 1992; 51:43-8

(11) Brnfort G, Nilsson N, Haas M, Evans RL, Goldsmith CH, Assendelft WJJ, Bouter LM. Noninvasive physical treatments for chronic/recurrent headache. Cochrane Database of Systematic Reviews 2004, Issue 3

(12) Torrente Castells E, Vzquez Delgado E, Gay Escoda C. Use of amitriptyline for the treatment of chronic tension-type headache. Review of the literature. Med Oral Patol Oral Cir Bucal. 2008

Sep 1;13(9):E567-72. Review.

(13) Vernon H, Jansz G, Goldsmith CH, McDermaid C. A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial. J Manipulative Physiol Ther. 2009 Jun;32(5):344-51. Erratum in: J Manipulative Physiol Ther. 2009 Nov-Dec