Behavioral treatments of chronic tension-type headache in adults: are they beneficial?

To assess the efficacy of behavioral treatments in patients with tension headache. Medline, Cinahl, EMBASE, and the Cochrane library were searched from inception to October 2007 and reference lists were checked. We selected randomized trials evaluating behavioral treatments (e.g., relaxation, electromyographic [EMG] biofeedback, and cognitive behavioral training) in patients with tension-type headache (TTH). We assessed the risk of bias using the Delphi list and extracted data from the original reports. A qualitative analysis was carried out. We found 44 trials (2618 patients), which were included in this review, of which only 5 studies (11.4%) were considered to have low risk of bias. Most trials lacked adequate power to show statistical significant differences, but frequently, recovery/improvement rates did not reach clinical relevance. In 8 studies, relaxation treatment was compared with waiting list conditions, and in 11 studies, biofeedback was compared with waiting list conditions, both showing inconsistent results. On the basis of the available literature, we found no indications that relaxation, EMG biofeedback, or cognitive behavioral treatment is better than no treatment, waiting list, or placebo controls.