{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T21:07:41Z","timestamp":1792789661073,"version":"4.5.0"},"reference-count":54,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T00:00:00Z","timestamp":1775779200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"FisiosurI+D","award":["FS1TTH26"],"award-info":[{"award-number":["FS1TTH26"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Tension-type headache (TTH) is the most prevalent primary headache disorder worldwide and represents a major source of disability related to chronic pain. Despite its high prevalence, uncertainty remains regarding optimal conservative management strategies, and limited evidence is available on how physiotherapists apply existing recommendations in routine clinical practice. Objective: The objective was to explore physiotherapists\u2019 perceptions, clinical experiences, and treatment strategies in the management of tension-type headache, with particular emphasis on commonly used interventions, clinical decision-making, and characteristics of physiotherapy care. Methods: A cross-sectional survey study was conducted using a self-administered online survey developed in accordance with the CHERRIES guidelines. One hundred Spanish physiotherapists with clinical experience in treating patients with TTH participated. Quantitative data were analyzed descriptively, while open-ended responses were examined using inductive thematic analysis following the framework proposed by Braun and Clarke. Results: Manual therapy was the most frequently reported intervention (96%), followed by therapeutic exercise (61%) and invasive techniques, primarily dry needling (48%). The suboccipital and upper cervical regions were consistently identified as primary therapeutic targets, reflecting a predominant craniocervical treatment focus. Most respondents reported individualized treatment plans, typically delivered in weekly sessions lasting 45\u201360 min, with expected clinical improvement within 4\u20136 weeks. Pain education strategies were reported infrequently. Considerable variability was observed in the selection and combination of therapeutic techniques. Conclusions: Physiotherapists managing tension-type headache commonly adopt a multimodal approach, largely centered on manual and tissue-focused interventions. Although many reported practices are aligned with current evidence, the substantial heterogeneity observed and the limited integration of biopsychosocial strategies highlight the need for consensus-based guidelines and further research addressing real-world clinical effectiveness.<\/jats:p>","DOI":"10.3390\/jcm15082896","type":"journal-article","created":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T13:16:17Z","timestamp":1775826977000},"page":"2896","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Clinical Practice Patterns in the Physiotherapy Management of Tension-Type Headache Among Spanish Physiotherapists"],"prefix":"10.3390","volume":"15","author":[{"given":"Ana","family":"Bravo-Vazquez","sequence":"first","affiliation":[{"name":"Doctoral Program in Health Sciences, University of Seville, 41009 Seville, Spain"},{"name":"Physiotherapy Department, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain"},{"name":"Fisiosur I+D, Research Institute, 04630 Garrucha, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elena","family":"De-La-Barrera-Aranda","sequence":"additional","affiliation":[{"name":"Fisiosur I+D, Research Institute, 04630 Garrucha, Spain"},{"name":"Morphological and Socio-Health Sciences Department, University of Cordoba, 14071 Cordoba, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9731-9039","authenticated-orcid":false,"given":"Ernesto","family":"Anarte-Lazo","sequence":"additional","affiliation":[{"name":"Fisiosur I+D, Research Institute, 04630 Garrucha, Spain"},{"name":"Faculty of Health, UNIE University, 28015 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8674-9180","authenticated-orcid":false,"given":"Cleofas","family":"Rodriguez-Blanco","sequence":"additional","affiliation":[{"name":"Physiotherapy Department, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain"},{"name":"Fisiosur I+D, Research Institute, 04630 Garrucha, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6235-8353","authenticated-orcid":false,"given":"Carlos","family":"Bernal-Utrera","sequence":"additional","affiliation":[{"name":"Physiotherapy Department, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain"},{"name":"Fisiosur I+D, Research Institute, 04630 Garrucha, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/ijcp.12650","article-title":"The burden of headache: Global and regional prevalence of headache and its impact","volume":"69","author":"Dowson","year":"2015","journal-title":"Int. J. Clin. Pract."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1111\/j.1526-4610.2007.00647.x","article-title":"Chronic daily headache in a primary care population: Prevalence and headache impact test scores","volume":"47","author":"Coeytaux","year":"2007","journal-title":"Headache"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Meng, W., and Sui, L. (2024). Headache disorders: A persistent public health challenge for the under 50s. Front. Neurol., 15.","DOI":"10.3389\/fneur.2024.1501749"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"102780","DOI":"10.1016\/j.msksp.2023.102780","article-title":"The cervical spine in tension-type headache","volume":"66","author":"Cook","year":"2023","journal-title":"Musculoskelet. Sci. Pract."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Headache Classification Committee of the International Headache Society (2018). The international classification of headache disorders, 3rd edition. Cephalalgia, 38, 1\u2013211.","DOI":"10.1177\/0333102417738202"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"774","DOI":"10.1177\/033310240102100708","article-title":"Epidemiology of headache","volume":"21","author":"Rasmussen","year":"2001","journal-title":"Cephalalgia"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1186\/s10194-025-02098-w","article-title":"Hallmarks of primary headache: Part 2\u2014Tension-type headache","volume":"26","author":"Pan","year":"2025","journal-title":"J. Headache Pain"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1007\/s11910-021-01138-7","article-title":"Current understanding of the pathophysiology and approach to tension-type headache","volume":"21","author":"Steel","year":"2021","journal-title":"Curr. Neurol. Neurosci. Rep."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1111\/head.13067","article-title":"Tension-type headache\u2014The normal and most prevalent headache","volume":"58","author":"Jensen","year":"2018","journal-title":"Headache"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1323","DOI":"10.1177\/0333102415576226","article-title":"Multimodal manual therapy versus pharmacological care for tension-type headache","volume":"35","year":"2015","journal-title":"Cephalalgia"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"944","DOI":"10.1177\/03331024221082073","article-title":"Effectiveness of physiotherapy interventions on headache intensity, frequency, duration and quality of life of patients with tension-type headache: A systematic review and network meta-analysis","volume":"42","author":"Jung","year":"2022","journal-title":"Cephalalgia"},{"key":"ref_12","first-page":"34","article-title":"The efficacy of physiotherapy approaches in chronic tension-type headache: A systematic review and meta-analysis","volume":"39","author":"Onan","year":"2025","journal-title":"J. Oral Facial Pain Headache"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Bravo-Vazquez, A., Anarte-Lazo, E., Rodriguez-Blanco, C., and Bernal-Utrera, C. (2025). Dry needling for tension-type headache: A scoping review on intervention procedures, muscle targets, and outcomes. J. Clin. Med., 14.","DOI":"10.3390\/jcm14155320"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"103526","DOI":"10.1016\/j.msksp.2026.103526","article-title":"Clinical features of manual therapy interventions in people with tension-type headache: A scoping review","volume":"82","year":"2026","journal-title":"Musculoskelet. Sci. Pract."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1186\/s10194-021-01298-4","article-title":"Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache: A systematic review and meta-analysis","volume":"22","author":"Callesen","year":"2021","journal-title":"J. Headache Pain"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1080\/10669817.2019.1645414","article-title":"Physical therapist clinical reasoning and classification inconsistencies in headache disorders: A United States survey","volume":"28","author":"Dale","year":"2019","journal-title":"J. Man. Manip. Ther."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Repiso-Guarde\u00f1o, A., Moreno-Morales, N., Armenta-Pend\u00f3n, M.A., Rodr\u00edguez-Mart\u00ednez, M.C., Pino-Lozano, R., and Armenta-Peinado, J.A. (2023). Physical therapy in tension-type headache: A systematic review of randomized controlled trials. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20054466"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2139","DOI":"10.4102\/sajp.v81i1.2139","article-title":"Current state of evidence-based practice in clinical physiotherapy","volume":"81","author":"Roos","year":"2025","journal-title":"S. Afr. J. Physiother."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1002\/msc.1720","article-title":"A survey of Indian physiotherapists\u2019 clinical practice patterns and adherence to clinical guidelines in the management of patients with acute low back pain","volume":"21","author":"Ganesh","year":"2023","journal-title":"Musculoskelet. Care"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e1964","DOI":"10.1002\/pri.1964","article-title":"Physiotherapy practice patterns in the management of patients with knee osteoarthritis: A national survey","volume":"27","author":"Ackah","year":"2022","journal-title":"Physiother. Res. Int."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1179\/2042618613Y.0000000048","article-title":"A survey of physical therapists\u2019 clinical practice patterns and adherence to clinical guidelines in the management of patients with whiplash-associated disorders","volume":"22","author":"Corkery","year":"2014","journal-title":"J. Man. Manip. Ther."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e1851","DOI":"10.1002\/msc.1851","article-title":"Musculoskeletal physiotherapists\u2019 discharge practices for people treated with low back pain: A United Kingdom survey","volume":"22","author":"Smith","year":"2023","journal-title":"Musculoskelet. Care"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"49","DOI":"10.3138\/ptc.2015-72","article-title":"Low back pain: Current patterns of Canadian physiotherapy service delivery","volume":"69","author":"Orozco","year":"2017","journal-title":"Physiother. Can."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1016\/j.aprim.2019.03.005","article-title":"Declaraci\u00f3n de la iniciativa CHERRIES","volume":"51","year":"2019","journal-title":"Aten. Prim."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"35","DOI":"10.7748\/nr.2025.e1958","article-title":"How many is enough? Justifying sample size in descriptive quantitative research","volume":"33","author":"Mursa","year":"2025","journal-title":"Nurse Res."},{"key":"ref_26","unstructured":"Sociedad Espa\u00f1ola de Neurolog\u00eda (2020). Manual de Pr\u00e1ctica Cl\u00ednica en Cefaleas: Recomendaciones Diagn\u00f3stico-Terap\u00e9uticas, Grupo de Estudio de Cefaleas, SEN."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"Braun","year":"2006","journal-title":"Qual. Res. Psychol."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Anarte-Lazo, E., and Bernal-Utrera, C. (2025). Perceptions and experiences of physiotherapists treating trismus in head and neck cancer patients: Findings from a Spanish web-based survey. J. Clin. Med., 14.","DOI":"10.3390\/jcm14197092"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1016\/j.jbmt.2014.06.001","article-title":"Effectiveness of myofascial release: A systematic review of randomized controlled trials","volume":"19","author":"Ajimsha","year":"2015","journal-title":"J. Bodyw. Mov. Ther."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"127","DOI":"10.2174\/1573397112666151231113625","article-title":"Tension type headache","volume":"12","year":"2016","journal-title":"Curr. Rheumatol. Rev."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1016\/j.ncl.2013.11.005","article-title":"The neck and headaches","volume":"32","author":"Bogduk","year":"2014","journal-title":"Neurol. Clin."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Jull, G., Sterling, M., Falla, D., Treleaven, J., and O\u2019Leary, S. (2008). Whiplash, Headache and Neck Pain: Research-Based Directions for Physical Therapies, Elsevier.","DOI":"10.1016\/B978-0-443-10047-5.50019-9"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1186\/s12998-022-00459-9","article-title":"The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: A systematic review and meta-analysis","volume":"30","author":"Bini","year":"2022","journal-title":"Chiropr. Man. Therap."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1016\/j.nrl.2017.12.004","article-title":"Terapia manual en adultos con cefalea tensional: Revisi\u00f3n sistem\u00e1tica","volume":"36","year":"2021","journal-title":"Neurolog\u00eda"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Valera-Calero, J.A., Plaza-Manzano, G., Rabanal-Rodr\u00edguez, G., D\u00edaz-Arribas, M.J., Kobylarz, M.D., Buffet-Garc\u00eda, J., Fern\u00e1ndez-de-Las-Pe\u00f1as, C., and Navarro-Santana, M.J. (2024). Current state of dry needling practices: A comprehensive analysis on use, training, and safety. Medicina, 60.","DOI":"10.3390\/medicina60111869"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"102255","DOI":"10.1016\/j.msksp.2020.102255","article-title":"A survey of American physical therapists\u2019 current practice of dry needling: Practice patterns and adverse events","volume":"50","author":"Gattie","year":"2020","journal-title":"Musculoskelet. Sci. Pract."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1179\/2042618613Y.0000000044","article-title":"Adverse events following trigger point dry needling: A prospective survey of chartered physiotherapists","volume":"22","author":"Brady","year":"2014","journal-title":"J. Man. Manip. Ther."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1111\/j.1468-2982.2007.01295.x","article-title":"Myofascial Trigger Points and Sensitization: An Updated Pain Model for Tension-Type Headache","volume":"27","author":"Cuadrado","year":"2007","journal-title":"Cephalalgia"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"944","DOI":"10.1016\/j.apmr.2014.12.015","article-title":"Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain","volume":"96","author":"Liu","year":"2015","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"3513","DOI":"10.1080\/09638288.2023.2251880","article-title":"Effectiveness of electrophysical agents in subjects with frozen shoulder: A systematic review and meta-analysis","volume":"46","author":"Brindisino","year":"2024","journal-title":"Disabil. Rehabil."},{"key":"ref_41","unstructured":"National Institute for Health and Care Excellence (2021). Chronic Pain (Primary and Secondary) in Over 16s: Assessment of All Chronic Pain and Management of Chronic Primary Pain (NICE Guideline NG193), NICE."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e051073","DOI":"10.1136\/bmjopen-2021-051073","article-title":"Efficacy and safety of transcutaneous electrical nerve stimulation for acute and chronic pain in adults: A systematic review and meta-analysis","volume":"12","author":"Johnson","year":"2022","journal-title":"BMJ Open"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"807","DOI":"10.1016\/j.jpain.2015.05.005","article-title":"Fifteen years of explaining pain: The past, present, and future","volume":"16","author":"Moseley","year":"2015","journal-title":"J. Pain"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2041","DOI":"10.1016\/j.apmr.2011.07.198","article-title":"The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain","volume":"92","author":"Louw","year":"2011","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"682","DOI":"10.1080\/09593985.2018.1423590","article-title":"The effects of pain neuroscience education and exercise on pain, muscle endurance, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain: A school-based pilot, randomized and controlled study","volume":"34","author":"Andias","year":"2018","journal-title":"Physiother. Theory Pract."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"645","DOI":"10.1007\/s11916-023-01132-3","article-title":"Neuromodulation for the sphenopalatine ganglion: A narrative review","volume":"27","author":"Lim","year":"2023","journal-title":"Curr. Pain Headache Rep."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1186\/s10194-017-0826-y","article-title":"Sphenopalatine ganglion: Block, radiofrequency ablation and neurostimulation\u2014A systematic review","volume":"18","author":"Ho","year":"2017","journal-title":"J. Headache Pain"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Isteni\u010d, S., Jerman, A., Pu\u0161nik, L., Stopar Pintari\u010d, T., and Umek, N. (2025). Transnasal spread of bupivacaine into the pterygopalatine fossa following endoscopically assisted cotton swab placement: A cadaveric study. Reg. Anesth. Pain Med., rapm-2025-106553.","DOI":"10.1136\/rapm-2025-106553"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1186\/1129-2377-15-67","article-title":"Manual therapies for primary chronic headaches: A systematic review","volume":"15","author":"Chaibi","year":"2014","journal-title":"J. Headache Pain"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"52","DOI":"10.5606\/tftrd.2018.1238","article-title":"Effectiveness of physical therapy and exercise on pain and functional status in patients with chronic low back pain: A randomized-controlled trial","volume":"64","author":"Karahan","year":"2017","journal-title":"Turk. J. Phys. Med. Rehabil."},{"key":"ref_51","first-page":"CD004249","article-title":"Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment","volume":"2015","author":"Gross","year":"2015","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Trulsson Schouenborg, A., Rivano Fischer, M., Bondesson, E., and J\u00f6ud, A. (2021). Physiotherapist-led rehabilitation for patients with chronic musculoskeletal pain: Interventions and promising long-term outcomes. BMC Musculoskelet. Disord., 22.","DOI":"10.1186\/s12891-021-04780-x"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1179\/2042618612Y.0000000025","article-title":"Conservative physical therapy management for tension-type headache: A systematic review","volume":"21","author":"Racicki","year":"2013","journal-title":"J. Man. Manip. Ther."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1835","DOI":"10.1097\/00007632-200209010-00004","article-title":"A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache","volume":"27","author":"Jull","year":"2002","journal-title":"Spine"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/8\/2896\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T13:19:31Z","timestamp":1775827171000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/8\/2896"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,10]]},"references-count":54,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["jcm15082896"],"URL":"https:\/\/doi.org\/10.3390\/jcm15082896","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,10]]}}}