Effects of Spinal Manipulation and Dry Needling on Headache and Migraine

Research Update: A 2026 systematic review examined randomized controlled trials of dry needling and spinal manipulation for migraine, tension-type headache, and cervicogenic headache. The review included 13 randomized controlled trials involving 791 adults and found improvements in several pain, sensitivity, disability, and quality-of-life outcomes, while also emphasizing substantial heterogeneity and limited evidence about long-term effects.

For chiropractors and other clinicians who manage patients with headache, the important question is not simply whether a technique “works.” It is which headache population was studied, what intervention was actually delivered, what it was compared with, how large the observed benefit was, and how durable that benefit appears to be.

This ChiroSecure Research Update reviews those points and places the 2026 systematic review in the context of the broader headache and spinal-manipulation literature.

Video overview: This video summarizes the 2026 systematic review and its findings concerning dry needling, spinal manipulation, headache pain, headache frequency, sensitivity, function, disability, and related outcomes.

What did the 2026 systematic review examine?

Díez and colleagues conducted a systematic review of randomized controlled trials evaluating dry needling (DN), spinal manipulation (SM), or combinations of these interventions in adults with primary or secondary headache disorders. The review searched PubMed, Scopus, and ScienceDirect for eligible studies published during the preceding five years and followed PRISMA methods.

The initial search identified 897 records. After screening and full-text assessment, 13 randomized controlled trials met the eligibility criteria. Together, the trials included 791 participants. The studies primarily involved adults with cervicogenic headache, migraine, or tension-type headache.

Methodological quality was assessed with the PEDro scale. Scores ranged from 6 to 8. The authors characterized the included evidence as generally good quality, although one study had a higher risk of bias. Importantly, the trials differed substantially in patient populations, treatment protocols, comparison groups, outcome measures, and follow-up periods.

What types of headache were represented?

Headache is not a single clinical entity. The International Classification of Headache Disorders separates primary headache disorders such as migraine and tension-type headache from secondary headaches attributed to another disorder or structure. Cervicogenic headache is classified within the secondary headache disorders.

The distinction matters because an intervention studied in patients with a prominent cervical musculoskeletal component should not automatically be assumed to have the same effect in every patient with migraine or another headache disorder.

• Migraine: a primary headache disorder with characteristic recurrent attacks and associated symptoms that can include nausea, photophobia, phonophobia, and, in some patients, aura.
• Tension-type headache: a primary headache disorder commonly characterized by pressing or tightening pain rather than the pulsating quality often associated with migraine.
• Cervicogenic headache: a secondary headache attributed to a disorder of the cervical spine or its component structures, with diagnostic criteria that require more than simply finding neck tenderness.

The 2026 review included these categories, but the included trials were not evenly distributed across them. The authors reported that the studies primarily involved cervicogenic or migraine-type headaches, and many participants had recurrent headaches accompanied by cervical or muscular tenderness.

What did the researchers find?

The review synthesized outcomes rather than producing one pooled effect estimate for all studies. That approach reflects the clinical and methodological differences among the trials.

Pain intensity, frequency, and pressure sensitivity

Pain-related outcomes were central to the evidence base. Across the included studies, investigators measured headache intensity, headache frequency, headache duration, and pressure pain thresholds using instruments such as the visual analogue scale, numeric pain rating scale, and algometry.

Nine trials reported favorable results for pain-related outcomes or pressure sensitivity with dry needling and/or spinal manipulation. This does not mean every intervention improved every outcome in every trial. Rather, the direction of findings across several studies was generally favorable, while individual trial results varied.

Function and disability

Eight studies reported favorable findings involving functional capacity, disability, or quality of life. Measures included the Neck Disability Index and headache-specific instruments such as HIT-6.

Some combination interventions produced statistically significant improvements over comparison groups. However, statistical significance does not automatically mean that every observed difference was large enough to be clinically important. The review itself noted this issue in several trials.

Headache medication use

Two studies included medication-related outcomes. The review reported favorable findings for medication intake in those trials. Because medication use was not a primary outcome across all 13 studies, these findings should be interpreted as supportive observations rather than evidence that dry needling or spinal manipulation generally reduces medication requirements.

What about combining dry needling and spinal manipulation?

Several trials evaluated combinations of interventions rather than isolated techniques. Some included dry needling alongside conventional physiotherapy, while others combined manipulation with exercise or electrical dry needling.

Combination protocols sometimes produced larger improvements than comparison interventions. However, combination treatment makes attribution more difficult. If a program includes manipulation, dry needling, exercise, education, and other physical-therapy components, the trial cannot necessarily tell a clinician how much of the observed change came from one individual component.

Why the clinical context matters

A useful way to interpret this evidence is to separate the question “Can this intervention be associated with improvement?” from the more specific questions “For which patients?”, “Compared with what?”, and “For how long?”

The 2026 review provides evidence relevant to the first question. It is less definitive for the others.

How should clinicians interpret the evidence for migraine?

Migraine deserves particular caution because the broader evidence base is not uniform. A 2024 systematic review and meta-analysis of six randomized trials involving 645 people with migraine reported very low- to low-certainty evidence and concluded that the effectiveness of spinal manipulation for migraine remained unproven. That review found no clear effect on migraine intensity, duration, or emotional quality of life at post-intervention and identified limitations involving risk of bias, inconsistency, imprecision, and clinical heterogeneity.

That finding does not directly contradict the 2026 review. The reviews asked somewhat different questions, used different eligibility criteria, and included different bodies of evidence. The practical point is that evidence for spinal manipulation should not be generalized across all headache diagnoses.

For clinicians, headache classification and appropriate clinical assessment remain important before selecting a manual or needling intervention. Treatment findings from patients with cervicogenic headache, for example, should not automatically be presented as evidence for treatment of classic migraine.

What are the important limitations of the 2026 review?

The authors identify several limitations that should remain visible when the findings are communicated to clinicians or patients.

• Heterogeneous interventions: The studies used different manipulation and dry-needling protocols, treatment doses, target regions, and co-interventions.
• Different comparison groups: Controls included placebo or sham procedures, other manual therapies, conventional physiotherapy, exercise, and no treatment.
• Different headache populations: Migraine, tension-type headache, and cervicogenic headache were represented, but not in equal proportions.
• Small samples in individual trials: The total sample was 791, but the individual studies varied considerably in size.
• Limited long-term evidence: Follow-up periods differed and were not sufficient to establish durable effects for all interventions.
• Outcome variation: Studies used different measures of pain, frequency, disability, sensitivity, medication use, and quality of life.

These limitations are why the review’s conclusion is appropriately narrower than a claim that manipulation or dry needling is a universally effective treatment for headache.

What does this mean for clinical decision-making?

For a chiropractor or other qualified clinician, the evidence can be used as one part of a broader clinical reasoning process rather than as a standalone treatment prescription.

1. Identify the headache presentation. Determine whether the presentation is consistent with a primary headache disorder, cervicogenic headache, or another secondary cause.
2. Screen for features requiring medical evaluation. New, sudden, severe, progressive, atypical, or neurologically concerning headache presentations may require urgent or medical assessment rather than routine conservative care.
3. Assess the cervical and musculoskeletal contribution. Where appropriate, evaluate cervical mobility, muscular tenderness, headache provocation, function, and other relevant findings.
4. Choose an intervention that fits the patient and scope of practice. The trials do not establish a single optimal manipulation or dry-needling protocol.
5. Use multimodal care thoughtfully. Many trials incorporated exercise or other physiotherapy components, so outcomes cannot always be attributed to one technique.
6. Monitor outcomes that matter to the patient. Headache days, intensity, duration, disability, medication use, and functional goals can provide more useful information than relying on a single pain score.
7. Reassess the diagnosis and treatment plan. Lack of improvement, a changing clinical picture, or new warning features should prompt reconsideration of the working diagnosis and referral when appropriate.

What about safety?

The randomized trials in the 2026 review generally reported no serious adverse events, although transient post-needling soreness and bruising occurred in some dry-needling groups. The review’s individual trials therefore provide useful information about events observed within those study settings, but they should not be treated as a complete estimate of the risks of either intervention in routine practice.

More broadly, a 2026 systematic review of dry-needling adverse events found that minor adverse events were common across the literature, while major adverse events per treatment were uncommon but reported. Separate evidence reviews of spinal manipulation also emphasize the importance of consistent adverse-event reporting and the limitations of randomized trials for detecting very rare serious events.

For clinicians, informed consent, appropriate training, patient selection, technique-specific precautions, and clear documentation remain important components of risk management. The scope of practice and regulatory requirements for dry needling also vary by jurisdiction and professional license.

How does this update fit with earlier ChiroSecure research?

This review builds on a broader body of headache-related evidence already discussed by ChiroSecure. Earlier research updates have addressed spinal manipulation for chronic headache, evidence-based chiropractic guidelines for adult headache, and dose-response findings in chronic cervicogenic headache.

Taken together, those resources illustrate why headache evidence should be interpreted by diagnosis and clinical presentation rather than by treating “headache” as a single condition.

Read the ChiroSecure research update on spinal manipulation for chronic headache.

Review the evidence-based guidelines for chiropractic treatment of adults with headache.

See the ChiroSecure update on dose response and spinal manipulation for chronic cervicogenic headache.

Read the ChiroSecure update on comparative manual-therapy evidence for cervicogenic headache.

Bottom line

The 2026 systematic review adds a useful, current synthesis of randomized trials examining dry needling and spinal manipulation for headache disorders. Across 13 trials involving 791 adults, the authors found generally favorable findings for pain, headache frequency, pressure sensitivity, disability, and related outcomes. Many interventions were delivered as part of multimodal care.

At the same time, the evidence does not establish a universally effective technique, an optimal protocol, or consistent long-term benefit. The studies varied in headache diagnosis, intervention, comparator, co-intervention, and follow-up. The distinction is especially important when discussing migraine, where other systematic-review evidence has reached more uncertain conclusions.

For clinicians, the most defensible interpretation is therefore evidence-informed rather than absolute: dry needling and spinal manipulation are active areas of research with potentially useful short-term effects in selected headache populations, but treatment decisions should remain diagnosis-specific, patient-specific, appropriately scoped, and responsive to clinical reassessment.

Source presentation: ChiroSecure Research Update based on the 2026 systematic review by Díez and colleagues.