Central mechanisms in tension-type headaches

Regional homogeneity alterations in multi-frequency bands in tension-type headache: a resting-state fMRI study

OBJECTIVES

In this study, we aimed to investigate the spontaneous neural activity in the conventional frequency band (0.01-0.08 Hz) and two sub-frequency bands (slow-4: 0.027-0.073 Hz, and slow-5: 0.01-0.027 Hz) in tension-type headache (TTH) patients with regional homogeneity (ReHo) analyses.

METHODS

Thirty-eight TTH patients and thirty-eight healthy controls (HCs) underwent resting-state functional magnetic resonance imaging (RS-fMRI) scanning to investigate abnormal spontaneous neural activity using ReHo analysis in conventional frequency band (0.01-0.08 Hz) and two sub-frequency bands (slow-4: 0.027-0.073 Hz and slow-5: 0.01-0.027 Hz).

RESULTS

In comparison with the HC group, patients with TTH exhibited ReHo increases in the right medial superior frontal gyrus in the conventional frequency band (0.01-0.08 Hz). The between group differences in the slow-5 band (0.01-0.027 Hz) highly resembled the differences in the conventional frequency band (0.01-0.08 Hz); even the voxels with increased ReHo were spatially more extensive, including the right medial superior frontal gyrus and the middle frontal gyrus. In contrast, no region showed significant between-group differences in the slow-4 band (0.027-0.073 Hz). The correlation analyses showed no correlation between the ReHo values in TTH patients and VAS scores, course of disease and number of seizures per month in conventional band (0.01-0.08 Hz), slow-4 band (0.027-0.073 Hz), as well as in slow-5 band (0.01-0.027 Hz).

CONCLUSIONS

The results showed that the superior frontal gyrus and middle frontal gyrus were involved in the integration and processing of pain signals. In addition, the abnormal spontaneous neural activity in TTH patients was frequency-specific. Namely, slow-5 band (0.01-0.027 Hz) might contain additional useful information in comparison to slow-4 band (0.027-0.073 Hz). This preliminary exploration might provide an objective imaging basis for the understanding of the pathophysiological mechanism of TTH.

Osteopathic Manipulative Treatment in Tension Headaches

Tension-type headaches, associated with young age, poor health, sleep disturbances, anxiety, stress, and poor posture, account for 90% of all headaches diagnosed by healthcare professionals. Diagnosis and treatment of the various headache subtypes are often aimed at determining the underlying cause but commonly involve over-the-counter pain medication. Because recurrence is common in tension-type headaches, with a subsequent refractory response to over-the-counter medications, adjunctive and alternative treatment modalities should be further studied. Here we present a case of tension headache initially non-responsive to pain medication but resolved with osteopathic manipulative treatment and lifestyle modifications. Osteopathic considerations and literature are also reviewed in the broader context of headache management.

Primary Headache Disorders- Part 2: Tension-type headache and medication overuse headache

In Part 2 of Primary Headache disorders, we discuss the fourth Primary Headache Disorder, Tension-Type Headache (TTHA). We are again using the ICHD-III (Beta) definitions of such headaches, taking into consideration episodic and chronic TTHA, as well as the presence or absence of pericranial muscle tenderness. We discuss the pathophysiology and pharmacotherapeutic treatment of TTHA, and the aspects of the Myofascial Pain Syndrome that enhance and help the development of TTHA. We then discuss Medication Overuse Headache (MOH), itself a Secondary headache disorder, but one that is extremely important as it assists with the chronification of both migraine and TTHA. Finally we discuss how to manage and treat those patients with MOH. Chronic migraine, which is TTHA, Migraine as well as, in many patients, MOH, is discussed along with the treatment of this multifaceted disorder.

Effects of physical therapy and relaxation techniques on the parameters of pain in university students with tension-type headache: A randomised controlled clinical trial

INTRODUCTION

Non-pharmacological treatments help control tension-type headache; however, evidence about their effectiveness is still limited. This study evaluates the effectiveness of physical therapy based on cervical spine kinesiotherapy and posture correction exercises compared to a programme of relaxation techniques only (Schultz's Autogenic Training, AT).

METHODS

Tension-type headache is very common among university students. We randomly selected 152 university students with a diagnosis of tension-type headache according to the criteria of the International Headache Society. Eighty-four were women (55.3%) and 68 were men (44.7%). Mean age was 20.42±2.36 years. The study design is a randomised controlled trial of a non-pharmacological intervention with a blinded evaluation of response variables. We compared the results of two independent samples: AT was used in one of the groups while the other group received AT plus cervical spine kinesiotherapy and posture correction training. Patients recorded any changes in the parameters of pain (frequency, intensity, and duration) and drug consumption in a headache diary before treatment, at 4 weeks, and at 3 months.

RESULTS

Both interventions achieved a decrease in all the parameters of pain; however, decreases in frequency and intensity were more significant in the combined treatment group (P<0.01) (d=0.4).

CONCLUSIONS

Such active, non-invasive therapies as AT and cervical spine kinesiotherapy, and especially the combination of both, effectively reduce tension-type headache by preventing and managing the potential psychophysical causes of this disorder. Future research should aim to assess the long-term effects of these interventions.

Brainstem and Cervical Spinal Cord Fos Immunoreactivity Evoked by Nerve Growth Factor Injection into Neck Muscles in Mice

Although myofascial tenderness is thought to play a key role in the pathophysiology of tension-type headache, very few studies have addressed neck muscle nociception. The neuronal activation pattern following local nerve growth factor (NGF) administration into semispinal neck muscles in anaesthetized mice was investigated using Fos protein immunohistochemistry. In order to differentiate between the effects of NGF administration on c-fos expression and the effects of surgical preparation, needle insertion and intramuscular injection, the experiments were conducted in three groups. In the sham group ( n = 7) cannula needles were only inserted without any injection. In the saline ( n = 7) and NGF groups ( n = 7) 0.9% physiological saline solution or 0.8 µM NGF solution were injected in both muscles, respectively. In comparison with sham and saline conditions, NGF administration induced significantly stronger Fos immunoreactivity in the mesencephalic periaqueductal grey (PAG), the medullary lateral reticular nucleus (LRN), and superficial layers I and II of cervical spinal dorsal horns C1, C2 and C3. This activation pattern corresponds very well to central nervous system processing of deep noxious input. A knowledge of the central anatomical representation of neck muscle pain is an essential prerequisite for the investigation of neck muscle nociception in order to develop a future model of tension-type headache.

Efficacy of Physiotherapy Including a Craniocervical Training Programme for Tension-Type Headache; A Randomized Clinical Trial

We conducted a multicentre, randomized controlled trial with blinded outcome assessment. The treatment period was 6 weeks with follow-up assessment immediately thereafter and after 6 months. The objective was to determine the effectiveness of a craniocervical training programme combined with physiotherapy for tension-type headache. Eighty-one participants meeting the diagnostic criteria for tension-type headache were randomly assigned to an exercise group (physiotherapy and an additional craniocervical training programme) and a control group (physiotherapy alone). The primary outcome measure was headache frequency. Secondary outcomes included headache intensity and duration, Quality of Life (SF-36) and the Multidimensional Headache Locus of Control scale (MHLC). At 6 months' follow-up, the craniocervical training group showed significantly reduced headache frequency, intensity and duration ( P < 0.001 for all). Effect sizes were large and clinically relevant. Loss to follow-up amounted to 3.7±. Physiotherapy including craniocervical training reduces symptoms of tension-type headache significantly over a prolonged time frame.

Headache and Recurrent Abdominal Pain: A Controlled Study by the Means Of The Child Behaviour Checklist (CBCL)

Headache and recurrent abdominal pain (RAP) are common disorders in children and adolescents, frequently referred to paediatricians. Both disorders show similarities in trigger and comorbid factors, their burden on family and individual life, and a paroxysmal trend with risks of chronicization over time. However, very few studies have compared directly headache and RAP. The main aim of this study was to compare the psychological profile of headache and RAP patients vs. healthy controls. A total of 210 children and adolescents [99 boys, 111 girls; age range 4-18 years; mean age (m.a.) = 11.04, SD 4.05] were assessed: 70 headache patients (m.a. 12.4 years; SD 2.9; F = 35, M = 35), 70 RAP patients (m.a. 9 years; SD 3.6; F = 30, M = 40) and 70 controls (m.a. 11.7 years; SD 4.6; F = 46, M = 24). The diagnoses had been made according to international systems of classification both for headache (ICHD-II criteria) and RAP (Rome II criteria). The psychological profile had been made according to the Child Behaviour Checklist 4-18 (CBCL). ANOVA one-way analysis was used to compare CBCL scales and subscales between groups. Headache and RAP showed a very similar trend vs. control for the main scales of the CBCL, with a statistically significant tendency to show problems in the Internalizing scale (anxiety, mood and somatic complaints) and no problems in the Externalizing (behavioural) scale. Only for the Attention Problems subscale migraineurs showed a significant difference compared with RAP. In conclusion, headache and RAP show a very similar psychological profile that should be considered not only for diagnostic and therapeutic purposes, but also from the aetiological aspect.

Passive Paradigm Single-Tone Elicited ERPs in Tension-Type Headaches and Migraine

The active 'oddball' event-related potential (ERP) P3 is elongated or reduced in migraine and tension-type headaches, indicating a deficit of active attention in these primary headaches. It is then reasonable to study the passive attention function in these headaches through the technology of passive paradigm singletone elicited ERPs. We invited 32 patients suffering from chronic tension-type headache (CTTH), 17 from frequent episodic tension-type headache (FETH) and 32 from interictal migraine without aura, as well as 28 healthy subjects to undergo passive paradigm single-tone ERPs. There were no statistically significant differences when the mean latencies and amplitudes of N1, P2, N2 or the mean latencies of P3 of the four groups were considered. In contrast, the P3 amplitudes were significantly reduced in the patient groups when compared with healthy controls. However, no further significant difference was found between patient groups when considering P3 amplitude. Our study demonstrated a deficit of passive attention in CTTH, FETH and migraine, but could not separate these headache types in this regard. The reduced P3 in patients might be due to the head pain experienced.

Muscles and their role in episodic tension-type headache: implications for treatment

BACKGROUND AND OBJECTIVE

Tension-type headache (TTH) imposes a heavy burden on the global population but remains incompletely understood and poorly managed.

DATABASES AND DATA TREATMENT

Here, we review current knowledge of peripheral factors involved in the mechanism of TTH and make recommendations for the treatment of episodic TTH based on these.

RESULTS

Peripheral activation or sensitization of myofascial nociceptors is most probably involved in the development of muscle pain and the acute episode of TTH. Repetitive episodes of muscle pain may sensitize the central nervous system resulting in progression of TTH to the chronic form. Thus, muscular factors may be responsible not only for the acute headache episode but also for chronification of the disorder. Simple analgesics and non-steroidal anti-inflammatory drugs are the mainstays of management of individual headache episodes. Ibuprofen 400 mg and aspirin 1000 mg are recommended as drugs of first choice based on treatment effect, safety profile and costs. Non-pharmacological therapies include electromyographic biofeedback, physiotherapy and muscle relaxation therapy. Future studies should aim to identify the triggers of peripheral nociception and how to avoid peripheral and central sensitization. There is a need for more effective, faster acting drugs for acute TTH.

CONCLUSION

Muscular factors play an important role in episodic TTH. Ibuprofen 400 mg and aspirin 1000 mg are recommended as drugs of first choice.

Tension-Type Headache in Children: The Cinderella of Headache Disorders!

Tension-type headache (TTH) may be as common a headache disorder as migraine in children and adolescents. TTH has a neurobiological basis with genetic and environmental factors making variable contributions to the different sub-types. The diagnostic criteria for TTH in the second edition of the “International Classification of Headache Disorders” appear to be applicable to children. Anxiety and mood disorders may be co-morbid with frequent episodic and chronic TTH. Psychosocial stressors play an important role in precipitating and maintaining TTH. Hence, a biopsychosocial approach should be adopted for care. Standardized histories and examinations together with prospective headache diaries are the foundations for good management; attention to ‘red flags’ will help identify secondary causes that present with headache similar to TT. There are no randomized controlled drug trials for the treatment of TTH. Relaxation and cognitive behavioral therapies are effective. TTH in children and adolescents warrants greater recognition from the clinician and scientist. Studies focusing on TTH are overdue.

Personality characteristics of male sufferers of chronic tension-type and cervicogenic headache

Background and Purpose

Chronic tension-type headache (a primary headache disorder) and cervicogenic headache (a secondary headache disorder that is attributable to upper cervical spine pathology) share similar clinical manifestations, but their associated personality traits may differ. We evaluated the personality differences between sufferers of chronic tension-type headache and cervicogenic headache.

Methods

We administered the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) and the Zuckerman Sensation-Seeking Scale (SSS) to 18 patients suffering from chronic tension-type headache, 19 suffering from cervicogenic headache, and 26 healthy volunteers. Depressive trends were measured with the Plutchik-van-Praag Depression Inventory (PVP).

Results

Compared to healthy controls, the chronic tension-type headache group scored significantly higher on ZKPQ Neuroticism-Anxiety and on the PVP, while the cervicogenic headache group scored significantly lower on SSS Thrill and Adventure Seeking. In addition, the total SSS score was significantly lower in the cervicogenic headache group than in both the chronic tension-type headache group and the healthy controls.

Conclusions

The results of this study indicate that higher scores for neuroticism-anxiety and depression were associated with chronic tension-type headache, while lower sensation-seeking scores were associated with cervicogenic headache.

Central sensitization induced in trigeminal and upper cervical dorsal horn neurons by noxious stimulation of deep cervical paraspinal tissues in rats with minimal surgical trauma

OBJECTIVE

This study investigated if central sensitization is induced in the trigeminal subnucleus caudalis (also termed the medullary dorsal horn) and C1 and C2 dorsal horns by noxious stimulation of deep upper cervical paraspinal tissues in a preparation relatively free of surgical trauma.

METHODS

Adult male Sprague-Dawley rats (275-450 g) were anesthetized intraperitoneally. Animals were then placed in a stereotaxic frame; a small cutaneous incision was made 3 to 4 mm near the bregma in the midline, and an opening into the skull was prepared by a 1/32-inch drill, 1 mm to the left from the midline. An epoxylite-coated tungsten microelectrode was introduced at an 18 degrees angle to enter this small opening on the skull and was then carefully advanced about 16 mm through cortex, cerebellum, and brainstem to reach subsequently histologically confirmed sites in the Vc and upper cervical (C1 and C2) dorsal horn region. Thirty-three, 27, and 15 neurons recorded in medullary, C1, and C2 dorsal horns, respectively, of chloralose/urethane-anesthetized rats were activated by noxious stimulation of mechanoreceptive fields involving V1, V2, and/or V3 trigeminal nerve territories. The inflammatory irritant mustard oil was injected into the deep paraspinal tissues at the level of the left C1-C2 joint. Pre and postinjection receptive field (RF) sizes were mapped by nonnoxious mechanical stimuli and noxious mechanical and heat stimuli.

RESULTS

A 30- to 50-minute increase (mean, 165% +/- 38.1%) in RF size postinjection for 62% of neurons tested was demonstrated, suggesting central sensitization; for most (>70%) neurons, the RF expanded caudally into cervically innervated tissues.

CONCLUSIONS

These findings provide the first documentation that deep cervical nociceptive inputs can induce central sensitization in medullary and C1/C2 dorsal horns and suggest that these effects may reflect mechanisms contributing to deep cervical pain and its referral.

A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial

OBJECTIVES

Tension-type headache (TTH) is the most common headache experienced by adults in Western society. Only 2 clinical trials of spinal manipulation for adult tension-type headache have been reported, neither of which was fully controlled. In 1 trial, spinal manipulation was compared to amitriptyline. There is an urgent need for well-controlled studies of chiropractic spinal manipulation for TTH. This trial was stopped prematurely due to poor recruitment. The purposes of this report are (1) to describe the trial protocol, as it contained several novel features, (2) to report the limited data set obtained from our sample of completed subjects, and (3) to discuss the problems that were encountered in conducting this study.

METHODS

A randomized clinical trial was conducted with a factorial design in which adult TTH sufferers with more than 10 headaches per month were randomly assigned to four groups: real cervical manipulation + real amitriptyline, real cervical manipulation + placebo amitriptyline, sham cervical manipulation + real amitriptyline, and sham cervical manipulation + placebo amitriptyline. A baseline period of four weeks was followed by a treatment period of 14 weeks. The primary outcome was headache frequency obtained from a headache diary in the last 28 days of the treatment period.

RESULTS

Nineteen subjects completed the trial. In the unadjusted analysis, a statistically significant main effect of chiropractic treatment was obtained (-2.2 [-10.2 to 5.8], P = .03) which was just below the 3-day reduction set for clinical importance. As well, a clinically important [corrected] effect of the combined therapies was obtained (-9 [-20.8 [corrected] to 2.9], P = .13), but this did not achieve statistical significance. In the adjusted analysis, neither the main effects of chiropractic nor amitriptyline were statistically significant or clinically important; however, the effect of the combined treatments was -8.4 (-15.8 to -1.1) which was statistically significant (P = .03) and reached our criterion for clinical importance.

CONCLUSION

Although the sample size was smaller than initially required, a statistically significant and clinically important effect was obtained for the combined treatment group. There are considerable difficulties with recruitment of subjects in such a trial. This trial should be replicated with a larger sample.

Effect of acupuncture-like electrical stimulation on chronic tension-type headache: a randomized, double-blinded, placebo-controlled trial

OBJECTIVE

The aim of this study was to examine the effect of acupuncture-like electrical stimulation on chronic tension-type headache (TTH) in a randomized, double-blinded, placebo-controlled study.

METHODS

Thirty-six patients (18 men, 18 women) with chronic TTH in accordance with the criteria of International Headache Society were investigated. The patients were randomly assigned into 2 groups: a treatment group and a placebo group. Pain duration, pain intensity on a 0 to 10 cm visual analog scale, number of headache attacks, and use of medication were recorded in a diary for 2 weeks before treatment (baseline), early stage of treatment (Treat-1; 2 wk), late stage of treatment (Treat-2; 4 wk), and after the end of treatment (Post-1, Post-2, Post-3 corresponding to 2, 4, and 6-wk follow-up). The patients also provided an overall evaluation of the treatment effect at each stage. Patients were taught how to use either an acupuncture-like electrical stimulator or a sham stimulator (identical but incapable of delivering an electric current) and then instructed to use the device at home. Six acupoints, bilateral EX-HN5, GB 20, LI 4, were selected to be stimulated 3 minutes for each point, twice a day. Friedman repeated measure analysis of variance on rank was used to test the data.

RESULTS

The pain duration was shortened at Treat-1 and pain intensity was decreased at Treat-1 and Treat-2 compared with baseline. The overall evaluation of the 2 treatments indicated improvements in both the treatment and the placebo groups, but with no significant difference between the groups (P>0.061). Despite the apparent improvement in both the treatment and placebo groups, a decrease in analgesic use was only observed in the treatment group. There was also a significant positive correlation between the reported intensity of the stimulus-evoked sensation and the evaluation of the effect of either active or placebo treatments (P=0.039).

CONCLUSIONS

The use of acupuncture-like electrical stimulation was not associated with significant adverse effects. These results indicate that acupuncture-like electrical stimulation is a safe and potentially analgesic-sparing therapy that may be considered as an adjunctive treatment for patients with chronic TTH although the clinical effect on pain seems to be marginal in the present set-up.

Increased muscle pain sensitivity in patients with tension-type headache

Nociceptive mechanisms in tension-type headache are poorly understood. The aim was to investigate the pain sensitivity of pericranial muscles and a limb muscle in patients with tension-type headache. Experimental muscle pain was induced by standardized infusions of 0.5 ml of 1 M hypertonic saline into two craniofacial muscles (anterior temporalis (TPA) and masseter (MAS)) and a limb muscle (anterior tibial (TA)) in 24 frequent episodic tension-type headache patients (FETTH), 22 chronic tension-type headache patients (CTTH) and 26 age and gender matched healthy subjects. Headache patients were examined twice, both on days with and on days without headache. The pressure pain thresholds (PPTs) were determined before and after infusions. The subjects continuously reported intensity of saline-induced pain on an electronic visual analogue scale (VAS) and the perceived area of pain was drawn on anatomical maps. Headache patients demonstrated significantly lower PPTs, higher saline-evoked VAS pain scores and greater pain areas than healthy subjects at all the tested muscle sites (P<0.05). There was a significant gender difference for the PPTs in all three groups of participants (P<0.05) and for VAS pain scores in the CTTH patients (P<0.05). There was no difference in pain sensitivity between FETTH and CTTH or between patients with or without headache. In conclusion, the present study demonstrates the presence of generalized pain hypersensitivity both in FETTH and CTTH compared to controls which is unrelated to actual headache status and extends to include responses to longer-lasting stimuli which are clinically highly relevant. Gender differences in deep pain sensitivity seem to be a consistent finding both in healthy controls and patients with tension-type headache.

Diagnosis and management of cervicogenic headache

Upper cervical pain and/or headaches originating from the C0 to C3 segments are pain-states that are commonly encountered in the clinic. The upper cervical spine anatomically and biomechanically differs from the lower cervical spine. Patients with upper cervical disorders fall into two clinical groups: (1) local cervical syndrome; and (2) cervicocephalic syndrome. Symptoms associated with various forms of both disorders often overlap, making diagnosis a great challenge. The recognition and categorization of specific provocation and limitation patterns lend to effective and accurate diagnosis of local cervical and cervicocephalic conditions.

Topographic analysis of laser evoked potentials in chronic tension-type headache: Correlations with clinical features

In the present study, we examined clinical and laser-evoked potentials (LEP) features in a group of chronic tension-type headache (CTTH) patients, in order to perform a topographic analysis of Laser evoked potentials (LEPs) and a correlation with clinical features. Eighteen patients suffering from CTTH [Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders 2nd ed. Cephalalgia 2004; 24 Suppl 1, 1-159.] participated in the study. Twelve age- and sex-matched controls were also examined. We performed a basal evaluation of clinical features, Total Tenderness Score (TTS) and a topographic analysis of LEPs obtained by the hand and the pericranial points stimulation in all patients vs healthy subjects. The later LEPs, especially the P2 component, were significantly increased in amplitude in the CTTH group, specially when the pericranial points were stimulated. The P2 wave amplitude was correlated with TTS levels and anxiety scores. The results of this study confirm that pericranial tenderness is a phenomenon initiating a self-sustaining circuit, involving central sensitization at the level of the cortical nociceptive areas devoted to attentional and emotional components of pain.

Patterns of experimentally induced pain in pericranial muscles

Nociceptive mechanisms in the craniofacial muscle tissue are poorly understood. The pain pattern in individual pericranial muscles has not been described before. Experimental muscle pain was induced by standardized infusions of 0.2 ml 1 m hypertonic saline into six craniofacial muscles (masseter, anterior temporalis, posterior temporalis, trapezius, splenius capitis and sternocleidomastoid) in 20 healthy subjects. The pressure pain thresholds (PPTs) were determined before and after infusions. The subjects continuously reported intensity of saline-induced pain on an electronic visual analogue scale (VAS) and the perceived area of pain was drawn on anatomical maps. The pain areas were measured and the localization determined by a new centre-of-gravity method. The PPTs were lowest on the sternocleidomastoid muscle (anova: P<0.001), but the saline-evoked VAS pain scored highest following injection into the masseter muscle (anova: P<0.05). The centre-of-gravity measures demonstrated significantly different localization of the pain areas (anova: P<0.001). The trigeminally vs. the cervically innervated muscles had significantly different patterns of spread and referral of pain according to trigeminally vs. cervically innervated dermatomes (P<0.005). In conclusion, there appear to be characteristic pain patterns and pain sensitivity in different craniofacial muscles in healthy volunteers, which may be of importance for further research on different craniofacial pain conditions.

Noise as a Trigger for Headaches: Relationship Between Exposure and Sensitivity

OBJECTIVE

This study investigated how triggers acquire the capacity to precipitate headaches.

BACKGROUND

Traditional clinical advice is that the best way to prevent headache/migraine is to avoid the triggers. Avoidance of anxiety-eliciting stimuli, however, results in sensitization to the stimuli, so is there a danger that avoidance of migraine/headache triggers results in decreased tolerance for the triggers?

DESIGN

One hundred and fifty subjects, 60 of whom suffered from regular headaches, were randomly assigned to 5 experimental conditions, defined by length of exposure to the headache trigger of noise.

METHODS

Subjects attended a laboratory session divided into 3 phases: preintervention test, intervention (1 of 5 levels of exposure to the trigger), and postintervention test. Response to the intervention was measured in terms of noise tolerance, sensitivity to noise, and nociceptive response to noise.

RESULTS

A curvilinear relationship was found between length of exposure to the trigger and pain response for individuals who do not suffer from regular headaches, that is, short exposure was associated with sensitization and prolonged exposure with desensitization. The relationship for headache patients was less clear.

CONCLUSIONS

The findings are consistent with the proposition that 1 etiological pathway to suffering from frequent headaches is via trying to avoid, or escape from, potential trigger factors. These results suggest that the traditional clinical advice to headache patients, that the best way to prevent migraine/headache is to avoid the triggers, runs the risk of establishing an insidious sensitization process thereby increasing headache frequency.

Intra-oral orthosis vs amitriptyline in chronic tension-type headache: a clinical and laser evoked potentials study

BACKGROUND

In the present study, we examined clinical and laser-evoked potentials (LEP) features in two groups of chronic tension-type headache (CTTH) patients treated with two different approaches: intra-oral appliance of prosthesis, aiming to reduce muscular tenderness, and 10 mg daily amitriptyline.

METHODS

Eighteen patients with diagnosed CTTH participated in this open label, controlled study. A baseline evaluation was performed for clinical features, Total Tenderness Score (TTS) and a topographic analysis of LEPs obtained manually and the pericranial points stimulation in all patients vs. healthy subjects. Thereafter, patients were randomly assigned to a two-month treatment by either amitriptyline or intra-oral appliance.

RESULTS AND DISCUSSION

Both the intra-oral appliance and amitriptyline significantly reduced headache frequency. The TTS was significantly reduced in the group treated with the appliance. The amplitude of P2 response elicited by stimulation of pericranial zones showed a reduction after amitriptyline treatment.Both therapies were effective in reducing headache severity, the appliance with a prevalent action on the pericranial muscular tenderness, amitriptyline reducing the activity of the central cortical structures subtending pain elaboration

CONCLUSION

The results of this study may suggest that in CTTH both the interventions at the peripheral and central levels improve the outcome of headache.

Effects of Noise and a Stressor on Head Pain

OBJECTIVE

Can causal relationships be established between negative affect (NA) and headaches, and noise (N) and headaches? Do NA and N interact to cause headaches? Do NA and N cause headaches by means of the same or different physiological mechanisms? Are the answers to these questions a function of diagnostic status?

BACKGROUND

A functional model of chronic headaches has been proposed that seeks to understand the variance in headaches by focusing on the controlling variables, that is, the antecedents and consequences. This study is one in a series investigating the immediate antecedents of headaches, namely the trigger factors.

DESIGN

Twenty-four subjects with migraine and 44 subjects with tension-type headache were randomly assigned to one of four experimental conditions defined by the presence or absence of two antecedent challenges, a stressor (S) designed to induce NA and N.

METHODS

The S challenge consisted of difficult-to-solve anagrams accompanied by failure feedback. The N challenge consisted of 50 dB of white N. Laboratory sessions were divided into adaptation, baseline, challenge, and recovery phases. Responses were measured in terms of headache intensity ratings, forehead electromyographic activity, heart rate, blood pressure, and temporal pulse amplitude (TPA).

RESULTS AND CONCLUSIONS

Both NA and N precipitated headaches. These two factors did not interact in triggering headaches. Headaches induced by N were associated with elevated TPA but headaches induced by NA were not associated with significant physiological changes. Diagnosis was not related to any of the outcomes.

Long-term potentiation of orofacial sensorimotor processing by noxious input from the semispinal neck muscle in mice

Tension-type headache is the most common type of primary headaches but no conclusive concept of pathophysiology exists. This may be due to a lack of an appropriate animal model. This study addressed the hypothesis that noxious neck muscle input induces central sensitization of orofacial sensorimotor processing. The effect of hypertonic saline injection into the semispinal neck muscle on the jaw-opening reflex (JOR) was investigated in anaesthetized mice (n = 11). Hypertonic saline injection into the neck muscle facilitated the JOR for at least one hour: integral (+94.5%) and duration (+18.7%) increased, latency decreased (-7.5%). The reflex threshold decreased to 61% after injection. Isotonic saline injection into the neck muscle (n = 11) or hypertonic saline injection into a hindpaw muscle (n = 10) did neither change the reflex integral nor the threshold. Long-term potentiation of the JOR by noxious neck muscle input may be an appropriate model to investigate tension-type headache pathophysiology.

New developments in the pharmacotherapy of tension-type headaches

The first International Headache Society classification defined tension-type headaches (TTHs) by itemising those characteristics of migraines TTHs did not possess [1]. As a result, TTHs, both episodic and chronic, remain the most nonspecific of all the commonly observed primary headaches. Until recently, there has been little impetus on the part of the pharmaceutical industry to investigate TTHs; many of the potentially useful drugs are now generic and unprofitable. In addition, few investigators have pursued the study of TTHs in lieu of its more glamorous neighbour, migraine. As a result, there are few well-designed studies on the pharmacotherapy of TTHs. The few studies that exist support the use of age-old standard drug classes, the tricyclic antidepressants and the NSAIDs. New research is now emerging that points to the potential utility of botulinum toxin type A, NMDA-receptor antagonists including Mg(2+) and nitric oxide synthase inhibitors. More scientifically rigorous clinical studies are needed.

Nerve growth factor injection into semispinal neck muscle evokes sustained facilitation of the jaw-opening reflex in anesthetized mice?possible implications for tension-type headache

Nociceptive input from neck muscles probably plays a role in the pathophysiology of tension-type headache. In order to elaborate an animal model, the impact of noxious input from neck muscles on orofacial sensorimotor processing was investigated by electrophysiological means in anesthetized mice. Group IV muscle afferents of the semispinal neck muscle were excited by local injection of nerve growth factor (NGF, 0.8 microM, 20 microl). Orofacial sensorimotor processing was monitored by the jaw-opening reflex (JOR) elicited by electric tongue stimulation. After unilateral NGF injection into the right neck muscle (n = 10), JOR integral (+89%) and duration (+9%) increased and latency decreased (-5%) for at least 1 h. Bilateral injection of NGF (n = 10) into neck muscles induced an increase of JOR integral (+111%) and duration (+20%) and a reduction of latency (-9%). This facilitation of the JOR lasted for at least 90 min without any downward drift (n = 5). Electric JOR threshold diminished after NGF injection. After intramuscular injection of isotonic saline into the right semispinal neck muscle (20 microl), the JOR remained unchanged (n = 10). Local NGF injection into neck muscles evoked noxious input to the brainstem that induced a sustained central facilitation of the JOR for more than 1 h. This long-term facilitation of orofacial sensorimotor processing by a singular NGF injection possibly reflects plastic changes of nociceptive synaptic processing that may be involved in the pathophysiology of headache.

Temperament and character profiles of patients with tension-type headache and migraine

The aim of this present study was to evaluate the temperament and character profiles of persons with tension-type headache (TTH) and migraine, and to compare the results with those of healthy controls. The study population consisted of 81 patients with TTH (60 female, 21 male) and 56 patients with migraine (34 female, 17 male) aged 18-50 years, according to the criteria of the International Headache Society with age and gender - matched healthy control subjects (54 female, 28 male). All participants were instructed to complete a self-administered 240-item temperament and character inventory (TCI) questionnaire and Beck Depression Inventory (BDI). The TCI assesses four dimensions of temperament, namely, novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (P), and three dimensions of character, being self-directedness (SD), cooperativeness (C) and self-transcendence (ST). According to the TCI biosocial model, the temperament dimension HA is suggested to indicate central serotonergic turnover, which is further correlated with depressive state. It was found that mean BDI scores were significantly higher in patients with TTH and migraine than in those of the controls. The BDI scores were positively correlated with HA scores (r = 0.295, P < 0.001) and negatively correlated with SD (r = -0.386, P < 0.001) and C scores (r = -0.164, P= 0.016). Multivariate analysis showed that BDI scores had significant covariation for HA, SD and C. Despite using the BDI score as a covariate, TTH patients had higher HA scores (P = 0.01) than did the control subjects. No significant differences were found between the groups regarding main NS, RD, P, SD, C and ST scores. Based on the main results of this study, it is suggested that higher serotonergic activity related to HA scores in TTH patients and their relationship with depressive symptomatology supports the role of central serotonergic involvement in TTH.

Sintomas depressivos e ansiedade em pacientes com cefaléia do tipo tensional crônica e episódica

INTRODUÇÃO: A cefaléia do tipo tensional (CTT), dor cefálica mais comum, tem mecanismos fisiopatológicos, epidemiologia e apresentação clínica pouco estudados. Depressão e ansiedade são comorbidades especialmente enfocadas entre seus portadores. OBJETIVO: Estudar a ocorrência de sintomas depressivos e ansiedade entre portadores de CTT episódica (CTTE) e crônica (CTTC). METODOLOGIA: Cinqüenta pacientes com CTTE e cinqüenta com CTTC preencheram os inventários de depressão e de ansiedade de Beck. Somente foram considerados aqueles com escores moderado ou grave. RESULTADOS: Entre portadores de CTTE, ansiedade e sintomas depressivos foram encontrados em 60 e 32 % dos pacientes, respectivamente. Em pacientes com CTTC, ansiedade foi detectada em 44 % e sintomas depressivos foram observados em 40 % da amostra. CONCLUSÃO: ambas as comorbidades são importantes em pacientes com CTT. Negligenciá-las significa risco de falência no tratamento, contribuindo para queda na qualidade de vida .