Tension-type headache and systemic medical disorders

Trigger Point Therapy Techniques as an Effective Unconventional Method of Treating Tension Headaches: A Systematic Review

Background/Objectives The main aim of the literature review was to determine whether different trigger point therapy techniques are effective in decreasing the intensity, frequency, and duration of tension-type headaches. An additional aim was to assess the impact of trigger point therapy on other physical and psychological variables in tension-type headaches. Methods This literature review was conducted in accordance with PRISMA guidelines, and the inclusion and exclusion criteria were developed using the PICO(s) strategy. Searches were carried out in four databases: PubMed, Science Direct, Cochrane Library, and PEDro. Results Of the 9 included studies with 370 participants, 6 studies were randomised controlled trials, 2 were pilot studies, and 1 was a case report. Conclusions Trigger point therapy has reduced the duration, intensity, and frequency of headaches. Dry needling, ischaemic compression, Positional Relaxation Techniques, and massage protocols focused on deactivating trigger points are effective methods of unconventional treatment of tension-type headaches.

Research Progress on the Experimental Model and Underlying Mechanistic Studies of Tension-Type Headaches

PURPOSE OF REVIEW

Tension-type headaches (TTH) significantly diminish patients' quality of life and increase absenteeism, thereby imposing a substantial economic burden. Animal models are essential tools for studying disease mechanisms and drug development. However, until now, little focus has been placed on summarizing the animal models of TTH and associated mechanistic studies. This narrative review discusses the current animal models of TTH and related mechanistic studies to provide insights into the pathophysiological mechanisms of and treatments for TTH.

RECENT FINDINGS

The primary method for constructing an animal model of TTH involves injecting a solution of pain relievers, such as adenosine triphosphate, nerve growth factor, or a high concentration of salt solution, into the neck to initiate harmful cervical muscle responses. This model enables the examination of the interaction between peripheral muscles and central sensitization, which is crucial for understanding the pathophysiology of TTH. Mechanistic studies based on this model have investigated the effect of the P2X receptor antagonist, P2X7 receptor blockade, the P2Y1 receptor agonist 2-MESADP, P2Y1 receptor antagonist MRS2179, nitric oxide synthase inhibitors, and acetylsalicylic acid. Despite notable advancements, the current model of TTH has limitations, including surgical complexity and the inability to replicate chronic tension-type headache (CTTH). To gain a more comprehensive understanding and develop more effective treatment methods, future studies should focus on simplifying surgical procedures, examining other predisposing factors, and establishing a model for chronic TTH. This will offer a deeper insight into the pathophysiological mechanism of TTH and pave the way for improved treatment approaches.

The Effect of Flunarizine Prophylactic Treatment on Headache Frequency and Plasma Glutamate Levels in Chronic Tension-type Headache Patients

Background: Previous research has shown that flunarizine may be used for the prophylactic treatment of migraine and that plasma glutamate level monitoring in patients with migraine can serve as a biomarker of response to treatment. Our aim was to assess the efficacy of flunarizine and the correlation of glutamate levels in Chronic Tension-type Headache (CTTH) with response to medication. Methods: We studied 19 patients with diagnosis of CTTH according to International Classification of Headache Disorder, 2nd edition criteria. The level of plasma glutamate was measured before and after 8-weeks prophylactic treatments. Subjects were randomized into three interventional groups (flunarizine 5 mg, flunarizine 10 mg and placebo). Glutamate levels were measured by means of Glutamate ELISA Kit KA1909 Abnova.        Results: Flunarizine 5 mg group had lower mean plasma glutamate levels significantly compared to placebo (p < 0.00; 95% CI: 0.40-1.07). Flunarizine 10 mg group had lower mean of plasma glutamate levels significantly compared to placebo (p< 0.00; 95% CI: 0.53-1.27). However, there were no significant differences of mean plasma glutamate levels between flunarizine 5 mg group and flunarizine 10 mg group (p < 0.37; 95% CI: -(0.54) - 0.21). There were no significant differences in headache frequency reduction among the three interventional groups. Conclusions: The usage of flunarizine as prophylactic treatment can reduce plasma glutamate levels significantly in CTTH patients. Either flunarizine or placebo showed no significant difference in reducing headache frequency in CTTH patients.

Hypertension and Headache: the Effect of Antihypertensive Drugs

Headache is considered to be one of the main symptoms of arterial hypertension (HT). Complaints of headache are presented by many patients with HT: from 44% to 87%. It is obvious that the majority of complaints of headache in patients with HT is not due to headaches due to increased blood pressure (BP), but multimorbidity (polymorbidity) – the presence of coexisting primary headaches, most often, as in the population as a whole, chronic tension headache (57-85%) and migraine (15-30%). On the other hand, the frequency of HT in patients with migraine ranges from 32% to 44%. The relationship between migraine and HT may be due to common exogenous (external) and endogenous (genetic) factors, as well as common pathophysiological mechanisms. External risk factors, which can be associated with both migraine and HT, include the nature of the diet (excessive consumption of table salt with food), low physical activity, chronic stress; both diseases are also associated with the presence of a connection with the metabolic syndrome. The role of hyperactivation of the renin-angiotensin-aldosterone and adrenergic system and endothelial dysfunction are actively discussed. Angiotensin-converting enzyme takes an active part in the BP control and vascular tone; it is known that some angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) have demonstrated efficacy in preventing migraine attacks. The presence of HT can contribute to the chronic course of primary headache, and effective treatment of HT with antihypertensive drugs, on the contrary, can have a positive effect on the course of primary headaches. Antihypertensive drugs reduce the frequency of headaches compared to placebo, but heterogeneity between different classes was revealed. There was a statistically significant decrease in the frequency of headaches compared to placebo during treatment with beta-blockers, ACEI, ARB, diuretics, while calcium antagonists did not reduce the frequency of headaches. According to a number of studies, the frequency of headaches during the treatment with ARB (candesartan) is comparable to that in the placebo group. Some antihypertensive drugs are used to prevent migraine attacks.

Increased risk of Parkinson's disease following tension-type headache: a nationwide population-based cohort study

PURPOSE

Previous studies have suggested associations between primary headache and neurodegenerative diseases; however, the relationship between tension-type headache (TTH), which is the most common type of primary headache, and Parkinson's disease (PD) remains controversial. Hence, in this nationwide, population-based, retrospective cohort study, we explored the temporal association between TTH and PD.

METHODS

Using claims data in the National Health Insurance Research Database of Taiwan, we evaluated 12,309 subjects aged ≥20 years who were newly diagnosed with TTH from 2000 to 2005. The non-TTH group included 49,236 randomly selected sex- and age-matched patients without TTH. Subjects were followed up until the end of 2011, diagnosis of PD, or death. The incidence of PD was compared between the two groups. A Cox multivariable proportional hazards model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) to estimate the risk of PD.

RESULTS

The overall incidence of PD (per 1,000 person-years) in the TTH and non-TTH groups was 3.01 and 1.68, respectively. After adjustment for sex, age, and comorbidities, the association between TTH and PD remained statistically significant (adjusted HR = 1.37, 95% CI = 1.19-1.57). The TTH group had a higher risk of PD than the non-TTH group did, regardless of subjects' sex, age, and comorbidity status.

CONCLUSIONS

These findings demonstrate that patients diagnosed with TTH exhibit an increased risk of PD. Additional studies should investigate the potential shared pathophysiological mechanisms of TTH and PD. Clinicians should be aware that TTH is a potential risk factor for PD.

Effect of Flunarizine on Serum Glutamate Levels and its Correlation with Headache Intensity in Chronic Tension-Type Headache Patients

BACKGROUND

Some of the excitatory neurotransmitters including glutamate have been suggested to be involved in headache pathophysiology. To our knowledge, there is a lack of publication about flunarizine efficacy in chronic tension-type headache (CTTH) treatments and the roles of glutamate in CTTH pathophysiology.

AIM

This study aimed to investigate the flunarizine effect on serum levels of glutamate and its correlation with headache intensity based on the Numeric Rating Scale for pain (NRS) scores in CTTH patients.

METHOD

In a prospective randomised, double-blind study with pre and post-test design, seventy-three CTTH patients were randomly allocated with flunarizine 5 mg, flunarizine 10 mg and amitriptyline 12.5 mg groups. The serum levels of glutamate and NRS scores were measured before and after 15-day treatment.

RESULTS

Flunarizine 5 mg was more effective than flunarizine 10 mg and amitriptyline 12.5 mg in reducing serum glutamate levels, whereas amitriptyline 12.5 mg was the most effective in reducing headache intensity. There was found nonsignificant, but very weak negative correlation between headache intensity and serum glutamate levels after flunarizine 5 mg administration (r = -0.062; P = 0.385), nonsignificant very weak negative correlation after flunarizine 10 mg administration (r = -0.007; P = 0.488) and there was found a significant moderate positive correlation (r = 0.508; P = 0.007) between headache intensity and serum glutamate levels after amitriptyline 12.5 mg administration.

CONCLUSION

Since there was no significant correlation found between serum glutamate and headache intensity after treatment with flunarizine, it is suggested that decreasing of headache intensity after flunarizine treatment occurred not through glutamate pathways in CTTH patients.

Comorbidity of gastrointestinal disorders, migraine, and tension-type headache: a cross-sectional study in Iran

Migraine can be accompanied by some gastrointestinal (GI) disorders. In this study, we aimed to investigate the relationship between migraine and tension-type headache (TTH) and different lower and upper GI disorders as well as non-alcoholic fatty liver (NAFLD) and cholelithiasis. This cross-sectional study included 1574 overweight and obese participants who were referred to the Obesity Research Center of Sina Hospital, Tehran, Iran. The diagnosis of migraine and TTH was made by an expert neurologist based on the international classification of headache disorders-III β (ICHD III β). GI disorders, including irritable bowel syndrome (IBS), constipation, heartburn, dyspepsia, non-alcoholic fatty liver (NAFLD), and cholelithiasis, were diagnosed by a gastroenterology specialist. The overall mean age of participants was 37.44 ± 12.62. A total of 181 (11.5%) migraine sufferers (with and without aura) and 78 (5%) TTH subjects were diagnosed. After adjusting for potential confounders by multivariable regression models, migraine had significant association with IBS (OR = 5.16, 95% CI = 2.07-12.85, P = 0.000), constipation (OR = 3.96, 95% CI = 2.25-6.99, P = 0.000), dyspepsia (OR = 4.12, 95% CI = 2.63-6.45, P = 0.000), and heartburn (OR = 5.03, 95% CI 2.45-10.33, P = 0.000), while the association between migraine and NAFLD was marginally significant (OR = 2.03, 95% CI = 0.98-4.21, P = 0.055). Furthermore, the prevalence of NAFLD (OR = 2.93, 95% CI 1.29-6.65, P = 0.010) and dyspepsia (OR = 4.06, 95% CI = 2.24-7.34, P = 0.000) was significantly higher in TTH patients than the headache-free group. These findings show an association between GI disorders and primary headaches especially migraine and are, therefore, of value to the management of migraine and TTH. Further studies should investigate the etiology of the relationship between all subtypes of primary headaches and GI disorders.

Relationship of the Lateral Rectus Muscle, the Supraorbital Nerve, and Binocular Coordination with Episodic Tension-Type Headaches Frequently Associated with Visual Effort

Objective

To study the relationship between tension-type headaches and the oculomotor system in terms of binocular coordination, mechanosensitivity of the supraorbital nerve, and myofascial trigger points in the lateral rectus muscle, assessing the influence of visual effort caused by using a computer at work.

Design

Observational study with blind evaluation of the response variable.

Methods

Two groups were compared: 19 subjects with tension-type headaches and 16 healthy subjects, both exposed to computer use at work. A blinded assessor conducted three tests: measurement of the supraorbital nerve pressure pain threshold using a pressure algometer, evaluation of myofascial trigger points of the lateral rectus using the verbal numerical scale, and assessment of binocular coordination in smooth pursuit eye movements using an innovative video-oculography system. Tests were performed before work began and four hours later, and subjects in the headache group were examined when they presented a headache score of less than or equal to 3 on the verbal numerical scale.

Results

The headache group presented a greater sensitivity of the supraorbital nerve and greater local and referred pain of the lateral rectus ( P  < 0.05). Visual effort caused a significant worsening of these variables in both groups. However, binocular coordination after visual effort was only significantly affected in the headache group ( P  < 0.05), primarily in horizontal movements.

Conclusions

The finding of a higher alteration of the sensitivity of the supraorbital nerve, the myofascial trigger points of the lateral rectus, binocular coordination, and the significant influence of visual effort in patients with tension-type headaches suggest a new clinical perspective for problems related to tension-type headaches.

Increased Risk of Dementia in Patients with Tension-Type Headache: A Nationwide Retrospective Population-Based Cohort Study

PURPOSE

The association between primary headaches, including tension-type headache (TTH) as one of the most common primary headache disorders, and dementia remains controversial. In this nationwide, population-based, retrospective, cohort study, we explored the potential association between TTH and dementia and examined sex, age, and comorbidities as risk factors for dementia.

METHODS

Using the Taiwan National Health Insurance Research Database (NHIRD) claims data, the sample included 13908 subjects aged ≥20 years with newly-diagnosed TTH in 2000-2006. The non-TTH group included 55632 randomly selected sex- and age-matched TTH-free individuals. All subjects were followed until dementia diagnosis, death, or the end of 2011. Patients with dementia, including vascular and non-vascular (including Alzheimer's) subtypes, were identified using International Classification of Diseases Ninth Revision, Clinical Modification codes. Multivariate Cox proportional hazards regression models were used to assess the risk of dementia and dementia-associated risk factors, such as migraine and other medical comorbidities.

RESULTS

During the average follow-up of 8.14 years, the incidence density rates of dementia were 5.30 and 3.68/1,000 person-years in the TTH and non-TTH groups, respectively. Compared with the non-TTH group, the risks of dementia were 1.25 (95% confidence interval [CI], 1.11-1.42) and 1.13 (95% CI, 1.01-1.27) times higher in the women and >65-year-old TTH group, respectively. TTH patients with comorbidities had a higher risk of dementia. TTH patients had a greater risk of non-vascular dementia (hazard ratio, 1.21; 95% CI, 1.09-1.34) than the non-TTH group.

CONCLUSION

TTH patients have a future risk of dementia, indicating a potentially linked disease pathophysiology that warrants further study. The association between TTH and dementia is greater in women, older adults, and with comorbidities. Clinicians should be aware of potential dementia comorbidity in TTH patients.

Impact of migraine on fibromyalgia symptoms

BACKGROUND

Fibromyalgia (FMS) and high frequency episodic/chronic migraine (M) very frequently co-occur, suggesting common pathophysiological mechanisms; both conditions display generalized somatic hyperalgesia. In FMS-M comorbidity we assessed if: a different level of hyperalgesia is present compared to one condition only; hyperalgesia is a function of migraine frequency; migraine attacks trigger FMS symptoms.

METHODS

Female patients with fibromyalgia (FMS)(n.40), high frequency episodic migraine (M1)(n.41), chronic migraine (M2)(n.40), FMS + M1 (n.42) and FMS + M2 (n.40) underwent recording of: -electrical pain thresholds in skin, subcutis and muscle and pressure pain thresholds in control sites, -pressure pain thresholds in tender points (TePs), -number of monthly migraine attacks and fibromyalgia flares (3-month diary). Migraine and FMS parameters were evaluated before and after migraine prophylaxis, or no prophylaxis, for 3 months with calcium-channel blockers, in two further FMS + H1 groups (n.49, n.39). 1-way ANOVA was applied to test trends among groups, Student's t-test for paired samples was used to compare pre and post-treatment values.

RESULTS

The lowest electrical and pressure thresholds at all sites and tissues were found in FMS + M2, followed by FMS + H1, FMS, M2 and M1 (trend: p < 0.0001). FMS monthly flares were progressively higher in FMS, FMS + M1 and FMS + M2 (p < 0.0001); most flares (86-87 %) occurred within 12 h from a migraine attack in co-morbid patients (p < 0.0001). Effective migraine prophylaxis vs no prophylaxis also produced a significant improvement of FMS symptoms (decreased monthly flares, increased pain thresholds)(0.0001 < p < 0.003).

CONCLUSIONS

Co-morbidity between fibromyalgia and migraine involves heightened somatic hyperalgesia compared to one condition only. Increased migraine frequency - with shift towards chronicity - enhances both hyperalgesia and spontaneous FMS pain, which is reversed by effective migraine prophylaxis. These results suggest different levels of central sensitization in patients with migraine, fibromyalgia or both conditions and a role for migraine as a triggering factor for FMS.

Reduced serum levels of adiponectin in tension-type headache

BACKGROUND AND OBJECTIVES

Inflammatory mediators have been studied in tension type headache (TTH) pathophysiology; however, their role is not yet well established. The aim of the present study was to investigate adiponectin (ADP) and its association with clinical parameters and psychiatric comorbidities in TTH patients.

METHODS

This was a cross sectional study including TTH patients and controls. Beck Depression (BDI) and Anxiety (BAI) Inventories, and Headache Impact Test (HIT-6) were recorded. Serum levels of ADP were measured by ELISA.

RESULTS

Forty-eight TTH patients and forty-eight controls without headache were enrolled in the study. ADP levels were significantly lower among patients with TTH [31.1 (20.4-69.20) versus 37.8 (24.9-71.4) ng/mL (P=0.008)]. ADP levels were not influenced by BDI and BAI scores, body mass index (BMI), or HIT-6.

CONCLUSION

ADP levels were reduced in TTH, independently of psychiatric comorbidities, BMI, and headache impact.

Headache and facial pain: differential diagnosis and treatment

Headaches affect 90% of the population sometime during their life. Most are benign and fleeting, some are serious and life-threatening, and others require ongoing medical consultation and treatment. A careful history and physical is necessary to establish a differential diagnosis and to guide the choice of testing to make an accurate diagnosis. The most common types of headaches are discussed in this review. They are divided into primary and secondary headache disorders as classified by the International Headache Society. Primary headache disorders include migraine without and with aura, cluster and tension-type headaches. Secondary headaches are those that occur as a result of some other disorder and include brain tumors, rhinosinusitis, diseases of intracranial and extracranial vasculature, and temporomandibular joint disease.

Triggers of migraine and tension-type headache in China: a clinic-based survey

BACKGROUND AND PURPOSE

Identification of the trigger factors of headache could be an important aspect of preventive management, but the characteristics of primary headache triggers in China are unknown. This study was performed to estimate the frequencies of the putative headache triggers, which are endorsed by patients with migraine and tension-type headache (TTH).

METHODS

From July 2011 to December 2011, a cross-sectional survey was conducted in the neurological clinic of a tertiary care hospital in Chongqing. All consecutive patients with the chief complaint of headache were interviewed by a board-certified headache specialist. The diagnoses were made according to International Classification of Headache Disorders - 2nd edition. Patients with migraine and TTH were recruited.

RESULTS

The number of investigated patients was 1219, of whom 394 were migraine and 344 were TTH; and 80.2% migraineurs and 67.4% TTH patients reported trigger factors. The most common triggers for both migraine and TTH were sleep disturbance, negative affect and sunlight. Menstrual cycle (OR 3.6, 95%CI 1.2, 11.2), change of the weather (OR 3.1, 95%CI 1.9, 4.8), noise (OR 2.2, 95%CI 1.1, 4.4) and alcohol (OR 1.8, 95%CI 0.7, 1.8) were more associated with migraineurs. Negative affect was more associated with TTH (OR 2.0, 95%CI 1.3, 2.9).

CONCLUSIONS

Trigger factors were frequent among both migraine and TTH patients. Avoidance of all headache triggers is impractical. Learning to cope with triggers is important to headache prevention.

Tension-type headache

PURPOSE OF REVIEW

This article provides an update on the appropriate diagnosis and evaluation of patients with tension-type headache, with reviews of the latest concepts regarding pathogenesis and the evidence-based recommendations for management of this disorder.

RECENT FINDINGS

Pericranial myofascial mechanisms are probably of importance in episodic tension-type headache, whereas sensitization of central nociceptive pathways and inadequate endogenous antinociceptive circuitry seem to be more relevant in chronic tension-type headache. While acute treatment with simple analgesics is generally helpful, recent data attempting to document the efficacy of preventive therapies are unconvincing.

SUMMARY

Tension-type headache is the most common form of headache in the general population. It is characterized by recurrent episodes of headache that are relatively featureless and mild to moderate in intensity. The diagnosis is based solely on the history and examination. Exclusion of secondary headaches or forms of migraine is important in the assessment process. Despite extensive investigation, the underlying pathophysiology remains a matter of speculation, with peripheral muscular and CNS components both likely involved. Acute management with simple analgesics, nonsteroidal anti-inflammatory drugs, and caffeine-containing compounds is typically effective. Preventive therapies include a number of nonpharmacologic recommendations as well as several antidepressant drugs. Prognosis is generally favorable.