Update of chronic tension-type headache

Facial recognition, laterality judgement, alexithymia and resulting central nervous system adaptations in chronic primary headache and facial pain-A systematic review and meta-analysis

INTRODUCTION

Patients with chronic headaches and chronic oro-facial pain commonly present psychosocial issues that can affect social interactions. A possible reason could be that patients with these disorders might present impairments in facial recognition, laterality judgement and also alexithymia. However, a systematic review summarizing the effects of facial emotion recognition, laterality judgement and alexithymia in individuals with headaches and oro-facial pain is still not available.

AIM

The main objective of this systematic review (SR) and meta-analysis (MA) was to compile and synthesize the evidence on the occurrence of alexithymia, deficits in laterality or left-right (LR) recognition and/or facial emotion recognition (FER) in patients with chronic headache and facial pain.

METHODS

Electronic searches were conducted in five databases (up to September 2023) and a manual search to identify relevant studies. The outcomes of interest were alexithymia scores, speed and accuracy in LR and/or FER, or any other quantitative data assessing body image distortions. The screening process, data extraction, risk of bias and data analysis were performed by two independent assessors following standards for systematic reviews.

RESULTS

From 1395 manuscripts found, only 34 studies met the criteria. The overall quality/certainty of the evidence was very low. Although the results should be interpreted carefully, individuals with chronic headaches showed significantly higher levels of alexithymia when compared to healthy individuals. No conclusive results were found for the other variables of interest.

CONCLUSION

Although the overall evidence from this review is very low, people with chronic primary headaches and oro-facial pain could be regularly screened for alexithymia to guarantee appropriate management.

Multimodal treatment, including extracorporeal shock wave therapy, for refractory chronic tension-type headache: a case report

BACKGROUND

Few reports have described multidisciplinary treatment, including extracorporeal shock wave therapy, for patients with refractory chronic tension-type headache. In this study, we conducted multidisciplinary treatment for a patient with chronic tension-type headache who suffered from chronic headache refractory to treatment.

CASE PRESENTATION

The patient was a 45-year-old Japanese male suffering from 20 years of headache. As his headache had worsened recently, he visited a local clinic. With the diagnosis of suspected tension-type headache, its treatment was unsuccessful and he was referred to our hospital. The neurology department confirmed the tension-type headache and prescribed another medication, but he showed no improvement. Then, the patient was referred to the rehabilitation medicine department for consultation. At the initial visit, we identified multiple myofascial trigger points in his bilateral posterior neck and upper back regions. At the initial visit, he was prescribed 10 mL of 1% lidocaine injected into the muscles in these areas. In addition, he received 2000 extracorporeal shock wave therapy into bilateral trapezius muscles, and was instructed to take oral Kakkonto extract granules, benfotiamine, pyridoxine hydrochloride, and cyanocobalamin. Cervical muscle and shoulder girdle stretches and exercises were also recommended. At follow-up treatment visits, we used extracorporeal shock wave therapy to bilateral trapezius muscles, which led to immediate pain relief. After 11 weeks, he was not taking any medication and his headache was subjectively improved and his medical treatment ended.

CONCLUSION

A patient with chronic tension-type headache refractory to regular treatment was successfully treated with a multimodal approach including extracorporeal shock wave therapy in addition to standard treatment. For patients with tension-type headache accompanied by myofascial trigger points, it may be recommended to promptly consider aggressive multimodal treatment that includes extracorporeal shock wave therapy.

A Bibliometric Analysis of Acupuncture Treatment of Tension-Type Headache from 2003 to 2022

Background

Acupuncture therapy is a unique technology created by the working people in ancient China. It is popular all over the world for its safety, effectiveness and no side effects, especially for the treatment of pain syndrome, it can often have an immediate effect. Tension-type headache is one of them. At present, many literatures have reported that many countries in the world are using acupuncture to treat tension-type headache, but there is no quantitative analysis of the relevant literature on this field. Therefore, This study aims to evaluate the research hotspots and trends of acupuncture treatment of tension-type headache through a macro review of the literature from 2003 to 2022 by using CiteSpace V6.1.R6 (64-bit) Basic.

Methods

Relevant literatures on acupuncture treatment of tension-type headache from 2003 to 2022 were extracted from the web of science core collection database. CiteSpace was used to analyze the data of publications, authors, institutions, countries, keywords and cited references, cited authors, cited journals. Draw the cited network map and analyze the research hotspots and trends.

Results

A total of 231 publications were retrieved from 2003 to 2022. In the past 20 years, the annual number of publications has shown an overall growth trend, and the most active journals, countries, institutions, authors, cite references and keywords in the field of acupuncture treatment of tension-type headache were identified.

Conclusion

This study provides the status and trends of clinical research in the field of acupuncture therapy for tension-type headache in the past 20 years, which will help researchers understand the research hotspots in this field and provide new directions for further research.

A Pilot Analysis on the Efficacy of Multiple Trigger-Point Saline Injections in Chronic Tension-Type Headache: A Retrospective Observational Study

This study aimed to investigate the efficacy of new targeted trigger-point injections (TPIs) using isotonic saline in patients with chronic tension-type headache (CTTH). Of 121 patients with headache who were retrospectively reviewed, 19 were included in this study and were categorized into two groups: those who received TPIs more than four times (group 1); and those who received TPIs less than, or equal to, four times (group 2). The patients received ultrasound-guided isotonic saline injections into the active trigger points once weekly. The primary outcome was an effect on headache intensity, determined using the visual analog scale (VAS), whereas the secondary outcome was an effect on quality of life, evaluated using the Henry Ford Hospital Headache Disability Inventory (HDI). The mean symptom duration of the 19 patients (11 men and 8 women; mean age, 52.5 years; and range, 23−81 years) was 16 months. The most frequently injected muscle was the splenius capitis. Patient demographics were similar between the two groups (p > 0.05). Simple linear regression revealed that symptom duration (p = 0.001) and baseline VAS score (p = 0.009) were significantly associated with the number of injections. At one month after the first injection, the mean VAS and HDI scores in group 2 were significantly lower than those in group 1 (p < 0.05), whereas the scores significantly decreased immediately after the last injection in both groups (p < 0.05). No adverse effects were reported in any patient. Our results indicate that the administration of new targeted TPIs using isotonic saline into the head and neck muscles of patients with CTTH can effectively relieve headache intensity and safely improve their quality of life.

Chronic Pain: Clinical Updates and Perspectives

The International Association for the Study of Pain (IASP) has defined pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, which also comprises a subjective component [...].

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.

The Effect of Hamstring Relaxation Program on Headache, Pressure Pain Threshold, and Range of Motion in Patients with Tension Headache: A Randomized Controlled Trial

The purpose of this study was to determine if the severity of headache is reduced by decreasing hamstring tension in patients with tension headache. Thirty patients participated in this study. The participants were randomly allocated to two groups: hamstring relaxation program (HR) group (n = 15) and control group (n = 15). The participants in the HR group participated in a HR program for 25 min per day, three times per week, for a period of 4 weeks, and the control group participated in an electrotherapy for 25 min per day, three times per week, for a period of 4 weeks. Both groups participated in a self-myofacial release for 5 min per day, three times per week, for a period of 4 weeks. Headache was evaluated using the headache impact test (HIT-6) and visual analog scale (VAS). The pain pressure threshold (PPT) was evaluated using a digital pressure algometer. The range of motion (ROM) was evaluated using a goniometer and two special tests: straight leg raise test (SLRT) and popliteal angle test (PAT). The two groups showed no significant differences in terms of age, sex, height, and weight. The VAS and HIT-6 scores (p < 0.05) and neck and hamstring PPT showed significant improvements (p < 0.05). Neck flexion ROM and SLRT and PAT scores showed significant improvements (p < 0.05) in both groups, and the HR group showed significantly more improvements than the control group. This study confirmed that the HR program has positive effects on tension headache and is a good intervention for alleviating headaches in patients with tension headache.

Effectiveness of suboccipital muscle inhibition combined with interferential current in patients with chronic tension-type headache: a randomised controlled clinical trial

INTRODUCTION

Manual therapy has been shown to reduce self-reported symptoms in patients with chronic tension-type headache (CTTH). However, simultaneous application of suboccipital muscle inhibition and interferential current has not previously been investigated. This study evaluates the effectiveness of combined treatment with suboccipital muscle inhibition and interferential current compared to standard treatment for pain, disability, and headache impact in patients with CTTH.

METHODS

Patients were randomly allocated to receive either standard treatment (n = 13) or the experimental treatment (n = 12), consisting of 20 minutes of suboccipital muscle inhibition plus interferential current twice weekly for 4 weeks. The primary outcome was improvement in pain, and secondary outcomes included improvement in headache-related disability and reduction in headache impact, which were assessed at baseline and at 4 weeks by a blinded rater.

RESULTS

Statistical analysis showed improvements in the experimental treatment group at 4 weeks for headache-related disability (Neck Disability Index: Hedges' g = 1.01, P = .001; and Headache Disability Inventory: Hedges' g = 0.48, P = .022) and headache impact (6-item Headache Impact Test: Hedges' g = 0.15, P = .037) but not for self-reported pain (numerical rating scale: Hedges' g = 1.13, P = .18).

CONCLUSIONS

Combined treatment with suboccipital muscle inhibition and interferential current in patients with CTTH did not significantly improve self-reported pain but did reduce disability and the impact of headache on daily life at 4 weeks. These improvements exceed the minimum clinically important difference, demonstrating the clinical relevance of our findings.

Efficacy of cranial microcurrent stimulation in patients with tension-type headache: A prospective, randomised, double-blinded, sham-controlled clinical trial

OBJECTIVE

To investigate the therapeutic effect of cranial microcurrent stimulation (CMS) in patients with tension-type headaches (TTH).

METHODS

This study was designed as a prospective, randomised, double-blinded and sham-controlled trial. A total of 22 patients with tension-type headache were selected as our study participants and randomly assigned into two groups: CMS group (n = 11) and Sham group (n = 11). To each of the participants, a sham or a true portable CMS stimulation device (CMS; intensity, 25 μA; frequency, 8 Hz) to wear was distributed, and 20-minute daily treatment was provided using the device for 2 weeks. In CMS group, treatment was given by means of electrodes clipped to the ear, whereas, in Sham group, sham treatment was provided by CMS without current. The measurements of Visual Analogue Scale (VAS), Headache Impact Test-6 (HIT6), Patient Health Questionnaire-9 (PHQ9), Generalised Anxiety Disorder 7-item (GAD7) and Hospital Anxiety and Depression Scale (HADS) were performed at pre-treatment (baseline), week 1 and 2 of treatment and two weeks post-treatment.

RESULTS

In CMS group, VAS of maximal headache and VAS of current headache, HIT6, PHQ9 and GAD7 significantly decreased by two weeks post-CMS therapy, but not in Sham group (P < .05). Scores of HADS-A (anxiety), HADS-D (depression) and HADS-T (total) significantly decreased by 2 weeks post-CMS therapy in CMS group, but not in Sham group (P < .05). Changes in scores of PHQ9 and GAD7, HADS-A, HADS-D and HADS-T in CMS group were significantly greater than in Sham group by 2 weeks post-CMS therapy (P < .05).

CONCLUSION

The results indicate that CMS, as an adjunctive treatment for patients with TTH, is safe and analgesic as well as reducing depression or anxiety.

Association of temporomandibular disorder-related pain with severe headaches-a Bayesian view

Objectives

Association of temporomandibular disorders (TMD)-related pain with severe headaches (migraine and tension-type headaches [TTH]) was studied over a follow-up period of 11 years.

Materials and methods

The data used was from two nationally representative health surveys in Finland—the Health 2000 Survey (baseline) and the Health 2011 Survey (follow-up) (Bioresource Research Impact Factor [BRIF] 8901)—conducted by the Finnish Institute for Health and Welfare (THL). The primary dataset of the current study included a subset of the population undergoing a clinical oral examination, including TMD examination, at baseline, and answering the questions related to severe headaches, both at baseline and at follow-up (n = 530). From the primary dataset, two datasets were created to study the onset of migraine (dataset 1) and TTH (dataset 2) separately. Dataset 1 included participants healthy of migraine, but not other headaches, at baseline (n = 345), and dataset 2 participants healthy of TTH and other headaches, except migraine, at baseline (n = 464). Bayesian logistic regression models with weakly informative priors were utilized to assess the association of muscle-related TMD pain (mTMD) at baseline and temporomandibular joint-related TMD pain (jTMD) at baseline with the presence of migraine and TTH at follow-up.

Results

Neither of the baseline TMD-related pain variables were associated with the presence of migraine at follow-up (posterior effect estimates-0.12, 95% credible interval [CI] -0.49–0.24, and 0.11, 95% CI -0.38–0.59, for mTMD and jTMD, respectively), whereas mTMD at baseline (posterior effect estimate 0.36, 95% CI 0.02–0.69), but not jTMD at baseline (posterior effect estimate -0.32, 95% CI -0.94–0.25), was associated with the presence of TTH at follow-up. Bayesian sensitivity analyses revealed that the estimates of the regression models were stable, demonstrating sufficient validity and consistency of the estimates.

Conclusion

These results indicate that diverse mechanisms may exist behind the associations of TMD-related painful conditions with different types of severe headaches.

Clinical relevance

TMD-related pain is a frequent comorbidity of severe primary headaches. Therapy of severe primary headaches may thus benefit significantly with the incorporation of a multi-disciplinary clinical team.

Effectiveness of Acceptance and Commitment Therapy in Central Pain Sensitization Syndromes: A Systematic Review

OBJECTIVES

Acceptance and commitment therapy (ACT) is considered by the American Psychological Association as an evidence-based treatment for a variety of disorders, including chronic pain. The main objective of the present systematic review was to determine the effectiveness of ACT in patients with central pain sensitization syndromes (CPSS).

METHODS

This systematic review was conducted according to the guidelines of the Cochrane Collaboration and PRISMA statements. The protocol was registered in advance in the Prospective Register of Systematic Reviews (PROSPERO) international database. The selected articles were evaluated using the Cochrane risk of bias (ROB) assessment tool. The PubMed, Scopus, and Web of Science databases were searched.

RESULTS

The literature search identified 21 studies (including investigations of fibromyalgia syndrome, irritable bowel syndrome, and migraine) eligible for the systematic review. There were no studies regarding the effectiveness of ACT for chronic tension-type headache (CTTH), interstitial cystitis (IC), or temporomandibular disorder (TMD). The evaluation of ROB showed that 12 of the selected studies were of low quality, 5 were of moderate quality, and 4 were high quality. ACT reduces some clinical symptoms, such as anxiety, depression, and pain. This positive effect of ACT might be mediated by pain acceptance, psychological flexibility, optimism, self-efficacy, or adherence to values. ACT showed better results in comparison to non-intervention (e.g., "waiting list") conditions, as well as pharmacological and psychoeducational interventions. It is not entirely clear whether extended ACT treatments are more advantageous than briefer interventions.

CONCLUSIONS

There are few studies about the effectiveness of ACT on CPSS. However, ACT seems to reduce subjective CPSS symptoms and improve the health-related quality of life of these patients. The absence of studies on the effectiveness of ACT in CTTH, IC, and TMD, indicate the pressing need for further ACT studies in these CPSS.

The efficacy of botulinum toxin A treatment for tension-type or cervicogenic headache: a systematic review and meta-analysis of randomized, placebo-controlled trials

OBJECTIVES

The pathogeneses of chronic tension-type headache (CTTH) and cervicogenic headache (CEH) are not well established. Peripheral activation or sensitization of myofascial nociceptors is suggested as a potential mechanism and injections of botulinum toxin (BONTA) have thus been used in the treatment for both headache conditions. BONTA inhibits the release of acetylcholine at the neuromuscular junction and inhibits contraction of skeletal muscles. If the pain is precipitated by increased tone in cervical muscles, local injections of BONTA could represent a prophylactic measure. However, the treatment is still controversial, and a thorough assessment of the current evidence is required. This review aims to assess the evidence of BONTA injection as a prophylactic treatment for CTTH and CEH by reviewing and examining the quality of placebo-controlled, randomized trials.

METHODS

Data sources: we searched in the following databases: PubMed (including Medline), Embase, Cochrane Central register of Controlled Trials, Cinahl, Amed, SCOPUS and Google Scholar including other repository sources. Both MeSH and free keywords were used in conducting the systematic search in the databases. The search covered publications from the root of the databases to November 2020.

STUDY ELIGIBILITY CRITERIA

The review included RCTs, comparing single treatment of BONTA with placebo on patients with CTTH or CEH above 18 years of age, by measuring pain severity/relief or headache frequency.

DATA EXTRACTION

The following data were extracted: year of publication, country, setting, trial design, number of participants, injection procedure, BONTA dosages, and clinical outcome measures.

STUDY APPRAISAL

To assess validity and quality, and risk of bias, the Oxford Pain Validity Scale, Modified Jadad Scale, last version of Cochrane Collaboration's tool for assessing risk of bias (RoB 2), and the CONSORT 2010 Checklist were used. The trials were assessed, and quality scored independently by two of the reviewers. A quantitative synthesis and meta-analyses of headache frequency and intensity were performed.

RESULTS

We extracted 16 trials, 12 on prophylactic BONTA treatment for CTTH and four on CEH. Of these 12 trials (8 on CTTH and 4 on CEH) were included in the quantitative synthesis. A majority of the trials found no significant difference on the primary outcome measure when BONTA treatment was compared with placebo. Three "positive" trials, reporting significant difference in favor of BONTA treatment, but two of these were hampered by low validity and quality scores and high risk of bias.

CONCLUSIONS

There is no clear clinical evidence supporting prophylactic treatment with BONTA for CTTH or CEH.

Frequency of Headaches in Macromastia Patients and Relief After Reduction Mammoplasty

BACKGROUND

Several studies have reported that neck, back, and shoulder pain can be reduced after macromastia. However, only 1 study has specifically investigated the relation between macromastia and headaches.

OBJECTIVES

This study aimed to determine the frequency of headaches in patients with macromastia by examining a sample from our clinic and to determine whether the patients experienced headache relief following breast reduction surgery.

METHODS

One hundred patients, out of 456 patients who met the criteria, were contacted by telephone and administered a questionnaire. Statistical analysis was performed with SPSS version 17.0. Normal distribution of the variables was examined by histograms and Kolmogorov-Smirnov tests. Pearson's chi-square and Fisher's exact tests were used to compare groups. The Mann-Whitney U test was used to evaluate nonparametric variables between the patients who has 1500 grams or less breast tissue removed and the patients more than 1500 grams breast tissue removed.

RESULTS

The incidence of headaches in patients with macromastia was found to be 29%. Among the patients with headaches, 65.52% reported relief after surgery. The relief rate for headaches was found to be associated with the amount of tissue removed.

CONCLUSIONS

The incidence of headaches increased in patients with macromastia compared with the general population, and patients reported headache relief after surgery. In addition, as the amount of tissue removal increased, the relief rate for headaches after surgery also increased. Although additional studies are essential, preoperative headaches should be evaluated in breast reduction patients, and the removal of larger amounts of breast tissue should be considered among patients who report headaches.

LEVEL OF EVIDENCE: 4

Complementary and alternative therapies for tension-type headache: A protocol for systematic review and network meta-analysis

BACKGROUND

Tension-type headache (TTH) is the most common form of primary headache with high prevalence, which affects the quantity of life seriously. The pharmacological treatment of TTH is not the most effective. Meanwhile, complementary therapies and alternative therapies play an essential role in the treatment of TTH, and there is an absence of comparison between various interventions. Therefore, we propose the network meta-analysis protocol to compare the efficacy and safety of various complementary therapies and alternative therapies for TTH.

METHODS

From the beginning to February 2021, we will search the database to collect randomized controlled trials of complementary and alternative therapies for TTH. Two researchers will be responsible for screening retrieve documents, extracting data. The risk of bias will be assessed based on the Cochrane bias risk tool. We will use STATA16.0 and WinBUGS1.4.3 for paired meta-analysis and Bayesian network meta-analysis. The quality of evidence will be assessed using the grading of recommendations assessment development and evaluation.

RESULTS

This study will compare and rank the efficacy and safety of various complementary and alternative treatments for TTH.

CONCLUSIONS

This study will provide more extensive evidence for the complementary and alternative therapies of TTH. We expect to assist clinicians and patients in choosing the optimum treatment.

PROTOCOL REGISTRATION NUMBER

INPLASY202130088.

Acupoints for Tension-Type Headache: A Literature Study Based on Data Mining Technology

Objectives

This study aimed to explore the characteristics and principles of acupoints, which were applied for treating tension-type headache (TTH).

Methods

Four databases were searched for the literature studies of treating TTH with acupuncture and moxibustion up to September 1, 2020. Titles, journals, authors, key words, interventions, main acupoints, and outcomes of the included literature studies were extracted and inputted into the self-established Data Excavation Platform of Acupoint Specificity for analysis.

Results

In total, 128 papers containing 137 prescriptions, 89 meridian acupoints, and 7 extraordinary acupoints of treating TTH with acupuncture and moxibustion were included. The total frequency of acupoints' application was 763 times. Fengchi (GB20), Baihui (GV20), Taiyang (EX-HN5), Hegu (LI4), and Taichong (LR3) were used most frequently. The acupoints in Yang meridians were utilized more than those in Yin meridians (66.1% vs. 17.8%), and the acupoints in the Gallbladder Meridian of Foot Shaoyang were applied most commonly. 59.9% (457/763) of the applied acupoints were on the head, face, and neck, and 31.7% (242/763) were on the four limbs. Additionally, the proportion of specific acupoints' application was 78.2% (597/763).

Conclusions

The prescription of Fengchi (GB20), Baihui (GV20), Taiyang (EX-HN5), Hegu (LI4), and Taichong (LR3) might be relatively reasonable in clinical practices of treating TTH with acupuncture, which should be verified in further studies.

Brain Excitability in Tension-Type Headache: a Separate Entity from Migraine?

PURPOSE OF REVIEW

Tension-type headache is often regarded as the "normal" headache due to its high prevalence and mild disability in contrast with migraine. Clinically, both headaches are common comorbidities to each other. To date there has been many studies linked migraine to a brain excitability disorder. This review summarized earlier studies on brain excitability of TTH and discuss if TTH is a separate clinical entity from migraine as suggested by the diagnostic criteria.

RECENT FINDINGS

A recent magnetoencephalographic study from our group enrolled patients with "strict-criteria" TTH (i.e., absence of any migraine characteristics and associated symptoms) to compare the somatosensory excitability with patients with migraine and controls. This study provided evidence that TTH and migraine differ in excitability profiles and the measurement of preactivation excitability was able to discriminate TTH from migraine. Earlier studies on brain excitability of TTH yielded negative findings or a common change shared with migraine. Future studies using strict diagnostic criteria to avoid the unwanted interference from migraine comorbidity may help decipher the "true" pathophysiology of TTH, which may pave the way to a TTH-specific brain signature and treatment.

Evidence of localized and widespread pressure pain hypersensitivity in patients with tension-type headache: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis evaluates pressure pain sensitivity values in symptomatic and distant pain-free areas comparing individuals with tension-type headache to controls.

DATABASES AND DATA TREATMENT

Electronic databases were searched for cross-sectional or prospective case-control studies comparing pressure pain thresholds in patients with tension-type headache to headache-free controls. Data were extracted by three reviewers. The methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Meta-analyses of trigeminal, extra-trigeminal (neck) and distant pain-free areas in tension-type headache were compared to headache-free controls. Frequency of tension-type headache and gender were taken into account.

RESULTS

Twenty studies were included. Patients with tension-type headache exhibited lower pressure pain thresholds than headache-free controls: Trigeminal (MD -49.11 kPa, 95% CI -66.05 to -32.17), cervical spine (MD -88.17 kPa, 95% CI -108.43 to -67.92) and distant pain-free areas (MD -98.43 kPa, 95% CI -136.78 to -60.09). Differences were significant for chronic, episodic, and mixed episodic and chronic tension-type headache within the trigeminal and neck (symptomatic areas), but only significant for chronic tension-type headache (MD -102.86, 95% CI -139.47 to -66.25 kPa) for distant pain-free areas. In general, women had lower pressure pain thresholds than men. The methodological quality ranged from fair (45%) to good (40%). The results showed a high heterogeneity and publication bias.

CONCLUSION

This first meta-analysis addressing pressure pain thresholds differences in symptomatic and distant pain-free areas between patients with tension-type headache and controls found low to moderate evidence supporting the presence of pressure pain hypersensitivity in the trigeminal and neck areas in tension-type headache in comparison with headache-free controls. Sensitivity to pressure pain was widespread only in chronic, not episodic, tension-type headache (moderate evidence).Registration number: https://doi.org/10.17605/OSF.IO/R29HY.

[Tension type headaches : Quo vadis?]

Episodic tension type headache is considered to be the most prevalent primary headache. If tension type headache occurs on more than 15 days per month for at least 3 consecutive months, it is classified as chronic tension type headache. In recent years, it has become obvious that it is difficult to distinguish between episodic tension type headache and a moderate migraine attack and also between chronic tension type headache and chronic migraine. In the paper, we discuss how the differential diagnosis can be more specific and which therapy is supported by the literature. In addition, we discuss differences and similarities of tension type headache and migraine and a possible similar pathophysiology of both (convergence hypothesis).

Patterns of pharmacological treatment of patients with migraine, tension-type headache, and cluster headache in a large group of patients in Colombia, 2019

The objective was to determine the pharmacological treatment patterns of headache disorders in a Colombian population. Cross-sectional study. The dispensations of drugs for the management of tension-type headache, migraine, and cluster headache in the first trimester of 2019 were reviewed from a national medication dispensing database. Sociodemographic, diagnostic, and treatment variables (acute or prophylactic; concomitant drugs) were analyzed. During the study period, 7450 patients were identified: 68.5% with migraine, 25.1% with tension-type headache, and 6.4% with cluster headache. A total of 79.7% (n = 5937) were women, and the mean age was 38.6 ± 14.7 years. The 87.8% (n = 6539) were prescribed drugs for acute pain management, mainly nonsteroidal anti-inflammatory drugs (n = 3559; 47.8%), acetaminophen (n = 3390; 45.5%), ergotamine (n = 2158; 29.0%), and opioids (n = 1750; 23.5%). The 50.3% (n = 3750) received at least one drug used for prophylaxis, mainly antidepressants (n = 1769, 23.7%), flunarizine (n = 927; 12.4%), and β-blockers (n = 764; 10.3%). The main comedication was proton pump inhibitors (n = 921; 12.4%). Patients with tension-type headache, migraine, and cluster headache receive mainly medications for acute management, some with low therapeutic value or not recommended, such as opioids or ergotamine. Prophylactic management is mainly directed to migraines, although patients with other kinds of headache also used it, even though it was not indicated.

Effectiveness of suboccipital muscle inhibition combined with interferential current in patients with chronic tension-type headache: a randomised controlled clinical trial

INTRODUCTION

Manual therapy has been shown to reduce self-reported symptoms in patients with chronic tension-type headache (CTTH). However, simultaneous application of suboccipital muscle inhibition and interferential current has not previously been investigated. This study evaluates the effectiveness of combined treatment with suboccipital muscle inhibition and interferential current compared to standard treatment for pain, disability, and headache impact in patients with CTTH.

METHODS

Patients were randomly allocated to receive either standard treatment (n = 13) or the experimental treatment (n = 12), consisting of 20 minutes of suboccipital muscle inhibition plus interferential current twice weekly for 4 weeks. The primary outcome was improvement in pain, and secondary outcomes included improvement in headache-related disability and reduction in headache impact, which were assessed at baseline and at 4 weeks by a blinded rater.

RESULTS

Statistical analysis showed improvements in the experimental treatment group at 4 weeks for headache-related disability (Neck Disability Index: Hedges' g = 1.01, P = .001; and Headache Disability Inventory: Hedges' g = 0.48, P = .022) and headache impact (6-item Headache Impact Test: Hedges' g = 0.15, P = .037) but not for self-reported pain (numerical rating scale: Hedges' g = 1.13, P = .18).

CONCLUSIONS

Combined treatment with suboccipital muscle inhibition and interferential current in patients with CTTH did not significantly improve self-reported pain but did reduce disability and the impact of headache on daily life at 4 weeks. These improvements exceed the minimum clinically important difference, demonstrating the clinical relevance of our findings.

Intramuscular innervation patterns of the splenius capitis and splenius cervicis and their clinical implications for botulinum toxin injections

INTRODUCTION

The purpose of this study was to clearly characterize the intramuscular nerve distributions of the splenius capitis and splenius cervicis muscles that are both responsible for the onset of a chronic tension type headache and to use this information to identify the effective botulinum toxin (BoNT) injection sites.

MATERIALS AND METHODS

Ten splenius capitis and splenius cervicis specimens were subjected to Sihler's staining to reveal intramuscular nerve arborization patterns and determined the optimal location for BoNT injection.

RESULTS

Nerve distribution patterns in the splenius capitis were identified as nerve pathways that travel down toward the origin point and others that travel up toward the insertion point. This neuromuscular innervation from the central (50%) point was distributed evenly in these two directions. The neural pathways of splenius cervicis traveled vertically from the insertion point to the origin point. If the length from the muscle origin point to the insertion point is normalized to 100%, motor neurons innervate the muscle from around the 30% to the 70% point.

CONCLUSIONS

The safest and most-effective BoNT injection sites for the splenius capitis and splenius cervicis were found at around the 50% point and the 30% to the 70% point, respectively.

Widespread Pressure Pain Sensitivity over Nerve Trunk Areas in Women with Frequent Episodic Tension-Type Headache as a Sign of Central Sensitization

Objective

Previous studies reported the presence of widespread pressure pain sensitivity in patients with tension-type headache. However, most of the studies assessed pressure pain sensitivity over muscle tissue. Our aim was to investigate the difference in pressure pain sensitivity over musculoskeletal and nerve symptomatic and distant areas between women with frequent episodic tension-type headache (FETTH) and healthy subjects.

Methods

Thirty-two women with FETTH and 32 matched healthy women participated. Pressure pain threshold (PPT) was bilaterally assessed over several nerve trunks (greater occipital, median, radial, ulnar, common peroneal, tibialis posterior) and musculoskeletal structures (temporalis muscle, C5/C6 joint, tibialis anterior) by an assessor blinded to the subject’s condition. A four-week headache diary was used to collect the intensity, frequency, and duration of headache. The Hospital Anxiety and Depression Scale was used to determine anxiety and depressive levels.

Results

Analysis of covariance found lower widespread and bilateral PPTs over all nerve trunks and musculoskeletal structures in women with FETTH pain (P &lt; 0.001). No significant effect of anxiety and depressive levels on PPTs was found (all P &gt; 0.222). PPT over the temporalis muscle was significantly negatively correlated with headache intensity.

Conclusions

This study found widespread pressure pain hypersensitivity over both nerve trunks and musculoskeletal structures in women with FETTH, suggesting that the presence of central altered nociceptive processing is not just restricted to musculoskeletal areas, for example, muscles, but also pain evoked from directly provoking the nerve trunks by pressure. It is also possible that nerve tissue treatment could lead to a decrease in central sensitization and headache features.

Efficacy of psychological treatment for headache disorder: a systematic review and meta-analysis

BACKGROUND

Headache disorder is not only a common complaint but also a global burden. Pharmacotherapeutic and non-pharmacotherapeutic approaches have been developed for its treatment and prophylaxis. The present study included a systematic review of psychological treatments for primary headache disorder accessible in Korea.

METHODS

We included English and Korean articles from EMBASE, MEDLINE, Cochrane library database, SCOPUS, ScienceDirect, Web of Science, CINAHL, PsycArticles and Korean database, KoreaMed and KMBASE which studied primary headache and medication-overuse headache. The primary efficacy measure was the number of headache days per month, while secondary efficacy measures were the number of headache attacks per week, headache index, treatment response rate, and migraine disability assessment. The meta-analysis was performed using R 3.5.1. to obtain pooled mean difference and pooled relative risk with 95% confidence interval (CI) for continuous data and dichotomous data, respectively.

RESULTS

From 12,773 identified articles, 27 randomized clinical trials were identified. Primary outcome showed significant superiority of psychological treatments (pooled mean difference = - 0.70, 95% CI [- 1.22, - 0.18]). For the secondary outcomes, the number of headache attacks (pooled mean difference = - 1.15, 95% CI [- 1.63, - 0.67]), the headache index (pooled mean difference = - 0.92, 95% CI [- 1.40 to - 0.44]) and the treatment response rate (pooled relative risk = 3.13, 95% CI [2.24, 4.37]) demonstrated significant improvements in the psychological treatment group over the control group.

CONCLUSION

Psychological treatments for primary headache disorder reduced headache frequency and the headache index. Future research using standardized outcome measures and strategies for reducing bias is needed.

A randomized trial of trigger point dry needling versus sham needling for chronic tension-type headache

BACKGROUND

In this randomized, double-blind, parallel-group trial, we aimed to explore the effectiveness of trigger point dry needling in patients with chronic tension-type headache in reducing headache frequency, intensity and duration, and improvement of health-related quality of life.

METHODS

The 168 patients in 2 neurology clinics with chronic tension-type headache. The participants were randomly assigned to one of two treatment groups for dry needling or sham dry needling, delivered in 3 sessions a week for 2 weeks. The 160 patients fulfilled the study requirements. The dry needling was applied in active trigger points located in the musculature of the head and the neck. The patients received dry needling using sterile stainless-steel acupuncture needles of 0.25 × 40 mm and 0.25 × 25 mm dimensions. The sham dry needling procedure was applied into the adipose tissue located at any area where an active trigger point was absent. The primary outcome measurement was the headache intensity. Secondary outcomes were frequency and duration of headache, and quality of life, assessed by the Short Form-36. All outcomes were measured at baseline, at the end of 2-week, and 1-month follow-up period.

RESULTS

In the dry needling group, intensity, frequency and duration of headache, and the scores of Short Form-36 subscales were significantly improved after treatment (P < .05). In the dry needling group, all the effect sizes for headache variables were large.

CONCLUSIONS

The results of this clinical trial suggest that trigger point dry needling in patients with chronic tension-type headache is effective and safe in reducing headache intensity, frequency and duration, and increasing health-related quality of life.

TRIAL REGISTRATION

Clinical Trials NCT03500861.

The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey

BACKGROUND

Headache management is common within chiropractic clinical settings; however, little is yet known about how this provider group manage headache sufferers. The aim of this study is to report on the prevalence of headache patients found within routine chiropractic practice and to assess how chiropractors approach key aspects of headache management applicable to primary care settings.

METHODS

A 31-item cross-sectional survey was distributed to a national sample of chiropractors (n = 1050) to report on practitioner approach to headache diagnosis, interdisciplinary collaboration, treatment and outcome assessment of headache patients who present with recurrent headache disorders.

RESULTS

The survey attracted a response rate of 36% (n = 381). One in five new patients present to chiropractors with a chief complaint of headache. The majority of chiropractors provide headache diagnosis for common primary (84.6%) and secondary (90.4%) headaches using formal headache classification criteria. Interdisciplinary referral for headache management was most often with CAM providers followed by GPs. Advice on headache triggers, stress management, spinal manipulation, soft tissue therapies and prescriptive neck exercises were the most common therapeutic approaches to headache management.

CONCLUSION

Headache patients make up a substantial proportion of chiropractic caseload. The majority of chiropractors managing headache engage in headache diagnosis and interdisciplinary patient management. More research information is needed to understand the headache types and level of headache chronicity and disability common to chiropractic patient populations to further assess the healthcare needs of this patient population.

Primary Headaches

The primary headaches are composed of multiple entities that cause episodic and chronic head pain in the absence of an underlying pathologic process, disease, or traumatic injury. The most common of these are migraine, tension-type headache, and the trigeminal autonomic cephalalgias. This article reviews the clinical presentation, pathophysiology, and treatment of each to help in differential diagnosis. These headache types share many common signs and symptoms, thus a clear understanding of each helps prevent a delay in diagnosis and inappropriate or ineffective treatment. Many of these patients seek dental care because orofacial pain is a common presenting symptom.

Frequency of Primary Headache Syndromes in Patients with a Major Depressive Disorder

Purpose The primary objective of this study was to assess the overall frequency of primary headaches in subjects with a moderate to severe major depressive disorder. A further objective was to determine the frequency of primary headache sub-types in this population. Materials and methods This descriptive, cross-sectional study was conducted at the outpatients' clinic of the department of psychiatry, Pakistan Railways Teaching Hospital, an affiliate of Islamic International Medical College, Rawalpindi. The duration of the study was from December 2016 to May 2017. One hundred and ten consecutive patients with a major depressive disorder (MDD) were assessed for a primary headache, according to the diagnostic criteria of International Classification of Headache Disorders second edition (ICHD-2). MDD patients with moderate to severe depression according to the diagnostic and statistical manual of mental disorders (DSM-5) were enrolled in the study. A semi-structured proforma was designed to gather information on sociodemographic variables. The data was analyzed by utilizing Statistical Package for Social Sciences, version 22 (IBM Corp., Armonk, NY, US). Results Of the 110 MDD patients enrolled, a primary headache was present in 45 (40.90%) cases. Additionally, five of these patients had a migraine with aura (11.11%), 12 had a migraine without aura (26.66%), and 28 had a tension-type headache (62.22%). In the females, migraines with or without aura was frequent (35.29%), while a tension-type headache was more common in males (72.72%). Conclusion More than one-third of the sample had a primary headache syndrome, which shows a high comorbidity between a migraine and its variants and MDD. There is a need to undertake further studies with larger samples to elucidate this relationship.

Incidental Treatment of a Subclinical Chronic Tension-Type Headache by Cosmetic Use of Botulinum Toxin A: A Case Report

Background

Headache is a common disorder of the nervous system; chronic headache in particular may affect quality of life negatively. The pathophysiology is multifactorial and not completely elucidated. Studies have demonstrated the beneficial effects of botulinum toxin A on chronic migraine headaches, but failed to show the same effect on chronic tension-type headaches.

Methods

We present the case of a 32-year-old woman who after receiving cosmetic injections with botulinum toxin A for fine lines of the forehead experienced relief of subclinical tension-type headaches.

Conclusions

Although the effect of botulinum toxin A on chronic tension-type headaches is limited, several studies demonstrate its pain-modulating effects, and as such it is worth paying attention to this potential beneficial effect when performing cosmetic injections with botulinum toxin A.

Assessment of deep dynamic mechanical sensitivity in individuals with tension-type headache: The dynamic pressure algometry

BACKGROUND

To explore the validity of dynamic pressure algometry for evaluating deep dynamic mechanical sensitivity by assessing its association with headache features and widespread pressure sensitivity in tension-type headache (TTH).

METHODS

One hundred and eighty-eight subjects with TTH (70% women) participated. Deep dynamic sensitivity was assessed with a dynamic pressure algometry set (Aalborg University, Denmark^© ) consisting of 11 different rollers including fixed levels from 500 g to 5300 g. Each roller was moved at a speed of 0.5 cm/s over a 60-mm horizontal line covering the temporalis muscle. Dynamic pain threshold (DPT-level of the first painful roller) was determined and pain intensity during DPT was rated on a numerical pain rate scale (NPRS, 0-10). Headache clinical features were collected on a headache diary. As gold standard, static pressure pain thresholds (PPT) were assessed over temporalis, C5/C6 joint, second metacarpal, and tibialis anterior muscle.

RESULTS

Side-to-side consistency between DPT (r = 0.843, p < 0.001) and pain evoked (r = 0.712; p < 0.001) by dynamic algometer was observed. DPT was moderately associated with widespread PPTs (0.526 > r > 0.656, all p < 0.001). Furthermore, pain during DPT was negatively associated with widespread PPTs (-0.370 < r < -0.162, all p < 0.05).

DISCUSSION

Dynamic pressure algometry was a valid tool for assessing deep dynamic mechanical sensitivity in TTH. DPT was associated with widespread pressure sensitivity independently of the frequency of headaches supporting that deep dynamic pressure sensitivity within the trigeminal area is consistent with widespread pressure sensitivity. Assessing deep static and dynamic somatic tissue pain sensitivity may provide new opportunities for differentiated diagnostics and possibly a new tool for assessing treatment effects.

SIGNIFICANCE

The current study found that dynamic pressure algometry in the temporalis muscle was associated with widespread pressure pain sensitivity in individuals with tension-type headache. The association was independent of the frequency of headaches. Assessing deep static and dynamic somatic tissue pain sensitivity may provide new opportunities for differentiated diagnostics and possibly a tool for assessing treatment effects.

Identification of subgroups of patients with tension type headache with higher widespread pressure pain hyperalgesia

Background

Identification of subgroups of patients with different levels of sensitization and clinical features can help to identify groups at risk and the development of better therapeutic strategies. The aim of this study was to identify subgroups of patients with tension type headache (TTH) with different levels of sensitization, clinical pain features, and psychological outcomes.

Methods

A total of 197 individuals with TTH participated. Headache intensity, frequency, and duration and medication intake were collected with a 4-weeks diary. Pressure pain thresholds were assessed bilaterally over the temporalis muscle, C5-C6 joint, second metacarpal and tibialis anterior muscle to determine widespread pressure pain hyperalgesia. The Hospital Anxiety and Depression Scale assessed anxiety and depression. The State-Trait Anxiety Inventory evaluated the state and trait levels of anxiety. The Headache Disability Inventory evaluated the burden of headache. Health-related quality of life was determined with the SF-36 questionnaire. Groups were considered as positive (three or more criteria) or negative (less than three criteria) on a clinical prediction rule: headache duration <8.5 h/day; headache frequency <5.5 days/week; bodily pain <47 and vitality <47.5.

Results

The ANCOVA revealed that subjects in group 1 (positive rule, n = 89) exhibited longer headache history, shorter headache duration, lower headache frequency, higher widespread pressure hyperalgesia, higher anxiety trait levels, and lower quality of life (all, P < 0.01) than those subjects within group 2 (negative rule, n = 108). Differences were similar between men and women.

Conclusions

This study identified a subgroup of patients with TTH with higher sensitization, higher chronicity of headaches and worse quality of life but lower frequency and duration of headache episodes. This subgroup of individuals with TTH may need particular attention and specific therapeutic programs for avoiding potential chronification.

Trigger points are associated with widespread pressure pain sensitivity in people with tension-type headache

Objective

To investigate the association between trigger points (TrPs) and widespread pressure pain sensitivity in people with tension-type headache (TTH) and to determine if this association is different between frequent episodic (FETTH) or chronic (CTTH) headache.

Design

A cross-sectional study.

Methods

One hundred and fifty-seven individuals (29% male) with TTH participated. Clinical features of headache, i.e., intensity, duration, and frequency, were recorded in a headache diary. Active and latent TrPs were bilaterally explored in the temporalis, masseter, suboccipital, upper trapezius, sternocleidomastoid, and splenius capitis muscles. Pressure pain thresholds (PPT) were assessed over the trigeminal area (i.e., temporalis muscle), extra-trigeminal (i.e., C5/C6 zygapophyseal joint), and two distant pain-free points (i.e., second metacarpal and tibialis anterior muscle).

Results

Eighty (51%) patients were classified as FETTH, whereas 77 (49%) were classified as CTTH. No differences in the number of either active or latent TrPs (all p > 0.171) or widespread pressure pain sensitivity (all p > 0.351) were observed between FETTH and CTTH groups. The number of active and latent TrPs was significantly and negatively associated with PPTs: The higher the number of active or latent TrPs, the lower the widespread PPT, and the more generalized sensitization. This association was stronger within the FETTH group than the CTTH group.

Conclusions

This study found that the number of TrPs in head and neck/shoulder muscles was associated with widespread pressure hypersensitivity independently of the frequency of headache.

Neural Plasticity in Common Forms of Chronic Headaches

Headaches are universal experiences and among the most common disorders. While headache may be physiological in the acute setting, it can become a pathological and persistent condition. The mechanisms underlying the transition from episodic to chronic pain have been the subject of intense study. Using physiological and imaging methods, researchers have identified a number of different forms of neural plasticity associated with migraine and other headaches, including peripheral and central sensitization, and alterations in the endogenous mechanisms of pain modulation. While these changes have been proposed to contribute to headache and pain chronification, some findings are likely the results of repetitive noxious stimulation, such as atrophy of brain areas involved in pain perception and modulation. In this review, we provide a narrative overview of recent advances on the neuroimaging, electrophysiological and genetic aspects of neural plasticity associated with the most common forms of chronic headaches, including migraine, cluster headache, tension-type headache, and medication overuse headache.