Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis

Differences in physical examination findings between those who present with or without headache soon after a whiplash injury: a cross-sectional study

AIM

To determine differences in physical examination findings between people with acute whiplash-associated disorders (WAD) with and without headache.

METHODS

In this cross-sectional study, participants with acute WAD were evaluated to assess differences in the presence of physical impairments. The following were assessed: pain intensity on manual palpation the over spinous process of C1-C3, zygapophyseal joints of C0-C4, and trapezius, sternocleidomastoid, suboccipitalis, masseter and temporalis muscles; cervical range of motion (ROM); flexion-rotation test (FRT); forward head posture; cranio-cervical flexion test (CCFT); neck flexor and extensor endurance; pressure-pain thresholds (PPT) over neural structures and upper limb neural tests (ULNT) in addition to median UNLT + CCF. Correlation analyses were performed to assess the association between examination findings and headache intensity. Logistic regression and discriminant analyses were also performed.

RESULTS

Forty-seven participants (26 men and 21 women; mean age = 38.9 years old) were included in the study. 60% of the participants presented with headache. Several examination findings were significantly different between groups. A group of examination findings composed of neck endurance, manual palpation over cervical and muscular structures, PPT, CCFT, ROM and FRT could discriminate between groups with a sensitivity of 86.7% and specificity of 90%.

CONCLUSIONS

Several neuromusculoskeletal features are different between people with acute WAD with or without headache. A combination of features could distinguish between groups with high levels of sensitivity and specificity.

Morphological and mechanical properties of cervical muscles in fibromyalgia with migraine: A case-control study

BACKGROUND

The precise manner in which morphological and mechanical properties of cervical muscles in patients with fibromyalgia and migraine are affected remains unclear.

OBJECTIVES

The objective of this study was to compare the morphological and mechanical properties of cervical muscles in individuals diagnosed with fibromyalgia who also experience migraine headaches with those who do not.

METHODS

The study included two groups of fibromyalgia patients: one with migraine (n = 18, age = 44.7 ± 7.5 years, body mass index = 28.7 ± 6.9 kg/m2) and one without migraine (n = 21, age = 42.6 ± 9.5 years, body mass index = 25.1 ± 4.4 kg/m2). Body pain intensity related to fibromyalgia and migraine attack severity were evaluated with a Visual Analog Scale (VAS). The cervical muscle morphological and mechanical properties, including thickness, cross-sectional area (CSA), and stiffness, were measured using ultrasound imaging.

RESULTS

It was found that there was a greater decrease in longus colli muscle CSA scores (p = 0.004) and a greater increase in upper trapezius muscle stiffness scores (p = 0.013) in the fibromyalgia + migraine group compared to the fibromyalgia group. No statistically significant differences were observed in trapezius muscle thickness (p = 0.261), sternocleidomastoid muscle thickness (p = 0.874), multifidus CSA (p = 0.963), or sternocleidomastoid muscle stiffness (p = 0.642) between the two groups.

CONCLUSION

Patients with fibromyalgia and migraine exhibited diminished longus colli muscle CSA and heightened upper trapezius muscle stiffness compared to those with fibromyalgia but no migraine. It should be considered that migraine comorbidity in fibromyalgia may negatively affect cervical muscle morphological and mechanical properties.

Reliability and construct validity of the Craniocervical Flexion Test in patients with migraine

BACKGROUND

Migraine may be accompanied by several cervical musculoskeletal dysfunctions, for example an altered performance on the Craniocervical Flexion Test (CCFT). However, CCFT measurement properties are still unclear in patients with migraine.

OBJECTIVES

To determine intra- and inter-examiner reliability, construct validity, standard measurement error (SEM), and minimal detectable change (MDC) of the CCFT in patients with migraine.

METHODS

Women diagnosed with migraine were considered eligible for this study. Participants were assessed by two examiners for the inter-examiner reliability, and with 7-10 days interval for the intra-examiner reliability. Construct validity was assessed considering headache and neck pain frequency and intensity, and self-reported questionnaires, including the Headache Impact Test - 6 items (HIT-6), the 12-item Allodynia Symptom Checklist/Brazil (ASC-12), and the Neck Disability Index (NDI). In addition, participants performed cervical endurance and maximal voluntary isometric contraction of the cervical flexors.

RESULTS

A total of 103 women with migraine were recruited. The intra-examiner reliability was rated as good (ICC= 0.81, 95% CI: 0.73, 0.87), while the inter-examiner reliability was rated as moderate (ICC= 0.55, 95% CI: 0.40, 0.67). The intra and inter-examiner SEM were 1.31 and 1.36 mmHg respectively, and MDC were 3.63 and 3.77 mmHg. The HIT-6 and the cervical endurance flexion test were associated with the CCFT in a multiple linear regression model (p = 0.004, R = 0.35).

CONCLUSION

The CCFT presents adequate intra- and inter-examiner reliability. Better performance on the CCFT test was associated with better HIT-6 scores and greater cervical endurance time, which was not influenced by the presence of neck pain.

[Non-medical Approaches to Headache Prevention: What is the Evidence?]

Primary headaches can be prevented by medication, exercise, behavioral therapy, or lifestyle changes. It is important to note that if medication is used for prophylaxis, non-drug approaches should also be recommended as a complement. Patients often wish to address their headaches without medication. Except for cognitive behavioral therapy and biofeedback, the evidence for nonmedication approaches to headache management has not been definitively established. This article reviews the current literature on the evidence for endurance exercise, relaxation exercises, physical therapy, lifestyle factors, and complementary procedures. For tension-type headache, there is an increasing number of studies reporting positive results from physical therapy; long-term follow-up, however, are still pending. Aerobic endurance exercise has the best evidence as a measure for prevention of migraine. However, other methods can also be used.

Dry needling in the management of chronic tension-type headache associated with levator scapulae syndrome: A case report

Key Clinical Message

The use of DN to the muscular trigger points and distal periosteal enthesis of the levator scapulae may be a useful adjunct intervention within a multi-modal plan of care for the management of work-related chronic tension-type headaches associated with LSS.

Abstract

Chronic tension-type headaches (CTTH) have a lifetime prevalence of 42% and account for more lost workdays than migraine headaches. Dry needling (DN) is being increasingly used by physical therapists in the management of CTTH; however, to date, the supporting evidence is limited. The purpose of this case report was to describe how three sessions of DN targeting myofascial trigger points in the levator scapulae (LS) muscle and its distal enthesis was used to treat a 63-year-old male patient who presented with work-related CTTH associated with levator scapulae syndrome (LSS). The patient was treated for five visits over the course of 2 months. At discharge and 6-month follow-up, the patient reported full resolution of symptoms. Self-report outcomes included the numeric pain rating scale and the Neck Disability Index. The use of DN to the LS muscle and its distal enthesis may be a valuable addition to a multi-modal plan of care in the treatment of work-related CTTH associated with LSS.

Cervical muscle parameters and allodynia in migraine and cervical pain-A controlled study

BACKGROUND

Neck pain is common among individuals with migraine, but there is a lack of information of how this comorbidity can be associated with cervical muscle function. This controlled cross-sectional study aimed to compare cervical muscle function, activity, and sensitization in women with migraine, neck pain, both, and neither.

METHODS

This study included women, between 18 and 55 years old, with either episodic migraine with or without aura, without any concomitant headache diagnosis; chronic neck pain, with at least moderate intensity and mild disability; or neither headache nor neck pain. Pain pressure threshold, allodynia, muscle strength, and endurance and cervical muscles activity were evaluated.

RESULTS

One hundred subjects, with mean age of 30.4 years old, were stratified by diagnosis (n = 25 per group) and by self-reported pain during tests. Lower endurance during flexion was observed for migraine and neck pain (34s) relative to neck pain alone (45s), migraine (40s), and controls (58s) (p = 0.04). For extensor endurance, means were 142s, 166s, 215s, and 270s, respectively (p < 0.001). Endurance times were impacted by the presence of test-induced pain decreasing about 40%-53% of the performance. Diagnostic groups did not differ significantly in strength (p > 0.05), but all pain groups presented significantly higher proportion of test-induced pain, lower muscle activity during the maximal isometric voluntary contractions, and lower pressure pain thresholds.

CONCLUSION

Patients with migraine, chronic neck pain, and the association of both present altered cervical muscle function and activity. Also, test-induced pain impacts significantly on neck muscles endurance.

SIGNIFICANCE

The diagnosis of migraine and chronic neck pain is associated with altered function and activity of the cervical muscles. However, the test-induced pain had an important contribution to worse cervical muscle endurance. This suggests that the therapeutic approach should focus on de-sensitization of the trigeminal-cervical complex when dealing with the comorbidity of migraine and cervical pain.

Effects of cervical stabilization training in patients with headache: A single-blinded randomized controlled trial

BACKGROUND

This study aimed to investigate the effects of Cervical Stabilization Training (CST) on the headache, neck pain and cervical musculoskeletal system in patients with headache compared to the control group.

METHODS

A total of 90 female patients with migraine, tension-type headache and cervicogenic headache (CGH) participated in this study. The patients were divided into the cervical stabilization training group (CSTG) and the control group (CG). The CSTG performed the CST three times a week for 8 weeks while the CG continued their ongoing medical treatment. The pain intensity was assessed by Visual Analogue Scale, forward head posture by craniovertebral angle measurement, the endurance of deep cervical flexor muscles by craniocervical flexion test and the endurance of cervical muscles by flexor and extensor endurance tests before and after 8 weeks. In addition, disability levels, health-related quality of life, sleep quality and mood were assessed by the Migraine Disability Assessment questionnaire, Neck Disability Index (NDI), Short Form 36 Quality of Life Scale, the Pittsburgh Sleep Quality Index and Beck Depression Scale, respectively.

RESULTS

Headache frequency, duration and intensity, neck pain intensity and forward head posture reduced while activation and performance of deep cervical flexor muscles, the endurance of cervical flexor and extensor muscles increased in the CSTG (p < 0.05). Furthermore, the disability levels, quality of life, sleep quality and mood also improved in the CSTG (p < 0.05).

CONCLUSIONS

This study suggests that CST reduces headaches and neck pain by improving the cervical musculoskeletal system in patients with headache.

SIGNIFICANCE

The CST improved the headache frequency, duration and intensity, neck pain intensity, cervical posture, activation of deep cervical flexor muscles and endurance of cervical muscles in patients with headache. In addition, improvements in the cervical musculoskeletal system contributed to a reduction in the intensity of headaches and neck pain. Therefore, CST may be preferred in the treatment of headaches, especially with coexisting neck pain.

Usability of a visual feedback system to assess and improve movement disorders related to neck pain: Perceptions of physical therapists and patients

A prototype visual feedback system has been developed to assess and improve movement disorders related to neck pain. The aim of this study was to assess the usability of the prototype in a rehabilitation setting. Twelve physical therapists integrated the device into their regular therapy programs for 24 neck pain patients with movement disorders. Each patient performed three individual therapy sessions with the device under physical therapist supervision. Usability was assessed by the physical therapists and patients using therapy diaries, the System Usability Scale, and focus group or personal interviews. Based on an overall usability rating of marginally acceptable, the visual feedback system was generally found to be a device with the potential to assess and train neck pain patients but needs improvement. To become a useful adjunct to regular physical therapy, improvements in the hardware and software, and further system developments are required.

Cervical impairments in subjects with migraine or tension type headache: an observational study

Objective

The aim of this investigation was to compare the thickness of the deep local muscles in the neck region, as well as local and widespread sensitivity and functionality, between individuals with migraine, Tension-Type Headache (TTH), and healthy controls. To date, we know that the onset of migraine and TTH share similar pathophysiological pathways. Nevertheless, there may be some anatomical and functional differences which would explain why clinicians may obtain variable results when treating both pathological entities with similar or equal approaches.

Methods

An observational study was conducted in accordance with STROBE guidelines. The flexor longus colli and multifidus, two neck-stabilizing muscles, were measured using B-mode ultrasound imaging. The upper trapezius, masseter, temporalis, tibialis anterior, and median nerve all underwent bilateral pressure-pain threshold (PPT) assessments.

Results

Ninety participants were enrolled in the study. All subjects were equally divided into TTH, migraine and control groups. The PPT values exhibited lower thresholds in patients with TTH than both migraine and healthy participants. Specifically, in the temporal muscle on both sides, patients with TTH exhibited a significantly lower threshold (p < 0.001)than both migraine and healthy participants. Patients with TTH displayed significantly lower thresholds in both upper trapezius muscles (right: p < 0.001; left: p = 0.001). Similar results were obtained for the tibialis anterior PPTs from both sides (p = 0.001 in both). However, both clinical groups exhibited lower thresholds than the healthy subjects (p < 0.001). In multifidus muscle cross-sectional area (CSA), no statistically significant differences were found between migraine patients and healthy subjects, both in relaxation and contraction (right; p > 0.05 and p > 0.05; left: p > 0.05 and p > 0.05). However, patients with TTH exhibited a smaller CSA than both migraine patients and healthy controls in multifidus relaxed and contracted state (right: p < 0.001 in both relaxed and contracted multifidus; left: p = 0.001 and p < 0.001, respectively). Similar results were obtained for the left longus colli muscle in both relaxation and contraction for patients with TTH and migraine compared with healthy subjects (p = 0.001 and p < 0.001, respectively, for muscle relaxation and p < 0.001 for muscle contraction). However, no significant differences were observed between patients with TTH and migraine (p < 0.05 in both relaxation and contraction). In the right longus colli, TTH and migraine patients had a significantly smaller CSA during contraction than healthy subjects (p < 0.001 in both comparisons). In the craniocervical flexion test, both groups of patients with TTH and migraine showed significantly lower values than healthy subjects (p < 0.001 in both comparisons). However, no significant differences were found between patients with TTH and migraineurs (p > 0.05).

Conclusion

The findings provide a significant message for clinicians since anatomical and functional impairments were shown in patients with TTH and migraine. This study corroborates a lack of strength and smaller CSA in both clinical groups compared to controls. Therefore, strengthening programs may be addressed successfully for people with these pathological entities. To be more accurate, according to PPTs and CSA lower values in patients with TTH compared to migraine and controls, manual therapy approaches to desensitize craniocervical soft tissues and exercise therapy to increase endurance of deep cervical muscles may become meaningful especially in subjects with TTH. Nevertheless, in order to distinguish precisely between patients with TTH and migraine, different diagnostic strategies may be used in the future to describe these populations in further detail, which will assist health professionals in a more accurate treatment selection.

Differences in musculoskeletal dysfunctions and in postural alterations between chronic migraine and chronic tension type headache: A cross-sectional study

OBJECTIVE

The aim of present study is to assess postural alterations and musculoskeletal dysfunctions over all spine in patients with chronic migraine and chronic tension type headache, moreover to highlight the differences between these two forms of primary headache.

METHODS

A Cross sectional study was adopted to evaluate the musculoskeletal profile in patients with chronic migraine and with chronic tension type headache. The Bio photogrammetric evaluation was performed using the postural assessment software PAS/SAPO, while unilateral passive accessory intervertebral motion (PAIMs) were applied for manual examinations of spine segments from C0 to L5 vertebra. The One-way Analysis of Variance (ANOVA) test was used to compare the three groups with the software GraphPad InStat 3.06.

RESULTS

A total of 60 patients were recruited, 20 for chronic tension type group, 20 for chronic migraine group and 20 healthy controls. The most interesting findings was that patients with chronic primary headaches presented postural alterations in all parameters (cranio-vertebral angle and lumbar-pelvic angle) and musculoskeletal dysfunctions in all spine with respect to healthy controls. Finally, the most clinically relevant finding was that no differences were found between chronic migraine and chronic tension type headache concerning the postural alterations nor the musculoskeletal dysfunctions.

CONCLUSION

The sensitization acts as a substrate or consequence of these musculoskeletal dysfunctions in chronic primary headache. Therefore, non-pharmacological treatments targeted in the musculoskeletal system may be a good option in the management of chronic primary headache, especially when these therapies integrate various techniques that involve all spine.

Efficacy of a strength-based exercise program in patients with chronic tension type headache: a randomized controlled trial

Background

Strength-based exercise is widely used to treat tension-type headache, but the evidence of its benefit is unclear. This study aims to analyze the efficacy of a strength-based exercise program in patients with chronic tension-type headaches.

Methods

A randomized controlled trial with a 12-week strength-based exercise program, with chronic tension-type headache. The headache characteristics (which were the primary outcomes: frequency, duration, and intensity), cervical muscle thickness at rest or contraction of multifidus and longus-colli muscle, cervical range of motion, pain pressure threshold of temporalis, upper trapezius, masseter, tibialis muscle and median nerve, and cervical craniocervical flexion test were assessed at baseline and 12-weeks of follow-up in the intervention group (n = 20) and the control group (n = 20) was performed on 40 patients (85% women, aged 37.0 ± 13.3 years).

Results

Between baseline and week-12 of follow-up the intervention group showed statistically significant differences compared to control group in the following primary outcomes: duration and intensity of headaches. In addition, the intervention group improved the thickness of deep cervical muscles, reduced the peripheral sensitization, and improved the strength of deep cervical flexors.

Conclusion

A 12-week strength training of neck and shoulder region induced changes in pain intensity and duration, and physical-related factors in patients with TTH. Future interventions are needed to investigate if normalization of pain characteristics and physical factors can lead to an increase of headache-related impact.

Cervical Impairments in Subjects with Chronic Migraine: An Observational Study

OBJECTIVE

The aim of this investigation was to compare the thickness of the deep local muscles in the neck region, as well as local and widespread sensitivity and functionality, between individuals with migraine and healthy control subjects.

METHODS

An observational study was carried out in accordance with the STROBE statements. The flexor longus colli and multifidus, two neck-stabilizing muscles, were measured using B-mode ultrasound imaging. The upper trapezius, masseter, temporalis, anterior tibialis, and median nerve all underwent bilateral pressure-pain threshold (PPT) assessments. The statistical program SPSS 29.0 was used to implement the Mann-Whitney U test and Chi-squared test. Spearman Rho was utilized to establish the correlations between the variables.

RESULTS

Sixty participants were enrolled in the study. The subjects, who were matched in terms of age, gender, and body mass index (BMI), were equally divided into migraine and control groups. No significant differences between the groups were found in the multifidus CSA regarding both sides at rest (right: p = 0.625; left: p = 0.203). However, in contraction, the multifidus CSA showed a significant decrease on the left side in the patients with migraine compared to the controls (p = 0.032), but no significant differences were found in the right multifidus CSA in contraction between the two groups (p = 0.270). In comparison to the healthy volunteers, the migraine sufferers showed a substantial reduction in CSA in the longus colli muscle on both the left side (p = 0.001) and the right side at rest (p = 0.003), as well as in the CSA of the left longus colli in contraction (p < 0.001). Furthermore, the migraine patients showed significantly lower PPT compared to the healthy subjects in local and widespread areas bilaterally. All the parameters revealed higher sensitization in the migraine group in the following areas: the right and left temporal regions (p < 0.001), the right and left upper trapezius (p < 0.001 and p < 0.01, respectively), the right and left masseter muscles (p < 0.01), the right and left median nerves (p < 0.001 and p < 0.01, respectively), and the right and left anterior tibialis muscles (p < 0.001). In terms of the craniocervical flexion test (CCFT), the migraine patients demonstrated significantly lower values than the healthy subjects (p < 0.001). A moderate positive correlation was noted between the PPT in the right temporalis muscle and that in the left longus colli and the right multifidus in contraction. The PPT in the right temporalis muscle also exhibited a positive correlation with the CCFT, although this correlation was low. Between the PPT values, the upper trapezius on both sides showed a moderate positive correlation with the median nerve bilaterally.

CONCLUSIONS

This research suggests that individuals with migraine may experience local and widespread pain sensitization. A decrease in functionality due to the low muscle endurance of the deep cervical muscles is also accompanied by low values of muscle thickness in contraction. These findings may help to select more accurate treatment approaches for patients with migraine.

The cervical spine in tension type headache

INTRODUCTION

The concept that headaches may originate in the cervical spine has been discussed over decades and is still a matter of debate. The cervical spine has been traditionally linked to cervicogenic headache; however, current evidence supports the presence of cervical musculoskeletal dysfunctions also in tension-type headache.

PURPOSE

This position paper discusses the most updated clinical and evidence-based data about the cervical spine in tension-type headache.

IMPLICATIONS

Subjects with tension-type headache exhibit concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, positive flexion-rotation test and also cervical motor control disturbances. In addition, the referred pain elicited by manual examination of the upper cervical joints and muscle trigger points reproduces the pain pattern in tension-type headache. Current data supports that the cervical spine can be also involved in tension-type headache, and not just in cervicogenic headache. Several physical therapies including upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling) and exercises targeting the cervical spine are proposed for managing tension-type headache; however, the effectiveness of these interventions depends on a proper clinical reasoning since not all will be equally effective for all individuals with tension-type headache. Based on current evidence, we propose to use the terms cervical "component" and cervical "source" when discussing about headache. In such a scenario, in cervicogenic headache the neck can be the cause (source) of the headache whereas in tension-type headache the neck will have a component on the pain pattern, but it will be not the cause since it is a primary headache.

Cervical musculoskeletal impairments and pain sensitivity in migraine patients

INTRODUCTION

Currently, examination of migraine patients relies on a clinical interview investigating symptoms characteristics. Despite this, to help identify distinct migraine subtypes and allow a personalized treatment approach, biomarkers to profile distinct migraine subtypes should be utilized in clinical and research settings. Therefore, there is a need to include physical and psychophysical examinations aimed at assessing migraine features quantitatively.

PURPOSE

This paper aimed to discuss if increased pressure pain sensitivity and impaired cervical musculoskeletal function could be considered 1) as quantitative features of migraine and 2) if they could be used as biomarkers to profile migraine patients in distinct subtypes.

IMPLICATION

Increased pain sensitivity and cervical musculoskeletal impairments have been suggested as quantitative biomarkers to phenotype and subgroup migraine patients in clinical and research settings. This could provide the first step for a mechanistically-driven and personalized treatment approach according to migraine phenotypes.

Cervicogenic headache

INTRODUCTION

Cervicogenic headache, first proposed as a distinct headache in 1983, is a secondary headache to a primary cervical musculoskeletal disorder. Research into physical impairments was integral to clinical diagnosis and to develop and test research informed conservative management as the first line approach.

PURPOSE

This narrative presents an overview of the body of cervicogenic headache research from our laboratory which was undertaken in the context of a broad program of research into neck pain disorders.

IMPLICATIONS

Early research validated manual examination of the upper cervical segments against anaesthetic nerve blocks, which was vital to clinical diagnosis of cervicogenic headache. Further studies identified reduced cervical motion, altered motor control of the neck flexors, reduced strength of flexor and extensor muscles, and occasional presentation of mechanosensitivity of the upper cervical dura. Single measures are variable and not reliable in diagnosis. We proved that a pattern of reduced motion, upper cervical joint signs and impaired deep neck flexor function accurately identified cervicogenic headache and differentiated it from migraine and tension-type headache. The pattern was validated against placebo controlled diagnostic nerve blocks. A large multicentre clinical trial determined that a combined program of manipulative therapy and motor control exercise is effective in the management of cervicogenic headache and outcomes are maintained in the long term. More specific research into cervical related sensorimotor controlled is warranted in cervicogenic headache. Further adequately powered clinical trials of current research informed multimodal programs are advocated to further strengthen the evidence base for conservative management of cervicogenic headache.

Cervical musculoskeletal impairments and pressure pain sensitivity in office workers with headache

BACKGROUND

Office workers are specifically vulnerable to headache conditions. Neck pain is reported by almost 80% of patients with headaches. Associations between currently recommended tests to examine cervical musculoskeletal impairments, pressure pain sensitivity and self-reported variables in headache, are unknown. The aim of this study is to evaluate whether cervical musculoskeletal impairments and pressure pain sensitivity are associated with self-reported headache variables in office workers.

METHODS

This study reports a cross-sectional analysis using baseline data of a randomized controlled trial. Office workers with headache were included in this analysis. Multivariate associations, controlled for age, sex and neck pain, between cervical musculoskeletal variables (strength, endurance, range of motion, movement control) and pressure pain threshold (PPT) over the neck and self-reported headache variables, such as frequency, intensity, and the Headache-Impact-Test-6, were examined.

RESULTS

Eighty-eight office workers with a 4-week headache frequency of 4.8 (±5.1) days, a moderate average headache intensity (4.5 ± 2.1 on the NRS), and "some impact" (mean score: 53.7 ± 7.9) on the headache-impact-test-6, were included. Range of motion and PPT tested over the upper cervical spine were found to be most consistently associated with any headache variable. An adjusted R2 of 0.26 was found to explain headache intensity and the score on the Headache-Impact-Test-6 by several cervical musculoskeletal and PPT variables.

DISCUSSION

Cervical musculoskeletal impairments can explain, irrespective of coexisting neck pain, only little variability of the presence of headache in office workers. Neck pain is likely a symptom of the headache condition, and not a separate entity.

Subgrouping individuals with migraine associated neck pain for targeted management

INTRODUCTION

Neck pain is one of the most common and burdensome symptoms associated with migraine. Many individuals with migraine and neck pain seek neck treatment, but evidence for such treatment is limited. Most studies have treated this population as a homogenous group, providing uniform cervical interventions that have yet to show clinically important effects. However, different neurophysiological and musculoskeletal mechanisms can underlie neck pain in migraine. Targeting treatment to specific underlying mechanisms may therefore be the key to improving treatment outcomes. Our research characterised neck pain mechanisms and identified subgroups based on cervical musculoskeletal function and cervical hypersensitivity. This suggests that specific management aimed towards addressing mechanisms relevant to each subgroup might be beneficial.

PURPOSE

This paper explains our research approach and findings to date. Potential management strategies for the identified subgroups and future research directions are discussed.

IMPLICATIONS

Clinicians should perform skilled physical examination with the aim of identifying if patterns of cervical musculoskeletal dysfunction and or hypersensitivity are present in the individual patient. There is currently no research into treatments differentiated for subgroups to address specific underlying mechanisms. It is possible that neck treatments addressing musculoskeletal impairments may be most beneficial for those subgroups where neck pain is primarily due to musculoskeletal dysfunction. Future research should define treatment aims and select specific subgroups for targeted management to determine which treatments are most effective for each subgroup.

TRIAL REGISTRATION

Not applicable.

Women with migraine presents similar altered performance in the craniocervical flexion test than women with chronic nonspecific neck pain: An observational study

BACKGROUND

Although patients with migraine show cervical muscle impairments previous studies investigating motor performance have not characterized the sample of patients with migraine according to the presence/absence of neck pain complaints.

OBJECTIVE

To verify if there are differences in the clinical and muscular performance of the superficial neck flexors and extensors during Craniocervical Flexion Test in women with migraine, considering the presence or absence of concomitant symptoms of neck pain.

METHODS

The cranio-cervical flexion test performance was assessed by its clinical stage test and by the surface electromyographic activity of the sternocleidomastoid, anterior scalene muscles upper trapezius and splenius capitis. It was assessed in 25 women with migraine without neck pain, 25 women with migraine and neck pain, 25 women with chronic neck pain and 25 pain-free control women.

RESULTS

Poorer performance of the cervical muscles was found during the execution of the cranio-cervical flexion test, in addition to higher muscle activity, especially in the sternocleidomastoid, splenius capitis, and upper trapezius muscles in the neck pain, migraine without neck pain, and migraine with neck pain groups in comparison with the results obtained for healthy women in the control group. No difference was observed between the groups of women experiencing pain. Analysis of the extensor/flexor muscle electromyographic ratio showed that there was no difference between the groups.

CONCLUSION

Poor cervical muscle performance was observed in both women with chronic nonspecific neck pain and women with migraine regardless of the presence of neck pain.

Cervical Range of Motion Analysis Performed with an Accelerometer: A Study of Intersession Reliability for Dental Practice

During the clinical examination of subjects with temporomandibular disorders (TMDs), the dentist sometimes must evaluate the cervical spine, due to the anatomical and functional connections between the cervical portion of the spine and the stomatognathic apparatus. The accelerometer is a device that evaluates the Range of Motion (ROM) of the main movements of the head on the neck. To date, only a few studies have investigated the repeatability of the use of the accelerometer in the assessment of cervical ROM. Therefore, the present longitudinal observational study analyzed the repeatability of acquired cervical movements on a sample of volunteer subjects who underwent accelerometer testing. A sample of 32 subjects was tested twice within 14 days to assess cervical ROM using a standardized protocol based on a review of existing literature. The results show that the examination is reliable for all the positions of the jaw, except for the parameters regarding the asymmetries of rotation and bending. In conclusion, the accelerometer can be considered a reliable tool for evaluating the active cervical ROM. However, further studies will be necessary to make better evaluations.

Temporomandibular disorders and neck pain in primary headache patients: a retrospective machine learning study

OBJECTIVES

To evaluate the linkage underpinning different clinical conditions as painful TMD and neck pain in patients affected by primary headaches.

MATERIALS AND METHODS

In this machine learning study, data from medical records of patients with headaches as migraine, tension-type headache (TTH) and other primary ones, referring to a University Hospital over a 10-year period were analysed. VAS was used to evaluate the intensity of the TMD and neck pain. Moreover, the magnetic resonance imaging was used to supplement the clinical data.

RESULTS

A total of 300 patients (72 male, 228 female), mean aged 37.78 ± 5.11 years, were included. Higher TMD and neck pain VAS in migraine patients were reported. The machine learning analysis focussed on type of primary headache demonstrated that a higher TMD VAS was correlated to migraine, whereas a higher neck pain VAS was correlated to TTH or migraine. Concerning the TMD type, arthrogenous and mixed TMD were correlated to mild-moderate TMD pain (depending on neck pain intensity), whereas myogenic TMD was correlated to moderate-severe TMD pain.

CONCLUSIONS

Machine-learning approach highlighted the complexity of diagnosis process and demonstrated that neck pain might be an influential variable on the belonging to different group of headaches in TMD patients.

Path Analysis Models Integrating Psychological, Psycho-physical and Clinical Variables in Individuals With Tension-Type Headache

Tension type headache (TTH) is a prevalent but poorly understood pain disease. Current understanding supports the presence of multiple associations underlying its pathogenesis. Our aim was to compare competing multivariate pathway models that explains the complexity of TTH. Headache features (intensity, frequency, or duration - headache diary), headache-related disability (Headache Disability Inventory-HDI), anxiety/depression (Hospital Anxiety and Depression Scale), sleep quality (Pittsburgh Sleep Quality Index), widespread pressure pain thresholds (PPTs) and trigger points (TrPs) were collected in 208 individuals with TTH. Four latent variables were formed from the observed variables - Distress (anxiety, depression), Disability (HDI subscales), Severity (headache features), and Sensitivity (all PPTs). Structural equation modelling (SEM) and Bayesian network (BN) analyses were used to build and compare a theoretical (model_theory) and a data-driven (model_BN) latent variable model. The model_BN (root mean square error of approximation [RMSEA] = 0.035) provided a better statistical fit than model_theory (RMSEA = 0.094). The only path common between model_bn and model_theory was the influence of years with pain on TrPs. The model_BN revealed that the largest coefficient magnitudes were between the latent variables of Distress and Disability (β=1.524, P = .006). Our theoretical model proposes a relationship whereby psycho-physical and psychological factors result in clinical features of headache and ultimately affect disability. Our data-driven model proposes a more complex relationship where poor sleep, psychological factors, and the number of years with pain takes more relevance at influencing disability. Our data-driven model could be leveraged in clinical trials investigating treatment approaches in TTH. PERSPECTIVE: A theoretical model proposes a relationship where psycho-physical and psychological factors result in clinical manifestations of headache and ultimately affect disability. A data-driven model proposes a more complex relationship where poor sleep, psychological factors, and number of years with pain takes more relevance at influencing disability.

Headache caused by the use of personal protective equipment in healthcare workers during the COVID-19 pandemic period

Objective

Coronavirus 2019 disease (COVID-19), the cause of the ongoing pandemic, is an acute respiratory tract infection, which has made it necessary for healthcare personnel to use protective equipment such as N95 masks, protective goggles and visors. External compression headaches caused by the compression of the pericranial soft tissues by wearing hats, helmets, or goggles (worn during swimming or diving) have been previously described. In our study, we aimed to evaluate the presence and characteristics of personal protective equipment-associated headaches in healthcare workers during the COVID-19 pandemic period and to determine the effects of such headaches.

Materials and methods

A face-to-face questionnaire was delivered to 300 male and female healthcare personnel between the ages of 18-56 working in healthcare units where COVID-19 patients were evaluated and treated. The data from 296 completed questionnaires was evaluated.

Results

We included 296 participants (166 females and 130 males) in our study; the mean age was 33.98 ± 8.52 years (range 18-56). One hundred ninety-six (66.22%) participants indicated that they had new onset personal protective equipment-associated headaches. Percentages of those with newly emergent headaches because of protective equipment were higher in the following participant groups: females (p = 0.045), those with COVID-19 disease history (p < 0.001), and those diagnosed with headaches before the pandemic (p = 0.001).

Conclusion

Our study showed the presence of new-onset headaches associated with personal protective equipment in healthcare workers during the COVID-19 pandemic. Personal protective equipment-related headaches were associated with the following factors: female sex, a history of COVID-19 disease, and the presence of primary headaches diagnosed before the pandemic.

Headache and orofacial pain: A traffic-light prognosis-based management approach for the musculoskeletal practice

Introduction

Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.

Purpose

The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.

Implications

Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

Are Morphometric Alterations of the Deep Neck Muscles Related to Primary Headache Disorders? A Systematic Review

This systematic review aims to summarise the evidence from studies that examined morphometric alterations of the deep neck muscles using diagnostic imaging (ultrasound imaging, magnetic resonance imaging, and computed tomography) in patients diagnosed with primary headache disorders (PHD). No previous reviews have focused on documenting morphometric changes in this population. We searched five databases (up to 12 November 2022) to identify the studies. The risk of bias (RoB) was assessed using the Quality in Prognostic Studies (QUIPS) tool and the overall quality of the evidence was assessed using The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. A total of 1246 studies were screened and five were finally included; most were at high RoB, and the overall level of confidence in results was very low. Only two studies showed a significant association between morphometric alterations of the deep neck muscles and PHD (p < 0.001); nevertheless, their RoB was high. Contradictory and mixed results were obtained. The overall evidence did not show a clear association between morphometric alterations of the deep neck muscles in patients diagnosed with PHD. However, due to the limited number of studies and low confidence in the evidence, it is necessary to carry out more studies, with higher methodological quality to better answer our question.

Cranial Autonomic Symptoms and Neck Pain in Differential Diagnosis of Migraine

Cranial autonomic symptoms and neck pain have been reported to be highly prevalent in migraine, although they are rarely considered in clinical evaluation. The aim of this review is to focus on the prevalence, pathophysiology, and clinical characteristics of these two symptoms, and their importance in the differential diagnosis between migraines and other headaches. The most common cranial autonomic symptoms are aural fullness, lacrimation, facial/forehead sweating, and conjunctival injection. Migraineurs experiencing cranial autonomic symptoms are more likely to have more severe, frequent, and longer attacks, as well as higher rates of photophobia, phonophobia, osmophobia, and allodynia. Cranial autonomic symptoms occur due to the activation of the trigeminal autonomic reflex, and the differential diagnosis with cluster headaches can be challenging. Neck pain can be part of the migraine prodromal symptoms or act as a trigger for a migraine attack. The prevalence of neck pain correlates with headache frequency and is associated with treatment resistance and greater disability. The convergence between upper cervical and trigeminal nociception via the trigeminal nucleus caudalis is the likely mechanism for neck pain in migraine. The recognition of cranial autonomic symptoms and neck pain as potential migraine features is important because they often contribute to the misdiagnosis of cervicogenic problems, tension-type headache, cluster headache, and rhinosinusitis in migraine patients, delaying appropriate attack and disease management.

Pain sensitivity in relation to frequency of migraine and tension-type headache with or without coexistent neck pain: an exploratory secondary analysis of the population study

OBJECTIVES

We aimed to investigate whether coexistent self-reported neck pain influences cephalic and extracephalic pain sensitivity in individuals with migraine and tension-type headache (TTH) in relation to diagnosis and headache frequency.

METHODS

A population of 496 individuals completed a headache interview based on ICHD criteria, providing data collected by self-administered questionnaires, assessments of pericranial total tenderness score (TTS) and pressure pain thresholds (PPT). Stimulus-response (SR) functions for pressure vs. pain were recorded. Presence of neck pain in the past year was assessed by the self-administered questionnaire. We categorized participants by primary headache type. We also categorized participants into 3 groups by headache frequency: chronic (≥15) or episodic (<15 headache days/month) headache and controls. TTS, PPTs and the area under the SR curve were compared between subgroups using Generalized Linear Models with pairwise comparisons controlling for age and sex.

RESULTS

Individuals with chronic followed by episodic headache had higher TTS than controls (overall p≤0.001). The difference between chronic and episodic headache subgroups was significant in the group with neck pain (p≤0.001) but not in the group without neck pain. In individuals with neck pain, mean TTS was higher in coexistent headache (migraine and TTH), 23.2 ± 10.7, and pure TTH, 17.8 ± 10.3, compared to pure migraine, 15.9 ± 10.9 and no headache 11.0 ± 8.3 (overall p<0.001). Temporal and finger PPTs did not statistically differ among the chronic headache, the episodic headache and controls in individuals with and without neck pain. Temporalis and trapezius SR-functions showed that tenderness was increased in individuals with chronic headache to higher degree than in those with episodic headache, and more so in those with neck pain.

CONCLUSIONS

Coexistent neck pain is associated with greater pericranial tenderness in individuals with chronic headache and to a lesser degree in those with episodic headache. Sensitization may be a substrate or consequence of neck pain and primary headache, but a longitudinal study would be needed for further clarification.

Inter-rater reliability, discriminatory and predictive validity of neck movement control tests in office workers with headache and/or neck pain

BACKGROUND

Movement control tests (MCTs) are clinical tests to evaluate impairment of movement and associated neuromuscular control and are commonly used to evaluate people with neck pain or headache conditions. The aim of this study was to establish inter-rater reliability as well as discriminatory and predictive validity for seven MCTs of the upper (UCS) and lower cervical spine (LCS) in office workers with headache or neck pain.

METHODS

Seven MCTs of the UCS (3) and LCS (4) were performed at baseline on 140 office workers which were included in a cluster randomized controlled trial. The occurrences of headache and neck pain were established at baseline (discriminatory validity) and at a 15-month follow-up (predictive validity). Inter-rater-reliability was established in a separate cross-sectional study.

RESULTS

MCTs showed slight to almost perfect inter-rater reliability but limited discriminatory (baseline) and limited to small predictive validity (15-month follow up) for different subgroups of office workers with headache and/or neck pain. MCTs of the UCS showed limited discriminatory validity, especially for rotation in participants with headache and neck pain compared to those with headache only (Negative Likelihood-ratio: 0.82, 95% CI: 0.69-0.98). Participants with neck pain only and ≥1/4 positive MCTs for the sagittal plane had an increased risk for future neck pain (Relative risk: 3.33, 95% CI: 1.05-10.56).

DISCUSSION

MCTs of the UCS and LCS are reliable but have only limited to small validity to predict future headache events in office workers. Insufficient sagittal plane movement control may predict neck pain relapses in the future.

Deep Cervical Muscles and Functionality in Patients with Chronic Tension-Type Headache: An Observational Study

Background and objectives: Chronic tension-type headache (TTH) is the type of headache with the highest prevalence. The involvement of musculoskeletal structures in TTH is supported by evidence in the scientific literature. Among these, deep cervical muscle strength appears to be related to the function of the cervical spine and the clinical characteristics of TTH. This study aimed to correlate anatomical, functional, and psychological variables in patients with TTH. Materials and methods: An observational descriptive study was carried out with 22 participants diagnosed with TTH for at least six months. The characteristics of headaches, including ultrasound-based deep neck flexor and extensor muscle thickness, range of motion (ROM), and pressure pain threshold (PPT), were recorded. We also conducted the Pain Vigilance and Awareness Questionnaire (PVAQ) and the Craniocervical Flexion Test (CCFT). Results: Moderate-large negative correlations were found between the PVAQ and the muscle thickness of right deep flexors contracted (r = -0.52; p = 0.01), left multifidus contracted (r = -0.44; p = 0.04), right multifidus at rest (r = -0.48; p = 0.02), and right multifidus contracted (r = -0.45; p = 0.04). Moderate-large positive correlations were found between the CCFT score and the left cervical rotation ROM (r = 0.53; p = 0.01), right cervical rotation ROM (r = 0.48; p = 0.03), muscle thickness of left multifidus contracted (r = 0.50; p = 0.02), and muscle thickness of right multifidus at rest (r = 0.51; p = 0.02). The muscle thickness of the contracted right deep cervical flexors showed a moderate negative correlation with headache intensity (r = -0.464; p = 0.03). No correlations were found between PPT and the rest of the variables analyzed. Conclusions: In patients with TTH, a higher thickness of deep cervical muscles was associated with higher ROM and higher scores in the CCFT. In turn, the thickness of deep cervical muscles showed negative correlations with pain hypervigilance and headache intensity. These results contribute to a better understanding of the physical and psychosocial factors contributing to the development of TTH, which is useful for implementing appropriate prevention and treatment measures.

Musculoskeletal mimics of cervical radiculopathy

Musculoskeletal mimics of cervical radiculopathy will be explored in this AANEM monograph. A review of the literature and textbooks was conducted. Musculoskeletal cervical radiculopathy mimics include: (1) head/neck pain, such as neck tension, cervicogenic headache, and temporomandibular disorder; (2) referred pain from shoulder pathology, such as rotator cuff tears/impingement; (3) elbow region abnormalities, including medial/lateral epicondylitis; (4) wrist/hand conditions, such as DeQuervain's tenosynovitis and intersection syndrome; (5) muscle connective tissue disorders, including myofascial trigger points; (6) conditions that have decreased range of motion, including frozen shoulder and rounded shoulders with tight pectoral/scalene muscles; (7) conditions with joint hyperlaxity and instability, as seen in post-stroke shoulder subluxation; (8) vascular conditions, such as thoracic outlet syndrome; and (9) autonomic controlled soft tissue changes associated with complex regional pain syndrome. Formulating a differential diagnosis and recognizing mimics of cervical radiculopathy can decrease the time between symptom onset and diagnosis/treatment plan.

Reliability of Cervicocephalic Proprioception Assessment: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to determine the reliability and, where possible, the validity of cervicocephalic proprioceptive (CCP) tests in healthy adults and clinical populations.

METHODS

A systematic search, utilizing 7 databases from the earliest possible date to April 14, 2021, identified studies that measured reliability of CCP tests. Studies were screened for eligibility, and included studies were appraised using Quality Appraisal Tool for Studies of Diagnostic Reliability (QAREL) and Quality Assessment and Diagnostic Accuracy Studies-2 Tool (QUADAS-2) tools. Validity outcomes were assessed for included studies.

RESULTS

Of 34 included studies, 29 investigated reliability for sense of position tests, 10 involved sense of movement tests, and 1 used a sense of force test. The head to neutral test was reliable and valid when 6 or more repetitions were performed within the test, discriminating between those with and without neck pain. Head tracking tests were reliable with 6 repetitions, and 1 study found discriminative validity in a whiplash population. Studies that found discriminative validity in sense of position reported mean joint position error generally >4.5° in the neck pain group and <4.5° in the asymptomatic group. No sense of force test was applied to a clinical population. Convergent validity analysis showed that these proprioceptive tests have low correlations with each other.

CONCLUSION

The reliability and validity of CCP tests for sense of position and movement are dependent upon equipment and repetitions. Six repetitions are generally required for good reliability, and joint position error >4.5° is likely to indicate impairment in sense of position.

Cervical musculoskeletal impairments in the 4 phases of the migraine cycle in episodic migraine patients

OBJECTIVE

To assess cervical musculoskeletal impairments during the 4 phases of a migraine cycle in episodic migraine patients, controlling for the presence of concomitant neck pain.

METHODS

Differences in cervical musculoskeletal impairments were assessed during the 4 migraine phases in episodic migraine patients and compared with healthy controls controlling for concomitant neck pain. Cervical musculoskeletal impairments were assessed as follow: cervical active range of motion; flexion rotation test; craniocervical flexion test and calculation of activation pressure score; the total number of myofascial trigger points in head/neck muscles; the number of positivevertebral segments (headache's reproduction) during passive accessory intervertebral movement; pressure pain thresholds over C1, C2, C4, C6 vertebral segments bilaterally, trigeminal area, hand, and leg. Signs of pain sensitization were assessed by evaluating mechanical pain threshold over trigeminal area and hand, pressure pain thresholds, and the wind-up ratio. The Bonferroni-corrected p-value (05/4 = 0.013) was adopted to assess the difference between groups, while a p-value of 0.05 was considered significant for the correlation analysis.

RESULTS

A total of 159 patients and 52 controls were included. Flexion rotation test and craniocervical flexion test were reduced in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). The number of myofascial trigger points and positive vertebral segments was increased in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). Flexion, extension, and total cervical active range of motion and cervical pressure pain thresholds were reduced in episodic migraine in the ictal phase versus controls (p < 0.007) with no other significant differences. Outside the ictal phase, the total cervical active range of motion was positively correlated with trigeminal and leg pressure pain threshold (p < 0.026), the number of active myofascial trigger points and positive positive vertebral segments were positively correlated with higher headache frequency (p=0.045), longer headache duration (p < 0.008), and with headache-related disability (p = 0.031). Cervical pressure pain thresholds were positively correlated with trigeminal, hand, and leg pressure pain threshold (p < 0.001), and trigeminal and leg mechanical pain thresholds (p < 0.005), and negatively correlated with the wind-up ratio (p < 0.004).

CONCLUSION

In all phases of the migraine cycle, independent of the presence of concomitant neck pain, episodic migraine patients showed reduced flexion rotation test and craniocervical flexion test and an increased number of myofascial trigger points and passive accessory vertebral segments. These impairments are correlated with enhanced headache duration, headache-related disability, and signs of widespread pain sensitization. Reduction in active cervical movement and increased mechanical hyperalgesia of the cervical was consistent in ictal episodic migraine patients and the subgroups of episodic migraine patients with more pronounced widespread sensitization.

Understanding the interaction between clinical, emotional and psychophysical outcomes underlying tension-type headache: a network analysis approach

OBJECTIVE

Evidence supports that tension-type headache (TTH) involves complex underlying mechanisms. The current study aimed to quantify potential multivariate relationships between headache-related, psychophysical, psychological and health-related variables in patients with TTH using network analysis.

METHODS

Demographic (age, height, weight), headache-related (intensity, frequency, duration, and headache-related disability), psychological and emotional (Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index), psycho-physical (pressure pain thresholds [PPTs] and myofascial trigger points) and health-related variables (SF-36 questionnaire) were collected in 169 TTH patients. Network connectivity analysis was unsupervised conducted to quantify the adjusted correlations between the modelled variables and to assess their centrality indices (i.e., the connectivity with other symptoms in the network and the importance in the modelled network).

RESULTS

The connectivity network showed local associations between psychophysical and headache-related variables. Multiple significant local positive correlations between PPTs were observed, being the strongest weight between PPTs over the cervical spine and temporalis area ([Formula: see text]: 0.41). The node with the highest strength, closeness and betweenness centrality was depressive levels. Other nodes with high centrality were vitality and headache intensity.

DISCUSSION

This is the first study applying a network analysis to understand the connections between headache-related, psychophysical, psychological and health-related variables in TTH. Current findings support a model on how the variables are connected, albeit in separate clusters. The role of emotional aspects, such as depression, is supported by the network. Clinical implications of the findings, such as developing TTH treatments strategies targeting these most important variables, are discussed.

Acupuncture Treatment is Associated with Reduced Dementia Risk in Patients with Migraine: A Propensity-Score-Matched Cohort Study of Real-World Data

BACKGROUND

Migraine is a recurrent headache disease that has been identified as a risk factor for subsequent dementia. The present study collected data from Taiwan's National Health Insurance Research Database (NHIRD) to investigate the incidence of dementia in patients with migraine who did or did not concurrently receive acupuncture treatment.

METHODS

A 1:1 propensity score method was used to match an equal number of patients (N = 4813) in the acupuncture and nonacupuncture cohorts based on sex, age, migraine diagnosis year, index year, insurance amount, urbanization level, baseline comorbidities, and medication usage. We employed Cox proportional hazards models to evaluate the risk of dementia.

RESULTS

Patients with migraine who received acupuncture treatment were found to have a lower risk of dementia (adjusted hazard ratio [aHR] = 0.51, 95% CI = 0.40-0.65) than those who did not undergo acupuncture treatment. The cumulative incidence of dementia was significantly lower in the acupuncture cohort than in the nonacupuncture cohort (Log rank test, p < 0.001). This propensity score-matched cohort study demonstrated an association between acupuncture treatment and dementia development in patients with migraine in Taiwan.

CONCLUSION

The results suggest that acupuncture treatment significantly reduced the development of dementia in patients with migraine.

Cervical musculoskeletal impairments in migraine

Background

Neck pain is common and disabling amongst individuals with migraine. Cervical musculoskeletal interventions are often sought but there is currently no evidence to support such interventions for this population. Improved understanding of how cervical musculoskeletal impairments present in migraine can elucidate neck pain mechanisms and guide clinicians and researchers in the management of patients with migraine and neck pain.

Main body

Migraine hypersensitivity is a major consideration when assessing for cervical impairments as it can aggravate migraine and confound findings. Current evidence of cervical impairments in migraine is limited by disregard for the different underlying causes of neck pain and possible influence of hypersensitivity. Findings of cervical musculoskeletal impairments are mixed within and across studies, indicating that different forms of neck pain are present in migraine. Some migraineurs have neck pain that is part of the migraine symptom complex and therefore exhibit little or no cervical musculoskeletal impairment. Others have a cervical source of neck pain and therefore exhibit a pattern of cervical musculoskeletal impairments akin to that of cervical disorders. The presence of cervical musculoskeletal dysfunction may or may not be related to migraine but knowledge of this is currently lacking which impacts decision making on management. Cervical musculoskeletal interventions may be indicated for migraineurs with identified cervical dysfunction but other factors requiring further clarification include determination of i) patient specific outcomes, ii) impact of co-existing migraine referred neck pain, and iii) potential moderating effects of migraine hypersensitivity on treatment efficacy.

Conclusions

Physiotherapists should seek a combination of cervical impairments through skilful assessment to identify if cervical musculoskeletal dysfunction is present or not in individual patients. The relevance of cervical dysfunction to migraine and influence of co-existing migraine referred neck pain need to be established through detailed evaluation of pain behaviours and further research. Future clinical trials should define expected treatment outcomes and select individuals with cervical musculoskeletal dysfunction when investigating the efficacy of cervical musculoskeletal interventions.

Psychophysical testing in chronic migraine and chronic tension type headache: An observational study

BACKGROUND

Clinical presentation is the key to the diagnosis of patients with migraine and tension-type headache, but features may overlap when both become chronic. Psychophysical parameters may distinguish both conditions. We aimed to compare psychophysical aspects of patients with chronic migraine, chronic tension-type headache and headache-free controls, and to determine whether these can predict headache frequency.

METHODS

An examiner blinded to the diagnosis assessed 100 participants (chronic migraine (n = 38), chronic tension-type headache (n = 31) and controls (n = 31)). Assessed variables included painful area, pressure pain thresholds, temporal summation, cervical range of motion, neck posture, headache and neck impact, quality of life, and kinesiophobia. Comparison between groups was performed with one-way ANOVA and multiple linear regression was used to assess the headache frequency predictors.

RESULTS

We found differences of both headache groups compared to controls (p < 0.01), but not between headache groups. Neck disability was a significant predictor of headache frequency for chronic tension-type headache (adjusted R² = 0.14; β = 0.43; p = 0.03) and chronic migraine (adjusted R² = 0.18; β = 0.51; p < 0.01).

CONCLUSIONS

Chronic tension-type headache and chronic migraine showed similar psychophysical results, but were significantly worse when compared to controls. The psychophysical examination did not discriminate between headache types. The variable best explaining headache frequency for both headache types was neck disability.

Neck Active Movements Assessment in Women with Episodic and Chronic Migraine

We aimed to compare movement parameters and muscle activity during active cervical spine movements between women with episodic or chronic migraine and asymptomatic control. We also assessed the correlations between cervical movement measures with neck-related disability and kinesiophobia. Women with episodic (n = 27; EM) or chronic (n = 27; CM) migraine and headache-free controls (n = 27; CG) performed active cervical movements. Cervical range of motion, angular velocity, and percentage of muscular activation were calculated in a blinded fashion. Compared to CG, the EM and CM groups presented a reduced total range of motion (p < 0.05). Reduced mean angular velocity of cervical movement was also observed in both EM and CM compared to CG (p < 0.05). Total cervical range of motion and mean angular velocity showed weak correlations with disability (r = −0.25 and −0.30, respectively; p < 0.05) and weak-to-moderate correlations with kinesiophobia (r = −0.30 and −0.40, respectively; p < 0.05). No significant correlation was observed between headache features and total cervical range of motion or mean angular velocity (p > 0.05). No differences in the percentage of activation of both flexors and extensors cervical muscles during active neck movements were seen (p > 0.05). In conclusion, episodic and chronic migraines were associated with less mobility and less velocity of neck movements, without differences within muscle activity. Neck disability and kinesiophobia are negative and weakly associated with cervical movement.

Instrumental assessment of physiotherapy and onabolulinumtoxin-A on cervical and headache parameters in chronic migraine

Introduction

The purpose of the present study is to compare the effect of the physiotherapy to onabolulinumtoxin-A, and their combination, in relation to cervical and headache parameters in patients with chronic migraine.

Methods

This is an observational cohort study conducted by a headache center and a physiotherapy degree course on 30 patients with chronic migraine. The patients were distributed in three groups of treatments for three months: onabolulinumtoxin-A only, physiotherapy only, and onabolulinumtoxin-A plus physiotherapy. The patients were evaluated, before and after each treatment, using the following: the postural assessment software SAPO for the forward head posture; the CROM goniometer for the cervical range of motion; the Migraine Disability Assessment Score for headache parameters.

Results

After 3 months of each treatment, the scores obtained for the headache-related disability and the frequency of migraine decreased significantly for all groups, but the pain intensity scores changed significantly only in the onabolulinumtoxin-A (p = 0.01) and in the onabolulinumtoxin-A plus physiotherapy groups (p = 0.007). On the other hand, the forward head posture was reduced significantly in the physiotherapy (p = 0.002) and in the onabolulinumtoxin-A plus physiotherapy groups (p = 0.003). The cervical range of motion increased significantly in certain directions in the physiotherapy group and in the onabolulinumtoxin-A plus physiotherapy groups.

Conclusions

The physiotherapy improved the cervical parameters. The onabolulinumtoxin-A decreased pain intensity. As a consequence, it can be said that the combined treatment was more useful than a mono-therapy alone. From our results, it can be concluded that onabolulinumtoxin-A plus physiotherapy could be a good option in the management of chronic migraine.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-021-05491-w.

Comparison of cervical muscle isometric force between migraine subgroups or migraine-associated neck pain: a controlled study

This study aimed to verify if migraine frequency or migraine-associated neck pain were associated with a reduction of normalized force and altered electromyographic activity during maximal cervical muscle isometric contractions. Additionally, it aimed to assess the correlation of normalized isometric force with years with migraine, headache frequency, headache intensity, migraine-related disability, and severity of cutaneous allodynia. The sample comprises 71 women with migraine (40/31 episodic/chronic, 42/18 with/without neck pain) and 32 women without headache. Cervical muscle isometric force in flexion, extension, and lateral flexion was assessed synchronized with the acquisition of superficial electromyography from the cervical muscles. Women with episodic migraine presented lower normalized isometric force in extension, flexion, and right and left lateral flexions than controls (P < 0.05). Women with migraine and neck pain exhibited lower cervical extension and right/left lateral-flexions normalized isometric force than controls (P < 0.05). No significant differences were observed in antagonist activity. Normalized isometric force in all directions showed weak to moderate correlations with the severity of self-reported symptoms of cutaneous allodynia (- 0.25 ≥ r ≥ - 0.39). No additional linear correlation with clinical migraine features was observed. In conclusion, cervical muscle weakness may be associated with episodic migraine and neck pain concurrent with migraine attacks without altered antagonist activity. Additionally, it may also be related to the severity of cutaneous allodynia.

Neck pain associated with migraine does not necessarily reflect cervical musculoskeletal dysfunction

OBJECTIVE

To identify how frequently the neck pain associated with migraine presents with a pattern of cervical musculoskeletal dysfunction akin to cervical musculoskeletal disorders, and to determine if pain hypersensitivity impacts on cervical musculoskeletal function in persons with migraine.

BACKGROUND

Many persons with migraine experience neck pain and often seek local treatment. Yet neck pain may be part of migraine symptomology and not from a local cervical source. If neck pain is of cervical origin, a pattern of musculoskeletal impairments with characteristics similar to idiopathic neck pain should be present. Some individuals with migraine may have neck pain of cervical origin, whereas others may not. However, previous studies have neglected the disparity in potential origins of neck pain and treated persons with migraine as a homogenous group, which does not assist in identifying the origin of neck pain in individuals with migraine.

METHODS

This cross-sectional, single-blinded study was conducted in a research laboratory at the University of Queensland, Australia. Persons with migraine (total n = 124: episodic migraine n = 106, chronic migraine = 18), healthy controls (n = 32), and persons with idiopathic neck pain (n = 21) were assessed using a set of measures typically used in the assessment of a cervical musculoskeletal disorder, including cervical movement range and accuracy, segmental joint dysfunction, neuromuscular and sensorimotor measures. Pain hypersensitivity was assessed using pressure pain thresholds and the Allodynia Symptom Checklist. People with migraine with diagnoses of comorbid neck disorders were excluded. Cluster analysis was performed to identify how participants grouped on the basis of their performance across cervical musculoskeletal assessments. Post hoc analyses examined the effects of pain hypersensitivity on musculoskeletal function, and if any symptoms experienced during testing were related to musculoskeletal function.

RESULTS

Two distinct clusters of cervical musculoskeletal function were found: (i) neck function similar to healthy controls (n = 108) and (ii) neck dysfunction similar to persons with neck pain disorders (n = 69). Seventy-six of the individuals with migraine (62 with neck pain and 14 without neck pain) were clustered as having normal cervical musculoskeletal function, whereas the remaining 48 with neck pain had cervical dysfunction comparable with a neck disorder. Musculoskeletal dysfunction was not related to pain hypersensitivity or symptoms experienced during testing.

CONCLUSIONS

Neck pain when present with migraine does not necessarily indicate the existence of cervical musculoskeletal dysfunction. Skilled assessment without reliance only on the person reporting symptoms is needed to identify actual cervical dysfunction. Treatments suitable for neck musculoskeletal disorders would seem inappropriate for the individuals without cervical dysfunction. Future studies evaluating any potential effects of such treatments should only select participants with neck pain of cervical origin.

Effects of combining manual therapy, neck muscle exercises, and therapeutic pain neuroscience education in patients with migraine: a study protocol for a randomized clinical trial

BACKGROUND

Non-pharmacological approaches for the management of migraine exhibit low to moderate effectiveness due to a lack of high-quality randomized clinical trials. In fact, previous studies applied isolated techniques, which were not representative of common clinical practice. A multimodal approach for migraine may benefit these patients more than isolated approaches. This randomized clinical trial aims to determine the effectiveness of a multimodal protocol combining manual therapy, exercise, and therapeutic pain neuroscience education versus the application of manual therapy or pain neuroscience education alone in patients with migraine.

METHODS

This clinical trial will include 75 individuals of both sexes, aged between 18 and 55 years, with migraine. Participants will be randomized into three groups: the therapeutic pain neuroscience education (TPNE; n = 25) group, the manual therapy (MT; n = 25) group, and the multimodal (MM; n = 25) group. The TPNE group will receive one orientation session on migraine and pain self-management, and recommendations for daily active stretching and walking, with subsequent therapist monitoring. The MT group will receive manual therapies targeting musculoskeletal disorders of the cervical spine. The MM group will receive manual therapies targeting musculoskeletal disorders of the cervical spine, active neck exercises, and therapeutic pain neuroscience education. The treatment period will last 12 weeks. The primary outcome will be the headache impact, measured using the Headache Impact Test (HIT-6). Secondary outcomes will include migraine frequency and intensity, cervical mobility and strength parameters, neck pain-related disability, kinesiophobia, cutaneous allodynia, pain-related catastrophizing, quality of life, and self-perception of change. All outcomes will be evaluated at the fourth, eighth, and twelfth weeks of the treatment period. Primary and secondary clinical outcomes, such as headache impact, frequency, and intensity, will also be evaluated at the 1-, 2-, and 4-month follow-ups.

DISCUSSION

The results of this randomized clinical trial may provide high-quality clinical evidence of the effects of non-pharmacological treatment options for the management of migraine.

TRIAL REGISTRATION

This study was registered under the access code RBR-7s22c75 in the Registro Brasileiro de Ensaios Clínicos (ReBEC) in December 2020.

Headache Related to PPE Use during the COVID-19 Pandemic

PURPOSE OF REVIEW

Personal protection equipment (PPE)-associated headache is an unusual secondary headache disorder that predominantly occurs in healthcare workers as a consequence of the donning of protective respirators, face masks and/or eyewear. The appreciation of this entity is important given the significant ramifications upon the occupational health of healthcare workers and could additionally have an impact on persons living with pre-existing headache disorder(s).

RECENT FINDINGS

There has been a renewed interest and recognition of PPE-associated headaches amongst healthcare professionals, largely brought about by the ongoing COVID-19 pandemic which has besieged healthcare systems worldwide. De novo PPE-associated headaches may present with migrainous or tension-type features and can be viewed as a subtype of external compression headache. The prognosis of the disorder is generally favourable, given that most headaches are short-lived without long-term sequalae. Several aetiologies have been postulated to account for the development of these headaches. Notably, these headaches can affect the occupational health and work performance of healthcare workers. In this review, we discuss the epidemiology, clinical characteristics, probable etiopathogenesis, management and prognosis of PPE-associated headaches in the context of the COVID-19 pandemic. Future directions for research and PPE development are proposed.

Chronic Primary Headache Subjects Have Greater Forward Head Posture than Asymptomatic and Episodic Primary Headache Sufferers: Systematic Review and Meta-analysis

OBJECTIVE

To summarize the cervical physical examination characteristics in subjects with chronic primary headache and compare those with a healthy population and a population with episodic primary headache.

DESIGN

Systematic review and meta-analysis.

SUBJECTS

Humans ≥18 years old. At least one of the study groups should be constituted by subjects diagnosed with one of the chronic primary headache subtypes according to the International Classification of Headache Disorders, 3rd Edition.

COMPARISON

Neck physical examination outcomes of subjects with chronic primary headache compared with a healthy population or subjects with episodic primary headache.

OUTCOMES

Forward head posture (FHP), cervical range of movement, motor control, neck muscle activity, and reproduction and resolution of symptoms.

METHODS

Two reviewers assessed independently the MEDLINE, EMBASE, WOS, MEDES, PEDro, and CINAHL databases to select observational studies. First, both implemented an agreement for a search strategy. Then, they screened independently for duplicates, titles, abstracts, and full-text information. A meta-analysis was conducted to compare measures between groups.

RESULTS

Twelve studies (N = 1,083) with moderate quality (mean ± SD = 7.75 ± 1.48 on the Newcastle Ottawa Scale) were selected for the qualitative analysis. The meta-analysis showed that patients with chronic primary headache presented greater forward head posture than asymptomatic participants (N = 275, Hg = 0.68, 95% CI = 0.25-1.1, Z = 3.14, P < 0.01) and patients with episodic primary headache (N = 268, Hg = 0.39, 95% CI = 0.13-0.65, Z = 2.98, P < 0.01).

CONCLUSIONS

There is moderate to strong evidence that patients with chronic primary headache present greater FHP than asymptomatic individuals and moderate evidence that patients with chronic primary headache present greater forward head posture than those with episodic primary headache.

Inter, intra-examiner reliability and validity of inertial sensors to measure the active cervical range of motion in patients with primary headache

We analyzed the inter- and intra-examiner reliability of Werium inertial sensors and the cervical range of motion (CROM) instrument for the measurement of active CROM (AcROM) in patients with primary headache. Another objective is to analyze the validity of the inertial sensors (Werium). The literature has reported symptomatology features in patients diagnosed with primary headache similar to that of patients with cervicogenic headache. The International Classification of Headache (ICHD-III) established the presence of reduced AcROM as a diagnostic criterion for cervicogenic headache. Several instruments are used for this measurement, with limitations in their applicability in daily clinical practice. A prospective longitudinal repeated measures study was conducted to assess the intra- and inter-rater reliability and validity of Werium inertial sensors in 20 adults with chronic primary headache. For the inter-rater analysis, the intraclass correlation coefficient (ICC) values were above 0.75 for all movements, indicating a good level of reliability. For the intra-rater results, the ICC values obtained by the Werium inertial sensors for all cervical movements were good for rater A (ICC >0.80) and rater B (ICC >0.84). For the validity, the ICCs obtained by the Werium inertial sensors compared with the CROM instrument for all cervical movements were moderate for both raters (ICC > 0.70, respectively). Values obtained in the standard error of measurement, minimum detectable change at 90% and limits of agreement also indicated good agreement. Werium inertial sensors have shown good to excellent reliability results, both intra- and inter-examiner (ICC > 0.75). Likewise, when the sensors were compared with another validated instrument (CROM device) they obtained high reliability results (ICC > 0.70). These results plus its relatively low price and ease of use allow us to recommend it in daily clinical practice to measure AcROM in patients with chronic primary headache.

A Two Joint Neck Model to Identify Malposition of the Head Relative to the Thorax

Neck pain is a frequent health complaint. Prolonged protracted malpositions of the head are associated with neck pain and headaches and could be prevented using biofeedback systems. A practical biofeedback system to detect malpositions should be realized with a simple measurement setup. To achieve this, a simple biomechanical model representing head orientation and translation relative to the thorax is introduced. To identify the parameters of this model, anthropometric data were acquired from eight healthy volunteers. In this work we determine (i) the accuracy of the proposed model when the neck length is known, (ii) the dependency of the neck length on the body height, and (iii) the impact of a wrong neck length on the models accuracy. The resulting model is able to describe the motion of the head with a maximum uncertainty of 5 mm only. To achieve this high accuracy the effective neck length must be known a priory. If however, this parameter is assumed to be a linear function of the palpable neck length, the measurement error increases. Still, the resulting accuracy can be sufficient to identify and monitor a protracted malposition of the head relative to the thorax.

Facemask headache: a new nosographic entity among healthcare providers in COVID-19 era

BACKGROUND

SARS-CoV-2 is a novel infectious agent causing coronavirus disease 2019, which has been declared as pandemic in March 2020. Personal protective equipment has been mandatory for healthcare workers in order to contain the outbreak of pandemic disease. Mild neurological disturbances such as headache have been related to the extensive utilization of facemask. This study aims to examine headache variations related to the intensive utilization of facemask among a cohort of healthcare professionals in a setting of low-medium risk of exposure to SARS-CoV-2.

METHODS

This is a cross-sectional study among healthcare providers from different hospital and clinics in Italy. Each participant completed a specifically designed self-administered questionnaire. Headache features and outcome measures' change from baseline were evaluated over a 4-month period, in which wearing facemask has become mandatory for Italian healthcare workers.

RESULTS

A total of 400 healthcare providers completed the questionnaire, 383 of them met the inclusion criteria. The majority were doctors, with a mean age of 33.4 ± 9.2 years old. Among 166/383 subjects, who were headache free at baseline, 44 (26.5%) developed de novo headache. Furthermore, 217/383 reported a previous diagnosis of primary headache disorder: 137 were affected by migraine and 80 had tension-type headache. A proportion (31.3%) of these primary headache sufferers experienced worsening of their pre-existing headache disorder, mainly for migraine frequency and attack mean duration.

CONCLUSIONS

Our data showed the appearance of de novo associated facemask headache in previous headache-free subjects and an exacerbation of pre-existing primary headache disorders, mostly experienced by people with migraine disease.

Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study

BACKGROUND

Though a large amount of research on the management of headache has been conducted, the clinical effectiveness of these treatments remains unclear.

OBJECTIVES

To reach consensus among international musculoskeletal experts on what the most appropriate management is in patients that suffer from headache.

DESIGN

Expert group and Delphi-study.

METHODS

A total of 11 experts participated in the expert panel groups, where the role of physiotherapy in the management of headache was discussed. Afterwards, 14 of the initial 25 participants in the field of headache completed the whole Delphi study, which was conducted over 4 rounds. The first round aimed to identify clinical indicators and treatments that are useful in patients with headache. These questions were then categorized and ranked during the second, third, and fourth rounds. Consensual agreement was set at ≥ 80%.

RESULTS

After the final round, 9 interventions were rated as useful by the participants. In the final extra round, 14 clinical indicators were retrieved as important to decide whether or not to start one of the consensual treatments. The top 3 management strategies were (1) upper cervical spine mobilisations in cervivogenic headache, (2) active mobilisation exercises of the cervical spine in cervivogenic headache, and (3) lifestyle advice in tension-type headache and migraine.

CONCLUSION

International experts agreed that most scientifically established effective treatments are useful in cervicogenic headache. Consensual agreement on treatments for migraine and tension-type headache were only reached for specific treatments. Their recommendations provide a framework for further research and the clinical management of headache.

Comparison and Association of Neck Extensor Muscles’ Endurance and Postural Function in Subjects with and without Chronic Neck Pain – A Cross-Sectional Study

Purpose Neck extensor endurance (NEE) and position sense are vital for maintaining cervical spine function and defects in these processes may be associated with impaired postural control in chronic neck pain (CNP) subjects. The study’s objectives are 1) to compare the cervical extensor endurance capability and postural control of CNP subjects with those of asymptomatic controls; 2) to investigate the association between NEE and postural control.

Materials and Methods Sixty-four participants (38 asymptomatic, 38 with CNP) participated in this cross-sectional study. NEE was assessed using a clinical extensor endurance test. Under open and closed eyes conditions, postural control measures were tested with the Good Balance system. The postural control parameters were AP-velocity (mm/s), ML-velocity (mm/s) and Velocity moment (mm2). NEE capacity and postural control parameters were compared and correlated between asymptomatic and CNP subjects.

Results and Discussion CNP subjects showed lower NEE capacity (p<0.001) and significantly larger AP-velocity (p<0.001), ML-velocity (p<0.001) and Velocity moment (p<0.001) than asymptomatic participants. NEE negatively correlated with AP-velocity (r=−0.51, p=0.001), ML-velocity (r=0.46, p=0.003) and velocity moment (r=0.38, p=0.020) in asymptomatic subjects in eyes open condition and no correlations in subjects with CNP. CNP subjects showed increased postural sway velocities and lowered extensor endurance capacity compared to asymptomatic participants. No correlations existed between NEE and postural control parameters in CNP subjects.

A pilot study on non-invasive treatment of migraine: The self-myofascial release

The aims of this paper was to determine the effect of self-myofascial release (SMFR) on postural stability and to analyze if it can influence migraine condition. Twenty-five subjects (age 49.7± 12.5) affected by migraine were enrolled. Assessments included a stabilometric analysis in order to evaluate balance and plantar support, with eyes open (OE) and closed (CE); cervical ROM measurement; evaluation of upper limb strength through handgrip. All the analysis were carried out before and after the administration of a single SMFR protocol, using medium density small balls laid in the three most painful trigger points in migraine patients: trapezius, sternocleidomastoids and suboccipital muscles. Performing a T test for paired samples, there was a significant increase in two ranges of the stabilometric analysis: ellipse surface, both with open and closed eyes (p value EO = 0.05; p value EC = 0.04) and length of the sway path, but just with closed eyes (p value = 0.05). SMFR might have a positive impact on postural stability in subjects with migraine. Further investigation should be conducted to confirm the hypothesis.

A Survey of Personnel Protective equipment's (PPE) Use and Comfort Levels Among Surgeons During Routine Cancer Surgery in the COVID-19 Pandemic

Personnel protective equipment (PPE) are recommended during surgery even in COVID-19 negative patients especially in a high-prevalence region due to its higher false-negative rates. However, the use of PPE has not been universal mainly due to the perception of discomfort and associated stress and fatigue. This study was done to understand the pattern of PPE use by cancer surgeons during the pandemic and the associated discomfort, stress, and fatigue with its use. The survey, consisting of 29 questions, was circulated widely across the country by email and chat groups among cancer surgeons. The study was registered with the Clinical Trials Registry of India (CTRI/2020/08/027050). We received a total of 342 evaluable responses that could be included for analysis. All the respondents used appropriate PPE in different combinations. N-95 mask and the face shield were the two components of the PPE that gave rise to a lot of discomforts. Fogging (of face shields) (p < 0.001,OR 3.61), dryness of mouth (p < 0.001,OR 3.35), and breathing difficulty/feeling of suffocation (p = 0.034,OR 1.68) contributed to the stress, whereas headache (p < 0.001,OR 11.34) and breathing difficulty/feeling of suffocation (p < 0.001,OR 4.24) contributed to the fatigue associated with PPE use the most. PPE was routinely used during cancer surgery in COVID-19 negative patients during the pandemic. However, most surgeons experienced different degrees of discomfort, especially with the N-95 masks and eye protection.