Tension-type headache: current research and clinical management

Preliminary External Validation Results of the Artificial Intelligence-Based Headache Diagnostic Model: A Multicenter Prospective Observational Study

The misdiagnosis of headache disorders is a serious issue, and AI-based headache model diagnoses with external validation are scarce. We previously developed an artificial intelligence (AI)-based headache diagnosis model using a database of 4000 patients' questionnaires in a headache-specializing clinic and herein performed external validation prospectively. The validation cohort of 59 headache patients was prospectively collected from August 2023 to February 2024 at our or collaborating multicenter institutions. The ground truth was specialists' diagnoses based on the initial questionnaire and at least a one-month headache diary after the initial consultation. The diagnostic performance of the AI model was evaluated. The mean age was 42.55 ± 12.74 years, and 51/59 (86.67%) of the patients were female. No missing values were reported. Of the 59 patients, 56 (89.83%) had migraines or medication-overuse headaches, and 3 (5.08%) had tension-type headaches. No one had trigeminal autonomic cephalalgias or other headaches. The models' overall accuracy and kappa for the ground truth were 94.92% and 0.65 (95%CI 0.21-1.00), respectively. The sensitivity, specificity, precision, and F values for migraines were 98.21%, 66.67%, 98.21%, and 98.21%, respectively. There was disagreement between the AI diagnosis and the ground truth by headache specialists in two patients. This is the first external validation of the AI headache diagnosis model. Further data collection and external validation are required to strengthen and improve its performance in real-world settings.

Brain structural and functional abnormalities in patients with tension-type headache: A systematic review of magnetic resonance imaging studies

Tension-type headache (TTH) stands as the most prevalent form of headache, yet an adequate understanding of its underlying mechanisms remains elusive. This article endeavors to comprehensively review structural and functional magnetic resonance imaging (MRI) studies investigating TTH patients, to gain valuable insights into the pathophysiology of TTH, and to explore new avenues for enhanced treatment strategies. We conducted a systematic search to identify relevant articles examining brain MRI disparities between TTH individuals and headache-free controls (HFC). Fourteen studies, encompassing 312 diagnosed TTH patients, were selected for inclusion. Among these, eight studies utilized conventional MRI, one employed diffusion tensor imaging, and five implemented various functional MRI modalities. Consistent findings across these studies revealed a notable increase in white matter hyperintensity (WMH) in TTH patients. Furthermore, the potential involvement of the specific brain areas recognized to be involved in different dimensions of pain perception including cortical regions (anterior and posterior cingulate cortex, prefrontal cortex, anterior and posterior insular cortex), subcortical regions (thalamus, caudate, putamen, and parahippocampus), cerebellum in TTH pathogenesis was identified. However, no significant association was established between TTH and intracranial abnormalities or total intracranial volume. In conclusion, these findings support the hypotheses regarding the role of central mechanisms in TTH pathophysiology and offer probable brain regions implicated in these mechanisms. Due to the scarce data on the precise role of these regions in the TTH, further preclinical and clinical investigations should be done to advance our knowledge and enhance targeted therapeutic options of TTH.

Heart rate variability and tension-type headache: A population-based cross-sectional study

Background

The relationship between tension-type headache (TTH) and autonomic functions is poorly understood, although TTH is one of the most prevalent disorders in the general population. The aim of this study was to investigate the direct and indirect effects of TTH on the autonomic functions measured by heart rate variability (HRV).

Methods

This population-based cross-sectional study was carried out in the general population of Ulaanbaatar between July and September in 2020. After physical examination, trained researchers applied structured interviews to examine the remote history of TTH and mental distress, followed by a recording of HRV to detect autonomic activity. Psychological factors and the quality of life were measured using Hospital Anxiety Depression Scale (HADS), Pittsburgh Sleep Quality Index (PSQI), and the World Health Organization Quality of Life-Brief (WHOQOL-BREF). Binary logistic regression and GLM mediation model analysis were used to examine the effects of risk factors on the associations between TTH and autonomic functions.

Results

Among participants (n = 217, mean age=41.8 ± 11.5 years), a total of 117 (53.9%) participants had a remote history of TTH. The age and sex-adjusted prevalence was 43%. Groups did not differ statistically in the HRV indices. LF/HF (ratio of low-frequency to high frequency), the index of sympathovagal balance, was correlated with the HADS anxiety. TTH was associated with mental distress. Binary logistic regression analysis confirms the relationship suggesting that TTH was associated with increased likelihood of mental distress, and decreasing RMSSD (root mean square of the sum of the squares of differences between adjacent NN intervals) and pNN50 (NN50 divided by the total number of NN intervals) were the independent predictors of TTH. GLM mediation model indicated that the relationship between TTH and RMSSD was mediated by mental distress.

Conclusions

The present study suggests that mental distress is a critical factor in the association between TTH and autonomic dysfunction. Additionally, our findings demonstrate the influence of age and gender on TTH. These results highlight the need to understand the mechanisms underlying pathophysiology to facilitate targeted and efficacious prevention and management approaches for TTH.

Efficacy and safety of the Chaixiong Qiwei granule for tension-type headache: study protocol for a randomised controlled trial

INTRODUCTION

Tension-type headache (TTH) is the most prevalent headache disorder worldwide. Although current treatments for TTH are beneficial, they are not without adverse effects. Chaixiong Qiwei granule (CXQW) is an experienced prescription medicine for TTH management. This study will evaluate the efficacy and safety of CXQW for the treatment of TTH.

METHODS AND ANALYSIS

This study will be a multicentre, randomised, double-blind, placebo-controlled trial. A total of 148 eligible participants will be divided into the intervention (CXQW treatment) and control (placebo treatment) groups. The primary outcome will be the reduction in the number of headache days (headache-days reduction) within 9-12 weeks after randomisation, while secondary outcomes will include the number of headache days, headache intensity, responder rate, drug consumption for acute treatment, quality of life and symptoms related to traditional Chinese medicine use based on a symptom-observation table. This protocol describes the design of the randomised controlled trial.

ETHICS AND DISSEMINATION

The study design was approved by the Institutional Review Board of Human Research at Xiyuan Hospital, China Academy of Chinese Medical Sciences (No. 2020XLA030-2).

TRIAL REGISTRATION NUMBER

ChiCTR2100042514.

New management strategies for primary headache disorders: Insights from P4 medicine

Primary headache disorder is the main cause of headache attacks, leading to significant disability and impaired quality of life. This disorder is increasingly recognized as a heterogeneous condition with a complex network of genetic, environmental, and lifestyle factors. However, the timely diagnosis and effective treatment of these headaches remain challenging. Precision medicine is a potential strategy based on P4 (predictive, preventive, personalized, and participatory) medicine that may bring new insights for headache care. Recent machine learning advances and widely available molecular biology and imaging data have increased the usefulness of this medical strategy. Precision medicine emphasizes classifying headaches according to their risk factors, clinical presentation, and therapy responsiveness to provide individualized headache management. Furthermore, early preventive strategies, mainly utilizing predictive tools, are critical in reducing headache attacks and improving the quality of life of individuals with headaches. The current review comprehensively discusses the potential application value of P4 medicine in headache management.

Effectiveness of Physical Exercise on Pain, Disability, Job Stress, and Quality of Life in Office Workers with Chronic Non-Specific Neck Pain: A Randomized Controlled Trial

Neck pain is a widespread medical condition among office workers worldwide. This study aimed to compare physical exercises, including basic body awareness, neck-specific training exercises and ergonomic modifications, and ergonomic modifications alone in the management of chronic non-specific neck pain (NSNP) among office workers. Sixty participants were randomly allocated to an experimental group (physical exercises and ergonomic modifications) or a control group (ergonomic modifications) and received the intervention two times a week for eight weeks. The Numerical Pain Rating Scale, Neck Disability Index, Health and Safety Stress Tool, and Short Form Health Survey-36 were used to measure pain, disability, job stress, and quality of life at baseline, and at weeks 4 and 8 of the study period. A repeated measure ANOVA was used to determine the within-group significant differences and an independent t-test was utilized to compare group differences. The baseline data of the experimental and control groups showed no significant difference (p ≥ 0.05). The 2 × 3 mixed models ANOVA showed a significant difference in pain intensity (p = 0.001, ηp2 = 0.042), functional disability (p = 0.001, ηp2 = 0.052), work-related stress (p = 0.001, ηp2 = 0.036), and QoL (p = 0.012, ηp2 = 0.025). Four weeks post-intervention, the experimental group showed significant changes in primary (pain intensity and disability) (1.9; 95% confidence interval 1.65-2.14) and secondary (quality of life and work-related stress) outcomes (p < 0.001). The same gradual improvement in these variables was observed in the 8-week follow-up (p < 0.001). There was a significant improvement in clinical outcomes following the application of physical exercises with ergonomic modifications for chronic NSNP among office workers. This is significant for office workers because it suggests the importance of incorporating physical exercises into their daily routine and making ergonomic changes to their workspaces.

The effect of manual therapies on tension-type headache in patients who do not respond to drug therapy: a randomized clinical trial

BACKGROUNDS

Tension-Type Headache (TTH) is one of the most common types of headache. In patients with TTH, manual therapy can be used to treat myofascial pain.

OBJECTIVES

This study aimed to evaluate the effect of manual therapy on TTH in patients who did not respond to drug therapy.

METHODS

A total of 24 patients with TTH were randomly enrolled into this prospective trial. The participants were divided into an intervention and a control group. The intervention group received the common medication and manual therapy, while the control group only received the common medication. Headache pain intensity, frequency, and duration, tablet count, and Neck Disability Index (NDI) were measured in both groups before, after, and one week after the intervention.

RESULTS

There were significant differences between the two groups (treatment, control) regarding pain intensity (3.04, 6.75, P = 0.0001; effect size (ES) = 1.85), headache frequency (2.33, 5, P = 0.004; ES = 1.48) and duration (91.29, 284.74, P = 0.002; ES = 1.48), tablet count (1.83, 4.91, P = 0.01; ES = 1.04), and NDI (7.33, 20.16, P = 0.003; ES = 1.37). Within group differences were recorded in intervention group only for all dependent variables immediately after intervention and one week after the intervention (p < 0.05).

CONCLUSION

Manual therapy reduced headache pain intensity, frequency and duration, tablet count, and NDI score in patients with TTH.

Cross-sectional, hospital-based analysis of headache types using ICHD-3 criteria in the Middle East, Asia, and Africa: the Head-MENAA study

BACKGROUND

Headaches are frequent neurological disorders that are yet to be unveiled and treated comprehensively worldwide. Bearing in mind that the distribution of headache subtypes in neurology clinics (NC) is essential for planning appropriate diagnostic and therapeutic approaches, the primary goals of this multi-centric study are to carry out inter-regional comparisons by using current diagnostic criteria with evaluations of neurologists to delineate headache burden.

METHODS

A cross-sectional study between April 1 and May 16, 2022 was conducted with the participation of 13 countries from the Middle East, Asia, and Africa. Patients were included in the study on a specific day each week during five consecutive weeks. All volunteers over the age of 18 and whose primary cause for admission was headache were examined. The patients admitted to NC or referred from emergency services/other services were evaluated by neurologists by means of the International Classification of Headache Disorders (ICHD-3) criteria.

RESULTS

Among the 13,794 patients encountered in NC, headache was the primary complaint in 30.04%. The headache patients' mean age was 42.85 ± 14.89 (18-95 years), and 74.3% were female. According to the ICHD-3 criteria, 86.7% of the main group had primary headache disorders, 33.5% had secondary headaches, 4% had painful cranial neuropathies along with other facial and headaches, and 5.2% had headaches included in the appendix part showing some overlapping conditions. While the most common primary headache was migraine without aura (36.8%), the most common secondary headache was medication-overuse headache (MOH) (9.8%). Headaches attributed to COVID-19, its secondary complications, or vaccines continue to occur at rates of 1.2%-3.5% in current neurology practice. Pain severity was significantly lower in Ivory Coast and Sudan than in Türkiye, Turkish Republic of Northern Cyprus, Iran, Egypt, Senegal, Tatarstan, and Azerbaijan (p < 0.001).

CONCLUSIONS

The study showed that migraine is still the most common motive for admissions to NC in different regions. Furthermore, MOH, an avoidable disorder, is the most common secondary headache type and appears to be a significant problem in all regions. Remarkably, pain perception differs between regions, and pain intensity is lower in Africa than in other regions.

Efficacy of Kampo medicine Kakkonto as acute medication to treat tension-type headache among musculoskeletal pain patients using regular analgesics

OBJECTIVES

Tension-type headache (TTH) is the most prevalent type of primary headache disorder. Its acute pharmacotherapy is acetaminophen or non-steroidal anti-inflammatory drugs based on the Japanese Clinical Practice Guideline for Headache Disorders 2021. With Japan's aging population, however, the number of TTH patients with comorbidities that have been treated by analgesics is increasing. Under this context, it is sometimes difficult to select an acute pharmacotherapy for TTH. Kakkonto, Japanese traditional herbal kampo medicine, is empirically used for TTH. We hypothesized that kakkonto has efficacy for TTH with painful comorbidities.

MATERIALS AND METHODS

We prospectively collected 10 consecutive TTH patients who had already taken analgesics for comorbidities. We prescribed 2.5 g of kakkonto (TJ-1), and patients took it. A numerical rating scale for pain before and 2 hours after kakkonto intake was evaluated.

RESULTS

Eight women and 2 men were included. The mean age was 71.0 ± 13.4 years old. Four patients had lower back pain, 2 had lumbar spinal stenosis, 2 had knee pain, 1 had neck pain, and 1 had shoulder myofasciitis. Celecoxib was used for 4 patients, acetaminophen for 3, loxoprofen for 2, and a combination of tramadol and acetaminophen for 1, as routinely used analgesics. The median numerical rating scale statistically improved from the median of 4 to that of 0. There were no side effects of kakkonto.

CONCLUSION

Kakkonto showed efficacy as an acute medication for TTH with comorbidities that have been treated by analgesic.

Suboccipital Muscles, Forward Head Posture, and Cervicogenic Dizziness

Dizziness or vertigo can be caused by dysfunction of the vestibular or non-vestibular systems. The diagnosis, treatment, and mechanism of dizziness or vertigo caused by vestibular dysfunction have been described in detail. However, dizziness by the non-vestibular system, especially cervicogenic dizziness, is not well known. This paper explained the cervicogenic dizziness caused by abnormal sensory input with references to several studies. Among head and neck muscles, suboccipital muscles act as stabilizers and controllers of the head. Structural and functional changes of the suboccipital muscles can induce dizziness. Especially, myodural bridges and activation of trigger point stimulated by abnormal head posture may be associated with cervicogenic dizziness.

A bibliometric analysis and visualization of tension-type headache

Background

Tension-type headache (TTH) is the most prevalent headache in the clinical practice, leading to impaired social activities, work-related disability, and heavy financial burdens. Previous studies have described possible inducement, potential pathophysiology, and clinical management of TTH; however, due to the lack of attention, literature involving bibliometric analysis is sporadic. Therefore, this study aimed to explore the current hotspots and future directions of the TTH field by bibliometric analysis.

Methods

By using CiteSpace and VOSviewer, literature regarding TTH between 2002 and 2021 from the Web of Science database was summarized and extracted. Annual publication trend, the most productive countries/regions and institutions, distribution of categories, co-citation of journals and references, and co-occurrence of keywords were analyzed.

Results

A total of 3,379 publications were included in the final visualization, indicating a stable trend in current research and a lack of breakthroughs over the past decades. These studies were mainly conducted in 120 countries/regions led by the United States and more than 600 institutions. Four eternal core themes were identified in TTH, including neurosciences, nursing, developmental psychology, and general/internal medicine. Cephalalgia ranked first, with the highest number of literature, and is the most influential journal in this area. Keyword analysis demonstrated that the similarities and differences between migraine and TTH, epidemiological studies, clinical double-blind trials, and potential populations have become key issues in the TTH field.

Conclusion

TTH has received less attention and breakthroughs in the past 20 years. To promote coordinated development between regions to fight headaches, cooperation and exchanges between countries and institutions are essential in the future. Relevant studies about headaches in children and adolescents, inducing factors such as emotional triggers and sleep disorders, concomitant diseases, possible pathogenesis, and headache treatments, are in the spotlight in recent years. This study offers a powerful roadmap for further research in this field.

Exercise and Manual Therapy for the Treatment of Primary Headache: An Umbrella and Mapping Review

OBJECTIVE

The main aim of this study was to assess through systematic review the efficacy of exercise and manual therapy (MT) interventions in individuals with primary headache.

METHODS

In this umbrella review, 2 authors reviewed systematic reviews by searching the Cochrane Database of Systematic Reviews, MEDLINE, PEDro, Web of Science, and Google Scholar. Systematic reviews that evaluated the effectiveness of MT. Exercise-based interventions, or both in patients with primary headaches were included. Methodological quality was analyzed using the ROBIS scale, and the strength of evidence was established according to the Grading Criteria of the Physical Activity Guidelines Advisory Committee.

RESULTS

Thirty-one systematic reviews containing 79 trials and involving 9103 patients were included. The 7 exercise-related systematic reviews reported beneficial effects on primary headache based on unclear to moderate evidence. Of the 23 MT-related systematic reviews, 11 reported enhanced effectiveness compared with usual care; however, overall heterogeneity and risk of bias were high. Systematic reviews that evaluated the effectiveness of MT, exercise-based interventions, or both in patients with primary headaches were included.

CONCLUSION

Results show that exercise could be an effective therapy for the treatment of primary headache, with moderate to limited quality of evidence regarding the positive effects in terms of pain intensity and frequency and duration of headache. Moderate quality of evidence was found regarding the ability of MT to reduce pain intensity in patients with tension-type headaches, but quality of evidence was limited in terms of frequency of headache and disability and pain reduction in patients with migraine.

IMPACT

Exercise could be an effective treatment in patients with primary headache. Manual therapy showed limited evidence to reduce pain intensity in patients with tension-type headache. It is not possible to establish a preferential exercise protocol or MT program, so psychosocial and behavioral variables need to be considered in future studies.

Scalp dysesthesia: a neuropathic phenomenon

Scalp dysesthesia is an abnormal sensation of the scalp in the absence of cutaneous disease. It is characterized by a burning and/or itching sensation and can be related to a variety of neurogenic or psychogenic causes. This condition is extremely bothersome and is also common- especially amongst the geriatric population, in women, in patients with diabetes mellitus and patients with psychiatric history. However, despite its prevalence in many populations, there is limited data about its causes and characteristics. Given its limited cutaneous manifestations it is also easily misdiagnosed and an underrecognized cause of scalp pruritus in the dermatological community. Therefore, education on scalp dysesthesia is paramount to helping physicians identify and provide appropriate treatment for these patients. This review focuses predominately on the neurogenic causes (with a brief review of psychogenic itch) of scalp dysesthesia and the therapeutics that have been found to be effective for this condition. Neurogenic causes of scalp dysesthesia occur with damage to the central or peripheral pathways of itch sensation, resulting in modification and heightened sensitivity of nerves that result in abnormal sensations in the absence of or out of proportion to external stimuli. A comprehensive review of etiologies is provided here, ranging from lesions to the central nervous system caused by cervical spine disease, trigeminal trophic syndrome, tumor, stroke, and multiple sclerosis, to small fiber neuropathies caused by diabetes, brow lifts, keloid and burn scarring. Recently, there have also been reports of scalp dysesthesias associated with post-infectious COVID-19. Treatment options tailored towards disease severity and different causes of disease will also be discussed. By elucidating the different mechanisms and therapeutic treatments of scalp dysesthesia, we hope to provide clinicians with the tools to identify and treat this condition as well as encourage further research into its etiologies and therapeutics.

Immunological findings in patients with migraine and other primary headaches: a narrative review

Experimental findings suggest an involvement of neuroinflammatory mechanisms in the pathophysiology of migraine. Specifically, preclinical models of migraine have emphasized the role of neuroinflammation following the activation of the trigeminal pathway at several peripheral and central sites including dural vessels, the trigeminal ganglion, and the trigeminal nucleus caudalis. The evidence of an induction of inflammatory events in migraine pathophysiological mechanisms has prompted researchers to investigate the human leukocyte antigen (HLA) phenotypes as well as cytokine genetic polymorphisms in order to verify their potential relationship with migraine risk and severity. Furthermore, the role of neuroinflammation in migraine seems to be supported by evidence of an increase in pro-inflammatory cytokines, both ictally and interictally, together with the prevalence of Th1 lymphocytes and a reduction in regulatory lymphocyte subsets in peripheral blood of migraineurs. Cytokine profiles of cluster headache (CH) patients and those of tension-type headache patients further suggest an immunological dysregulation in the pathophysiology of these primary headaches, although evidence is weaker than for migraine. The present review summarizes available findings to date from genetic and biomarker studies that have explored the role of inflammation in primary headaches.

Artificial intelligence in the GPs office: a retrospective study on diagnostic accuracy

OBJECTIVE

Machine learning (ML) is expected to play an increasing role within primary health care (PHC) in coming years. No peer-reviewed studies exist that evaluate the diagnostic accuracy of ML models compared to general practitioners (GPs). The aim of this study was to evaluate the diagnostic accuracy of an ML classifier on primary headache diagnoses in PHC, compare its performance to GPs, and examine the most impactful signs and symptoms when making a prediction.

DESIGN

A retrospective study on diagnostic accuracy, using electronic health records from the database of the Primary Health Care Service of the Capital Area (PHCCA) in Iceland.

SETTING

Fifteen primary health care centers of the PHCCA.

SUBJECTS

All patients that consulted a physician, from 1 January 2006 to 30 April 2020, and received one of the selected diagnoses.

MAIN OUTCOME MEASURES

Sensitivity, Specificity, Positive Predictive Value, Matthews Correlation Coefficient, Receiver Operating Characteristic (ROC) curve, and Area under the ROC curve (AUROC) score for primary headache diagnoses, as well as Shapley Additive Explanations (SHAP) values of the ML classifier.

RESULTS

The classifier outperformed the GPs on all metrics except specificity. The SHAP values indicate that the classifier uses the same signs and symptoms (features) as a physician would, when distinguishing between headache diagnoses.

CONCLUSION

In a retrospective comparison, the diagnostic accuracy of the ML classifier for primary headache diagnoses is superior to GPs. According to SHAP values, the ML classifier relies on the same signs and symptoms as a physician when making a diagnostic prediction.KeypointsLittle is known about the diagnostic accuracy of machine learning (ML) in the context of primary health care, despite its considerable potential to aid in clinical work. This novel research sheds light on the diagnostic accuracy of ML in a clinical context, as well as the interpretation of its predictions. If the vast potential of ML is to be utilized in primary health care, its performance, safety, and inner workings need to be understood by clinicians.

The efficacy of repetitive transcranial magnetic stimulation in treating patients with chronic daily headache

Background

Headache is the most common pain disorder, affecting around 66% of the global population. This study aimed to investigate the efficacy of high-frequency repetitive transcranial magnetic stimulation (rTMS) in treating patients with primary chronic daily headaches (chronic tension-type headache and chronic migraine).

Methods

Twenty-seven patients participated in the study, divided into 2 groups: a study group (16 patients) and a control group (11 patients). Treatment consisted of 12 high-frequency (5 Hz) real rTMS sessions, delivered over the left dorsolateral prefrontal cortex (DLPFC), whereas sham rTMS was used for the control group.

Results

Patients of the study group, after real rTMS stimulation, showed a high statistically significant reduction of the measured headache parameters compared to the control group (P value < 0.001), and the percentage of improvement was 94.5%. No significant reduction of headache parameters, after sham rTMS stimulation, was observed in the control group (P value > 0.05) and the percentage of improvement was 7.9%.

Conclusion

High-frequency rTMS is effective in reducing chronic tension headaches and chronic migraines. This finding runs with the approval of the suggested role of DLPFC in pain control. This might open opinions for new treatment strategies in tension-type headache and migraine prevention.

Exploring multidimensional characteristics in cervicogenic headache: Relations between pain processing, lifestyle, and psychosocial factors

OBJECTIVE

Although multidimensional interventions including physiotherapy, psychology, and education are generally recommended in managing headache, and to prevent chronification, such approach is lacking in cervicogenic headache (CeH). Therefore, exploring CeH within a biopsychosocial framework is deemed an essential first step.

METHODS

Non-randomized cross-sectional design to compare pain processing, lifestyle, and psychosocial characteristics between 18 participants with CeH (CeH group) (40.2 ± 10.9 years) and 18 matched controls (control group) (39.2 ± 13.1 years). Pain processing characteristics included degree of central sensitization (Central Sensitization Inventory), and (extra)-cephalic pressure pain thresholds (kPa/cm²/s). Lifestyle characteristics included sleep quality (Pittsburgh Sleep Quality Index), physical activity, screen time, and sedentary time (hours a week). Psychosocial characteristics included degree of depression, anxiety and stress (Depression Anxiety Stress Scale-21), and quality of life (Headache Impact Test-6).

RESULTS

Pain processing characteristics: More (p = .04) participants in the CeH group showed higher degrees of central sensitization compared to the control group. Lower (p < .05) (extra)-cephalic pressure pain thresholds were revealed in the CeH group compared to the control group for each muscle. Lifestyle and psychosocial characteristics: Compared to the control group, sleep quality and headache-related quality of life were worse (p < .0001) in the CeH group. Severe to extreme stress was experienced by more participants in the CeH group (p = .02). Further, significant relations between pain processing and (1) lifestyle characteristics and (2) psychosocial characteristics were seen in the CeH group.

CONCLUSION

Exploring multidimensional characteristics in CeH exposed relations between pain processing, lifestyle, and psychosocial characteristics. These novel findings fill a gap in the current scientific literature, and highlight the need for outcome research targeting lifestyle and psychosocial factors.

Can Headache Profile Predict Future Disability: A Cohort Study

OBJECTIVE

The aim of this study was to determine if headache profile can predict future disability in patients with tension-type headache (TTH).

MATERIALS AND METHODS

Eighty-three individuals with TTH were recruited. To be included in the study participants needed to fulfill the International Headache Society classification's criteria for episodic or chronic TTH form and to be at least 18 years old. Baseline clinical outcomes (headache and neck-related disability, kinesiophobia, self-efficacy, and anxiety) and physical outcomes (neck extensors muscles maximum voluntary contraction) were collected for all participants. A prospective data collection of headache characteristics (intensity and frequency) was conducted using daily SMS or e-mail over a 1-month period. Headache-related disability was assessed at the 3-month follow-up and was used as the disability criterion for TTH.

RESULTS

Correlations showed that the number of years with headache (r=0.53, P<0.001), self-reported neck pain intensity (r=0.29, P=0.025), headache frequency (r=0.60, P<0.001) and intensity (r=0.54, P<0.001), anxiety (r=0.28; P=0.031), as well as neck-related disability (r=0.64, P<0.001) were correlated to headache-related disability assessed at 3 months. Multiple regression showed that these determinants can be used to predict headache disability (R =0.583). Headache frequency (β=0.284) was the best individual predictor.

DISCUSSION

Results showed that TTH frequency and intensity and the presence of concomitant infrequent migraine are predictors of future disability over a 3-month period. Further studies are needed to evaluate the contribution of other potential physical outcomes on headache-related disability.

Standardized palpation of the temporalis muscle evoke referred pain and sensations in individuals without TMD

OBJECTIVES

This study aimed to determine if standardized palpations of the temporalis muscle evoke referred pain and/or sensations in individuals without TMD.

MATERIALS AND METHODS

This was a randomized, single-blinded study. The mechanical sensitivity of the right temporalis muscle was assessed in 32 participants without TMD with nine different stimulations to 15 test sites using palpometers (different stimulus intensities (0.5, 1.0, and 2.0 kg) and durations (2, 5, and 10 s). After each stimulus, participants were asked to score perceived pain intensity and intensity of unpleasantness on a 0-100 numeric rating scale as an indicator of mechanical sensitivity in the temporalis muscle and to indicate any areas of referred pain/sensations on a body chart.

RESULTS

Pain intensity significantly differed between palpation durations, intensities, and test sites (P < 0.001). In contrast, unpleasantness significantly differed between palparation duration and intensities (P < 0.001), but not test sites. Participants more frequently reported referred pain/sensations evoked by the 10-s (34.4%) as opposed to the 2-s (6.3%) and 5-s (15.6%) palpation duration at the 2.0-kg stimulus intensity (P < 0.05).

CONCLUSIONS

Our present results indicate that referred pain/sensations in the orofacial region can be evoked by standardized palpation of the temporalis muscle and influenced by the palpation duration in individuals without TMD.

CLINICAL RELEVANCE

Referred pain/sensations from the temporalis muscle were duration- and intensity-dependent processes originating from local stimuli.

Current advances and novel research on minimal invasive techniques for musculoskeletal disorders

The present review summarized the current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Different invasive approaches were proposed in the physical therapy field for the management of musculoskeletal disorders, such as ultrasound-guided percutaneous needle electrolysis, dry needling, acupuncture and other invasive therapy techniques, discussing about their worldwide status, safety and interventional ultrasound imaging. Indeed, dry needling may be one of the most useful and studies invasive physical therapy applications in musculoskeletal disorders of different body regions, such as back, upper limb, shoulder, arm, hand, pelvis, lower limb, neck, head, or temporomandibular joint, and multiple soreness location disorders, such as fibromyalgia. In addition, the assessment and treatment by acupuncture or electro-acupuncture was considered and detailed for different conditions such as plantar fasciitis, osteoarthritis, spasticity, myofascial pain syndrome, osteoporosis and rheumatoid arthritis. As an increasing technique in physical therapy, the use of ultrasound-guided percutaneous needle electrolysis was discussed in injuries of the musculoskeletal system and entrapment neuropathies. Also, ultrasound-guided percutaneous neuromodulation was established as a rising technique combined with ultrasound evaluation of the peripheral nerve system with different clinical applications which need further studies to detail their effectiveness in different musculoskeletal conditions. Thus, invasive physical therapy may be considered as a promising approach with different novel applications in several musculoskeletal disorders and a rising use in the physiotherapy field.

Tension-type headache

Tension-type headache (TTH) is the most prevalent neurological disorder worldwide and is characterized by recurrent headaches of mild to moderate intensity, bilateral location, pressing or tightening quality, and no aggravation by routine physical activity. Diagnosis is based on headache history and the exclusion of alternative diagnoses, with clinical criteria provided by the International Classification of Headache Disorders, third edition. Although the biological underpinnings remain unresolved, it seems likely that peripheral mechanisms are responsible for the genesis of pain in TTH, whereas central sensitization may be involved in transformation from episodic to chronic TTH. Pharmacological therapy is the mainstay of clinical management and can be divided into acute and preventive treatments. Simple analgesics have evidence-based effectiveness and are widely regarded as first-line medications for the acute treatment of TTH. Preventive treatment should be considered in individuals with frequent episodic and chronic TTH, and if simple analgesics are ineffective, poorly tolerated or contraindicated. Recommended preventive treatments include amitriptyline, venlafaxine and mirtazapine, as well as some selected non-pharmacological therapies. Despite the widespread prevalence and associated disability of TTH, little progress has been made since the early 2000s owing to a lack of attention and resource allocation by scientists, funding bodies and the pharmaceutical industry.

Adolescents' Explanatory Models for Headaches and Associations with Behavioral and Emotional Outcomes

More than one-third of adolescents experience recurrent headaches. Usually, these headaches are of primary origin and modulated by different biological and psychosocial factors. While parents are often consulted in scientific research and medical care about the nature of their child's headache, it is unclear to what extent parents and their children agree upon the factors that cause them. Adolescents' own attributions of headaches have rarely been investigated, and it is unclear how those attributions affect behavioral and emotional outcomes. In the present study, adolescents with chronic headaches (N = 248) and their parents (N = 120) rated the influence of various biological and psychosocial factors on the adolescents' headaches. Associations between these factors and several behavioral and emotional outcomes were examined. The most frequently reported factor by both samples was stress; however, concordance between parents and adolescents was generally low. The factor "other disease" was significantly associated with medication consumption and school absence. This study is one of the first to provide insights into adolescents' own attributions of headaches. Furthermore, the significant associations of the factor with behavioral outcomes reveal the importance of understanding personal explanatory models of headache. Future studies should examine associations between subjective headache causes and the individual's experience of the disorder to improve headache interventions.

Assessment of Pain Modulatory and Somatosensory Profiles in Chronic Tension-Type Headache Patients

Objective

The aim of this study was to thoroughly phenotype a group of chronic tension-type headache (CTTH) patients.

Methods

Fifteen CTTH patients diagnosed according to the International Classification of Headache Disorders–3 and 15 healthy controls were included in this study. Furthermore, 70 healthy controls were included to establish normative values. Quantitative sensory testing (QST), including temporal summation of pain (TSP), conditioned pain modulation (CPM), and psychological and sleep variables, was assessed in a single session. TSP and CPM were then combined to build pain modulation profiles (PMP) for each individual.

Results

No difference was found between groups for PMP, TSP, and CPM. However, 10 CTTH patients showed a pronociceptive PMP, with 8 related to a deficient CPM and 2 to both a deficient CPM and increased TSP. Increased cold detection thresholds were the most common sensory disturbance found in CTTH patients. Significant differences were seen between groups for pain catastrophizing, depression, and sleep quality although not all patient’s scores were above the clinically meaningful cutoffs.

Conclusions

In summary, CTTH patients presented with different PMP. These PMP may be related to increased TSP, deficient CPM, alterations in thermal detection that may be related to autonomic dysregulation, or a combination of all three. Overall, this suggests that due to their heterogeneous pathophysiology, CTTH patients should be managed according to their underlying pathophysiology and not with a one-size-fits-all approach.

Estrategias de afrontamiento, estrés percibido y bienestar psicológico en individuos con cefalea primaria

El propósito de este estudio fue evaluar la asociación entre las estrategias de afrontamiento, el bienestar subjetivo y el estrés en personas con cefalea primaria - es decir, con dolor de cabeza sin origen orgánico. En total, participaron 150 personas adultas -135 mujeres y 15 hombres-diagnosticadas con cefalea primaria y episodios de cefalea en los últimos seis meses. Los instrumentos de medida utilizados fueron la Escala de satisfacción con la vida de Diener, la escala de estrategias de afrontamiento Brief Cope, la Escala de estrés percibido de Cohen, dos preguntas sobre la intensidad y frecuencia del dolor, y un cuestionario sociodemográfico. En general, se encontró que el bienestar subjetivo se relaciona positivamente con la planificación y negativamente con el uso de sustancias y la frecuencia del dolor; a la vez que el estrés percibido se asocia positivamente con negar la realidad del acontecimiento estresante, culpabilizarse por la situación ocurrida y la frecuencia del dolor, y negativamente con la aceptación de la situación estresante. Además, se observó un mayor estrés percibido en usuarios de atención pública de salud que en aquellos que son atendidos en el sistema privado. Este estudio permite identificar las estrategias que deben ser potenciadas o modificadas con ayuda del personal de salud para mejorar la calidad de vida de las personas con cefalea primaria.

Telerehabilitation for Headache Management

Headache is one of the most disabling conditions in the world. Despite plentiful evidence supporting rehabilitation strategies, headache is significantly underassessed and undertreated. Obstacles to headache care include lack of available expertise in headache management, few available resources for effective assessment and treatment, and cost and disability that preclude treatment seeking in patients with headache. Telerehabilitation can allow providers to access expert consultation and gives patients easier access to assessment and treatment. This article covers existing telerehabilitation options for headache management and explores the strength of evidence supporting these approaches. Risks of telerehabilitation and recommendations for future development are discussed.

The comparative effects of spinal manipulation, myofascial release and exercise in tension-type headache patients with neck pain: A randomized controlled trial

OBJECTIVES

To evaluate the effects of two manual treatment methods on pain, disability, and pressure pain threshold (PPT) in tension-type headache (TTH) patients with and neck pain.

METHODS

Forty-five patients with TTH were randomly assigned to one of three groups and received eight sessions treatment: manipulation plus exercise (manipulation), suboccipital inhibition plus exercise (myofascial release), and exercise only (control). Headache frequency, pain severity (VAS-headache, VAS-neck pain) and headache and neck disability (HIT-6 and NDI, respectively) were measured at baseline, posttreatment, and at the third month follow-up. PPT was also evaluated on the temporalis muscle.

RESULTS

Manipulation group was statistically better than myofascial release group in terms of headache frequency, headache severity, and PPT scores. Also, manipulation group showed statistically significant improvements in all outcome criteria when compared control group.

CONCLUSIONS

Manipulation and exercise, in addition to pharmacologic treatment in TTH patients with cervical dysfunction appear to be a promising approach.

[Tension type headaches : Quo vadis?]

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

Efficacy of adding midazolam to paracetamol in pain control of patients with a primary headache: A randomized, clinical trial study

OBJECTIVES:

This study aimed to determine the effect of adding intravenous midazolam to paracetamol in the treatment of patients with primary headache referring to the emergency department.

METHODS:

In a randomized clinical trial, 120 patients (18–65 years old) with primary headache referring to the emergency department were enrolled. Patients were divided into two groups (case: paracetamol + midazolam and control: paracetamol + placebo), and the treatment was administered based on the treatment group. The severity of pain (according to the initial Visual Analog Scale) and at different times after the treatment onset (15, 30, and 60 min) and the degree of satisfaction with the treatment were compared in two groups of patients.

RESULTS:

There were no statistically difference between the two groups about the median of pain severity at the time of 0 min (case: 8 vs. control: 8), 15 min (case: 6 vs. control: 6), and 30 min (case: 4 vs. control: 4) with P > 0.05. Headache severity at 60 min after the treatment onset in the case group (median: 1) was less than that of the control group (median: 3). There was also a statistically significant difference in the median of patient satisfaction in the case group (case: 9 and control: 7 with P < 0.001) and satisfaction in the case group was higher.

CONCLUSIONS:

Based on our primary and secondary outcomes and the results of the study, we conclude that adding intravenous midazolam to paracetamol do not improve the therapeutic response ratio over time, but the effect of this intervention appeared after 1 h.

Current perspectives on sex differences in tension-type headache

INTRODUCTION

Clinical and experimental evidence supports the presence of several gender differences in the pain experience.

AREAS COVERED

The current paper discusses biological, psychological, emotional, and social differences according to gender and their relevance to TTH. Gender differences have also been observed in men and women with tension-type headache and they should be considered by clinicians managing this condition. It appears that multimodal treatment approaches lead to better outcomes in people with tension-type headache; however, management of tension-type headache should consider these potential gender differences. Different studies have observed the presence of complex interactions between tension-type headache, emotional stress, sleep, and burden and that these interactions are different between men and women.

EXPERT OPINION

Based on current results, the authors hypothesize that treatment of men with tension-type headache should focus on the improvement of sleep quality and the level of depression whereas treatment of women with TTH should focus on nociceptive mechanisms and emotional/stressful factors. Future trials should investigate the proposed hypotheses.

The fifth cranial nerve in headaches

The fifth cranial nerve is the common denominator for many headaches and facial pain pathologies currently known. Projecting from the trigeminal ganglion, in a bipolar manner, it connects to the brainstem and supplies various parts of the head and face with sensory innervation. In this review, we describe the neuroanatomical structures and pathways implicated in the sensation of the trigeminal system. Furthermore, we present the current understanding of several primary headaches, painful neuropathies and their pharmacological treatments. We hope that this overview can elucidate the complex field of headache pathologies, and their link to the trigeminal nerve, to a broader field of young scientists.

Remedial Massage Therapy Interventions Including and Excluding Sternocleidomastoid, Scalene, Temporalis, and Masseter Muscles for Chronic Tension Type Headaches: a Case Series

BACKGROUND

Tension-type headache (TTH) is the most prevalent primary headache type world-wide. Chronic TTH (CTTH) of >15 headache-affected days per month for > 3 months can cause considerable pain and disability.

PURPOSE

This case series aimed to investigate whether massage therapy interventions were more effective when muscles of the anterior neck, jaw, and cranium were included.

DESIGN

Four female clients suffering CTTH received six pre-determined massage therapy interventions, 45 minutes each, over three weeks. Case A and B (exclusion cases) received interventions addressing shoulder, posterior neck, and occiput muscles; Case C and D (inclusions cases) received interventions addressing the same areas as well as the sternocleidomastoid, scalene, temporalis, and masseter muscles.

INTERVENTION

Treatment included myofascial trigger point release, neuromuscular therapy, and consideration of central sensitization mechanisms present in CTTH.

OUTCOME MEASURES

Headache frequency (primary), intensity, and duration (secondary) were recorded via headache diaries for baseline measures (one week), interventions (three weeks), and a runout period (two weeks). Secondary measures also included a headache disability inventory (HDI) at baseline, intervention conclusion, and final measures. After final measures, clients received stretching education and four weeks later, a follow-up phone conversation to note subjective headache reports.

RESULTS

All cases had headache frequency and HDI score reductions, while intensity and duration measures fluctuated. At final measures, exclusion Case A and both inclusion cases (C and D) had headache frequency reductions to below CTTH diagnostic criteria, clinically meaningful (> 16%) HDI score reductions, and subjectively reported continued improvements after study completion. Inclusion cases overall had greater decreases in headache frequency and HDI measures.

CONCLUSION

Comparative results suggest there may be additional benefit in reducing headache frequency and disability with inclusion of anterior neck, jaw, and cranial muscles in treatment strategies of CTTH. However, limited sample size makes it difficult to rule out outliers or individual variables. Further investigation is recommended.

Gender differences in clinical and psychological variables associated with the burden of headache in tension-type headache

Our aim was to assess gender differences in variables associated with the emotional and physical burdens of tension-type headache (TTH). Participants with TTH diagnosed according to the ICHD-III were recruited from three university-based hospitals (in Spain, Italy, Denmark) between January 2015 and June 2017. The physical/emotional headache burden was assessed with the Headache Disability Inventory (HDI-P/HDI-E, respectively). Headache features were collected with a four-week diary. Sleep quality was assessed with Pittsburgh Sleep Quality Index. The Hospital Anxiety and Depression Scale evaluated anxiety and depressive symptom levels. Trait and state anxiety levels were evaluated with the State-Trait Anxiety Inventory. Two hundred and twelve (28% men) participants (aged 41-48 years old) participated. Multiple regression models revealed that sleep quality explained 36.7% of the variance of HDI-E and 31.1% of the variance of HDI-P in men, whereas headache intensity, depressive levels, and younger age explained 37.5% of the variance of HDI-E and 32.8% of the variance of HDI-P in women (all p < .001). This study observed gender differences in variables associated with headache burden in TTH. Management of men with TTH should focus on interventions targeting sleep quality, whereas the management of women with TTH should combine psychological approaches and interventions targeting pain mechanisms.

Effectiveness of dry needling for improving pain and disability in adults with tension-type, cervicogenic, or migraine headaches: protocol for a systematic review

Background

Headache is the most common neurological symptoms worldwide, as over 90% of people have noted at least one headache during their lifetime. Tension-type headaches, cervicogenic headaches, and migraines are common types of headache which can have a significant impact on social, physical, and occupational functioning. Therapeutic management of headaches mainly includes physical therapy and pharmacological interventions. Dry needling is a relatively new therapeutic approach that uses a thin filiform needle without injectate to penetrate the skin and stimulate underlying tissues for the management of neuromusculoskeletal pain and movement impairments.

The main objective of this systematic review and meta-analysis is to evaluate the effectiveness of dry needling in comparison to other interventions on pain and disability in patients with tension-type headache, cervicogenic headache, and migraine.

Methods/design

We will focus on clinical trials with concurrent control group(s) and comparative observational studies assessing the effect of dry needling in patients with tension-type headache, cervicogenic headache, and migraine. Electronic databases from relevant fields of research (PubMed/ Medline, Scopus, Embase®, PEDro, Web of Science, Ovid, AMED, CENTRAL, and Google Scholar) will be searched from inception to June 2019 using defined search terms. No restrictions for language of publication or geographic location will be applied. Moreover, grey literature, citation tracking, and reference lists scanning of the selected studies will be searched manually. Primary outcomes of this study are pain intensity and disability, and secondary outcomes are cervical spine ROM, frequency of headaches, health-related quality of life, and TrPs tenderness. Studies will be selected by three independent reviewers based on prespecified eligibility criteria. Three reviewers will independently extract data in each eligible study using a pre-piloted Microsoft Excel data extraction form. The assessment of risk of bias will be implemented using the Cochrane Back and Neck Review Group 13-item criteria and NOS. Direct meta-analysis will be performed using a fixed or random effects model to estimate effect size such as standardized mean difference (Morris’s d_ppc) and 95% confidence intervals. Statistical heterogeneity will also be evaluated using the I² statistic and the χ² test. All meta-analyses will be performed using Stata V.11 and V.14 softwares. The overall quality of the evidence for the primary outcomes will be assessed using GRADE.

Discussion

All analyses in this study will be based on the previous published papers. Therefore, ethical approval and patient consent are not required. The findings of this study will provide important information on the value of dry needling for the management of tension-type headache, cervicogenic headache, and migraine.

Trial registration

PROSPERO registration number: CRD42019124125.

Electronic supplementary material

The online version of this article (10.1186/s12998-019-0266-7) contains supplementary material, which is available to authorized users.

BDNF and serum S100B levels according the spectrum of structural pathology in chronic pain patients

Central sensitivity syndrome (CSS) consists of adaptive pathophysiological changes associated with neuroplasticity in some chronic pain disorders. It could be grouped in two main conceptual conditions: one includes those chronic pain patients without overt structural pathology such as fibromyalgia, and the other subgroup includes conditions with recognizable structural abnormalities, both somatic (osteoarthritis) and visceral (endometriosis). In order to understand the role of neuromodulators in CCS we aim to determine whether brain-derived neurotrophic factor (BDNF) and S100B are associated to specific chronic pain disorders. Serum BDNF and S100B were measured in chronic pain women with different diagnosis: 88 with osteoarthritis, 36 with endometriosis, 117 with fibromyalgia, 33 with chronic tension type headache and in 41 healthy controls. ANCOVA analysis followed by heteroscedasticity-consistent covariance matrix was performed to evaluate BDNF and S100B levels, adjusted for depression severity, pain levels and use of analgesics according different pathologies. Serum BDNF concentrations were higher and not different in patients with fibromyalgia and headache, the CSS group without structural pathology. In contrast, the concentrations of S100B were higher in patients with osteoarthritis and endometriosis, in comparison to controls, fibromyalgia and tensional headache patients. This study supports the hypothesis that BDNF and S100B neuromodulators present different serum levels according to the background disease associated to the chronic pain. These have the potential to be studied as markers of active disease or treatment evolution.

Not engaged in education, employment or training (NEET) in an Arctic sociocultural context: the NAAHS cohort study

OBJECTIVES

The purpose of the study is to explore the prevalence and predictors of not engaged in education, employment or training (NEET) status in a multicultural young adult population in Northern Norway.

DESIGN AND SETTING

The longitudinal design link a self-reported survey (2003-2005) with an objective registry linkage follow-up 8-10 years later.

PARTICIPANTS

Of all 5877 tenth graders (aged 15-16 years) in Northern Norway, 83% of the total age cohort from all 87 municipalities participated in the baseline survey. The follow-up studies consisted of 3987 consent giving adolescents (68%), were 365 (9.2%) reported indigenous Sami ethnicity.

OUTCOME MEASURES

Youth NEET at the age of 23-25 years.

METHODS

Explanatory variables were sociodemographic factors (gender, ethnicity, residency, parental education), mental health problems and musculoskeletal pain in adolescence. Outcome variable characterised as NEET-status was defined by no educational engagement, long-term recipient of sickness benefit, medical and non-medical benefit receipt or long-term unemployment.

RESULTS

NEET-status in young adulthood was significantly higher among females (20.9%) than among males (16.2%). Ethnic differences occurred as being NEET among Sami males was significantly higher than among non-Sami males, 23.0% and 15.2% respectively. Minority Sami females experienced NEET-status to a lower degree (16.6%) than non-Sami females (20.8%). Among females adolescent peer problems (adjusted OR=1.09) and hyperactivity problems (adjusted OR=1.10) were associated with later NEET-status. Peer problems (adjusted OR=1.23), conduct problems (adjusted OR=1.17) and musculoskeletal problems (adjusted OR=1.15) in male adolescents were associated with later NEET-status, whereas emotional problems among males predicted significantly less later NEET- status (adjusted OR=0.88).We found lower parental education to be significantly associated with being NEET-later in young adults (females: adjusted OR=2.11, males: adjusted OR=3.22).

CONCLUSIONS

To address the disengagement of education and work, particular emphasis must be placed on supporting young people struggling with mental and physical health problems.

Anxiety and the severity of Tension-Type Headache mediate the relation between headache presenteeism and workers' productivity

The primary objective of this study was to explore the mechanisms and conditions whereby Tension-Type Headache (TTH) presenteeism relates to health-related loss of productivity as a result of both reduced physical and mental health. To this end, Structural Equation Modeling (SEM) was used to conduct a secondary data analysis of a randomized clinical trial involving 78 Tension-type Headache (TTH) patients. The results showed that TTH presenteeism did not directly relate to health-related loss of productivity, either due to physical, or mental health problems. However, through anxiety-state, TTH presenteeism decreased patients' productivity, as consequence of reduced physical and mental health. Moreover, by increasing the severity of the Tension-Type Headache, TTH presenteeism indirectly decreased patients' productivity as consequence of reduced physical health (but not mental health). Finally, our results show that such indirect effects only occur when the cause of TTH is non-mechanical (e.g., hormonal causes, etc.). Our work provides an integrative model that can inform organizational behaviorists and health professionals (e.g., physiotherapists). Implications for organizational health are discussed.

Stress management for headaches in children and adolescents: A review and practical recommendations for health promotion programs and well-being

Stress is considered to be the most common factor reported to trigger headaches in children and adolescents. Although tension-type headache and migraine are the two most common types of headache in children and adolescents, they are often untreated, ignoring their stressful background. We provide a narrative review of the available evidence for health-care professionals involved in stress-related headache management and health promotion programs. An integrative plan is delivered through lifestyle improvement and biopsychosocial modifying stress response techniques. Healthy dietary choices, sleep hygiene, and regular exercise, although limited, are effective for young sufferers. Biopsychosocial therapies such as relaxation, biofeedback, hypnosis, yoga, cognitive behavioral therapy, and acupuncture focus at stress physiological and behavioral relief. Our purpose is to suggest a stress-related headache management to empower children to make healthy choices in order to improve their lifelong well-being and quality of life. We aim to authorize relationship between nurses and other health-care providers with background knowledge around stress management for pediatric headache populations.

Testing of diagnosis criteria of tension-type headache: A multicenter clinical study

Objective Tension-type headache is *These authors contributed equally to this work. usually manifested as head pain without associated symptoms, and the validation of diagnostic criteria presented are lacking and highly required in the International Classification of Headache Disorders. The aim of the present study was to explore the diagnosis criteria of tension-type headache in a multicenter-based sample from Chongqing, China. Methods Clinical characteristics and demographics were systematically and prospectively collected between March 2014 and December 2015 from 15 participating hospitals in Chongqing, using a semi-structured face-to-face interview. All patients were asked to complete a headache diary for at least 4 weeks. Results Out of 1832 patients with headache, 150 patients (97 female/53 male, 44.56 ± 11.9 years old) were diagnosed with tension-type headache based on the standard International Classification of Headache Disorders, 3rd edition beta version, and interestingly, 114 (76%) patients were diagnosed with tension-type headache based on the alternative criteria. One patient was excluded because only two of the four characteristics were fulfilled. Thirty-five (23.3%) patients did not meet the alternative criteria because of associated symptoms, including mild nausea (n = 6), photophobia (n = 1), and phonophobia (n = 28). All patients with TTH had mild or moderate headaches, 98.0% of patients suffered from non-pulsating headaches, 99.3% of patients said their headaches were not aggravated by routine physical activity, and 77.3% of patients had bilateral headache. Conclusions Non-pulsating headaches and headaches that are not aggravated by routine physical activity may represent core criteria for screening patients with tension-type headache. Nausea might not be an exclusion feature for diagnosis of TTH, but an important criterion for screening. Further studies are needed.

Pressure pain thresholds over the cranio-cervical region in headache: a systematic review and meta-analysis

BACKGROUND

Sensitivity of tissues can be measured by algometry. Decreased pressure pain thresholds over the cranio-cervical area are supposed to reflect signs of sensitization of the trigemino-cervical nucleus caudalis. A systematic review was conducted to assess the current scientific literature describing pressure pain threshold (PPT) values over the cranio-cervical region in patients with migraine, tension-type headache (TTH), and cervicogenic headache (CeH). A literature search was executed in three databases. The search strategy included the following keywords: migraine, TTH, CeH, PPT and algometry. A total of 624 papers was identified of which relevant papers were subsequently assessed for methodological quality. Twenty-two selected papers were assessed by two independent reviewers and the majority of studies scored low risk of bias on the selected items. Mean PPT values of several sites measured in the cranio-cervical region in patients with migraine, chronic TTH and CeH scored lower values compared to controls. The trapezius muscle (midpoint between vertebrae C7 and acromion) was the most frequently targeted site and showed significantly lower PPT values in adults with migraine (pooled standardized mean difference kPa: 1.26 [95%CI -1.71, -0.81]) and chronic TTH (pooled standardized mean difference kPa: -2.00 [95%CI -2.93, -1.08]). Most studies found no association between PPT values and headache characteristics such as frequency, duration or intensity. Further standardization of PPT measurement in the cranio-cervical region is recommended.

Prevalence, characteristics and management of headache experienced by people with schizophrenia and schizoaffective disorder: a cross sectional cohort study

OBJECTIVES

Headache is the most common type of pain reported by people with schizophrenia. This study aimed to establish prevalence, characteristics and management of these headaches.

METHODS

One hundred participants with schizophrenia/schizoaffective disorder completed a reliable and valid headache questionnaire. Two clinicians independently classified each headache as migraine, tension-type, cervicogenic or other.

RESULTS

The 12-month prevalence of headache (57%) was higher than the general population (46%) with no evidence of a relationship between psychiatric clinical characteristics and presence of headache. Prevalence of cervicogenic (5%) and migraine (18%) was comparable to the general population. Tension-type (16%) had a lower prevalence and 19% of participants experienced other headache. No one with migraine was prescribed migraine specific medication; no one with cervicogenic and tension-type received best-practice treatment.

CONCLUSIONS

Headache is a common complaint in people with schizophrenia/schizoaffective disorder with most fitting recognised diagnostic criteria for which effective interventions are available. No one in this sample was receiving best-practice care for their headache.