Recent advancements in tension-type headache: a narrative review

Non-Migraine Head Pain and Botulinum Toxin

Botulinum toxin A (BT-A), a potential neurotoxin produced by the bacterium Clostridium botulinum, is known for its ability to prevent the release of acetylcholine at the neuromuscular synapse, leading to temporary muscle paralysis. BT-A is used for a wide range of therapeutic applications. Several studies have shown mechanisms beyond the inhibition of acetylcholine release for pain control. BT-A inhibits the release of neurotransmitters associated with pain and inflammation, such as glutamate, CGRP, and substance P. Additionally, it would be effective in nerve entrapment leading to neuronal hypersensitivity, which is known as a new pathogenesis of painful conditions. BT-A has been applied to the treatment of a wide variety of neurological disorders. Since 2010, BT-A application has been approved and widely used as a chronic migraine prophylaxis. Moreover, due to its effects on pain through sensory modulation, it may also be effective for other headaches. Several studies using BT-A, at different doses and administration sites for headaches, have shown beneficial effects on frequency and severity. In this review, we provide an overview of using BT-A to treat primary and secondary headache disorders.

Efficacy and safety of Chinese patent medicines for tension-type headache: Systematic review and network meta-analysis

Objective

The high incidence of Tension-type headache (TTH) has led to significant social and economic challenges. Given the widespread use of Chinese patent medicines (CPM) for TTH patients, this study aim to evaluate the efficacy of different CPMs in treating TTH by network meta-analysis.

Methods

Eight databases were conducted to identify CPMs-related randomized controlled trials (RCTs) from database inception date to August 2023. The primary outcome was clinical efficiency rate. The secondary outcomes were numerical rating scale (NRS), frequency of headache, duration of headache, hamilton anxiety scale (HAMA), hamilton depression Scale (HAMD) and adverse reactions. ROB 2.0 were used for quality evaluation. Stata 15.1 and R 3.5.3 software were used for Bayesian network meta-analysis.

Results

A total of forty-one RCTs were included, involving 3,996 patients and 8 CPMs. The network meta-analysis revealed that Shugan Jieyu capsule plus western medicine (WM) was the best choice of CPM for improving clinical efficiency rate [vs. WM: relative risk (RR) = 7.31, 95 % confidence interval (CI): (1.65, 56.71)]. Yangxue Qingnao granule plus WM was superior to other therapeutic combinations in reducing duration of headache [vs. WM: MD = 1.05, 95%CI(0.74, 1.40)]. Jieyu pill plus WM might have best effect in reducing HAMD [vs. WM: MD = 7.15, 95%CI(-3.77, 18.14)], HAMA scores [vs. WM: MD = -7.41, 95%CI(-13.39, -1.42)], and NRS scores [vs. WM: mean difference (MD) = 2.01, 95%CI(1.47, 2.55)]. In terms of the frequency of headache, although Yangxue Qingnao granule plus WM and Toutong-ning capsule plus WM performed best, the optimal CPMs in reducing the frequency of headache remain to be further explored. Furthermore, due to the limited safety evidence available, reliable safety conclusions could not be drawn.

Conclusion

CPM can effectively improve headache symptoms, clinical efficiency, and quality of life in patients with TTH. However, research with high quality and large sample sizes is needed for further investigation due to the limitations of this study.

Evaluating the effectiveness of neurofeedback in chronic pain management: a narrative review

The prevalence and impact of chronic pain in individuals worldwide necessitate effective management strategies. This narrative review specifically aims to assess the effectiveness of neurofeedback, an emerging non-pharmacological intervention, on the management of chronic pain. The methodology adopted for this review involves a meticulous search across various scientific databases. The search was designed to capture a broad range of studies related to neurofeedback and chronic pain management. To ensure the quality and relevance of the included studies, strict inclusion and exclusion criteria were applied. These criteria focused on the study design, population, intervention type, and reported outcomes. The review synthesizes the findings from a diverse array of studies, including randomized controlled trials, observational studies, and case reports. Key aspects evaluated include the types of neurofeedback used (such as EEG biofeedback), the various chronic pain conditions addressed (like fibromyalgia, neuropathic pain, and migraines), and the methodologies employed in these studies. The review highlights the underlying mechanisms by which neurofeedback may influence pain perception and management, exploring theories related to neural plasticity, pain modulation, and psychological factors. The results of the review reveal a positive correlation between neurofeedback interventions and improved pain management. Several studies report significant reductions on pain intensity, improved quality of life, and decreased reliance on medication following neurofeedback therapy. The review also notes variations in the effectiveness of different neurofeedback protocols and individual responses to treatment. Despite the promising results, the conclusion of the review emphasizes the need for further research. It calls for larger, well-designed clinical trials to validate the findings, to understand the long-term implications of neurofeedback therapy, and to optimize treatment protocols for individual patients.

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.

Quantum Molecular Resonance Radiofrequency Disc Decompression and Percutaneous Microdiscectomy for Lumbar Radiculopathy

Within the practice of pain management, one of the most commonly encountered events is low back pain. Lumbar radiculopathy (LR) is a pain syndrome caused by the compression or irritation of the nerve roots in the lower back due to lumbar disc herniation, vertebra degeneration, or foramen narrowing. Symptoms of LR include low back pain that propagates toward the legs, numbness, weakness, and loss of reflexes. The aim of this study is to assess the long-term effectiveness of quantum molecular resonance disc decompression and its combination with a percutaneous microdiscectomy using Grasper© forceps (QMRG) in patients with persistent lumbar radiculopathy (LR) in relation to patient physical stress status. The main outcome measures of this prospective observational study were DN4, NRS, ODI, SF12, PGI, CGI, and MOS Sleep Scale. An improvement 12 months post-intervention was observed in patients without physical stress, presenting better overall results. The mean change was over the minimal clinically important difference in 64.3% of outcome measures studied for the whole sample. QMRG appears to be an effective treatment option for LR, but a reduction in physical stress is needed to ensure long-term effectiveness.

Debate: differences and similarities between tension-type headache and migraine

Tension-type headache (TTH) and migraine are two common primary headaches distinguished by clinical characteristics according to the 3^rd edition of the International Classification of Headache Disorders. Migraine is identified by specific features such as being more prevalent in females, being aggravated by physical activity, certain genetic factors, having photophobia, phonophobia, nausea, vomiting, or aura, and responding to specific drugs. Nonetheless, TTH and migraine share some common characteristics, such as onset occurring in the 20 s, and being triggered by psychological factors like stress, moderate pain severity, and mild nausea in chronic TTH. Both conditions involve the trigeminovascular system in their pathophysiology. However, distinguishing between TTH and migraine in clinical practice, research, and epidemiological studies can be challenging, as there is a lack of specific diagnostic tests and biomarkers. Moreover, both conditions may coexist, further complicating the diagnostic process. This review aims to explore the similarities and differences in the pathophysiology, epidemiology, burden and disability, comorbidities, and responses to pharmacological and non-pharmacological treatments of TTH and migraine. The review also discusses future research directions to address the diagnostic challenges and improve the understanding and management of these conditions.

Disease burden of migraine and tension-type headache in non-high-income East and Southeast Asia from 1990 to 2019

BACKGROUND

The world faces severe challenges from migraine and tension-type headache (TTH), which cause grave disability to patients and place a heavy burden on their caregivers. However, headaches in specific individual regions have rarely been investigated. Therefore, we aimed to fully analyse and describe the current status and changing trends in migraine and TTH in non-high-income East and Southeast Asia to provide more detailed real-world information for policy-making.

METHODS

The migraine and TTH data used for analysis were all extracted from the Global Burden of Disease (GBD) database. We adopted three major indicators of disease burden, including prevalence, incidence, and years lived with disability (YLD), and two major metrics, including the absolute number and the age-standardized rate, in our present study for further evaluation by age and sex. The results are presented in the form of mean values and 95% uncertainty intervals (UIs). In addition, the differences between non-high-income East and Southeast Asia and other regions, as well as the potential associations between headache burden and socioeconomic background, were explored.

RESULTS

In 2019, approximately 195,702,169 migraine patients and 291,924,564 TTH patients lived in non-high-income East Asia, and 113,401,792 migraine patients and 179,938,449 TTH patients lived in non-high-income Southeast Asia. In terms of specific countries and regions, the highest age-standardized YLD rate (ASYR) of migraine was in Thailand [645 (95% UI: 64 to 1,554)]. The highest ASYR of TTH was in Indonesia [54 (95% UI: 15 to 197)]. Furthermore, people between the ages of 40 and 44, especially females, were identified as the main population that suffered from migraine and TTH. Unfortunately, we did not observe a significant association between headache burden and socioeconomic background.

CONCLUSIONS

To date, the threats from migraine and TTH in non-high-income East and Southeast Asia are still serious and ongoing, leading to prominently negative impacts on the daily life and work of local residents. Therefore, full attention and sound guidelines are urgently needed to obtain greater advantages in fighting against the burden of headache disorders in the future.

The Role of the Autonomic Nervous System in Headache: Biomarkers and Treatment

Purpose of Review

In this review, the role of the autonomic nervous system in tension-type headache and migraine is reviewed.

Recent Findings

A pathophysiological model for tension-type headache is proposed that is compatible with most physiological and behavioral literature.

Summary

A treatment protocol is described that follows from this model. For migraine, incorporating autonomic factors into the pathophysiology offers rationales for behavioral interventions that have been shown to be useful in migraine treatment and a biofeedback protocol is proposed.

Recently approved and emerging drug options for migraine prophylaxis

INTRODUCTION

: Migraine occupies the first position regarding to the disability caused in female working population (15-49 years). Research in the field of prophylaxis of this pathology has made enormous strides in recent years.

AREAS COVERED

In this narrative review we retrace the most important scientific evidence regarding recently approved and emerging drug for prophylactic treatment of migraine. The purpose of this article is in fact to evaluate currently approved or emerging pharmacological agents for migraine prophylaxis. This review is based on literature published in peer review journal obtained through PubMed, Cochrane library, Clinicaltrials.gov and US FDA.

EXPERT OPINION

: Monoclonal antibodies (mAbs) that target the calcitonin gene-related peptide signalling pathway (CGRP) have marked an innovation in prophylactic migraine therapy. The combination of Onabotulinumtoxin-A (OBTA) and mAbs appears to be an effective, but costly, therapeutic option for resistant cases. New classes of molecules like gepants and ditans seem to give exceptional results. In addition, new prophylactic drugs are emerging with several targets: the pituitary adenylate cyclase-activating polypeptide (PACAP), ion channels, several receptors coupled to G proteins, orexin, and glutamate. All these therapies will implement and improve migraine management, as well as personalized medicine for each patient.

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.

Tele-healthcare in migraine medicine: from diagnosis to monitoring treatment outcomes

INTRODUCTION

: Primary headaches represent a huge cost in terms of decreased productivity and migraine occupies the first position among disabilities in working population. Migraine has a high incidence, disproportionate to the available primary care centres. In most cases, migraine can be managed through the simple and accurate collection of clinical history, which makes it an ideal candidate for tele-healthcare.

AREAS COVERED

: In this narrative review we retrace the most important scientific evidence regarding use of tele-healthcare in headache medicine. Over the last few years, it has proved to be a valid and useful tool for the management of migraine. Furthermore, current pandemic has imposed a drastic change in the way of thinking and setting up medicine, forcing clinicians and patients to a huge expansion of telemedicine.

EXPERT OPINION

: We should permanently insert the culture of telemedicine in the headache care not only in academies and scientific societies, but extend it to specialized hospitals for the treatment of headaches. Only by broadening the old book-based strategy, we will be able to open the door to the multidimensional culture of headache medicine. Experts of excellence centres should set an example and pave the way for the rest of the clinicians.