Tension-type headache: an update on mechanisms and treatment

THE EFFECT OF BODY AWARENESS THERAPY AND AEROBIC EXERCISES ON PAIN AND QUALITY OF LIFE IN THE PATIENTS WITH TENSION TYPE HEADACHE

BACKGROUND

This study is to investigate the effect of Body Awareness Therapy (BAT) and Aerobic Exercises on pain and quality of life in patients with Tension-Type Headache (TTH).

MATERIALS AND METHOD

Sixty individuals with TTH diagnosis who referred Neurologist were incorporated into study. The individuals were randomly grouped into 3 as BAT (n=20), aerobic exercise (n=20) and control group (n=20). Pain severity of the individuals was evaluated by Visual Analog Scale (VAS) and pain diary, disability with ache; by Pain Disability Index (PDI) and Headache Impact Tests (HIT) and quality of life was evaluated by SF-36. Subsequent to first assessments, 3 sessions of 60 minutes per week throughout 6 weeks totally.

RESULTS

When the groups were compared at the end of the study, a significant decrease was observed in VAS, PDI and HIT values in the individuals in the BAT and aerobic exercise groups. With the individuals in group BAT and aerobic exercise all parameters of quality of life were observed to be increased significantly.

CONCLUSION

BAT and aerobic exercise programs to be applied on TTH patients were concluded to be important in decreasing the pain, in increasing the quality of life and in reducing pain-related daily constraints of the individuals.

A Randomized, Double-Blind, Placebo-Controlled Study of Venlafaxine XR in Out-Patients With Tension-Type Headache

The aim of this study was to evaluate in a double-blind, randomized, placebo-controlled study the safety and efficacy of venlafaxine extended release (XR) in the prophylactic treatment of out-patients with tension-type headache (TTH) and no current depression or anxiety disorders. Sixty neurology and headache clinic out-patients meeting the International Headache Society diagnostic criteria for TTH were treated with venlafaxine XR (150 mg/day, n = 34) or placebo ( n = 26) for 12 weeks. The primary efficacy variable was the decline in number of days with headache. At end-point, the venlafaxine XR group had a significantly greater decrease in the number of days with headache compared with placebo ( P = 0.05). Differences with regard to secondary efficacy variables where not significant. The number needed to treat for responders (≥50% reduction in days with headache) was 3.48. Six patients in the venlafaxine XR group interrupted therapy due to adverse events, while no patients in the placebo group did so for the same reason. The number needed to harm was 5.58. This study provides preliminary evidence for the efficacy and safety of venlafaxine XR 150 mg/day in reducing the number of days with TTH.

Treatment of Chronic Tension-Type Headache with Botulinum Toxin: A Double-Blind, Placebo-Controlled Clinical Trial

Botulinum toxin is increasingly advocated as effective treatment in chronic tension-type headache. We conducted a randomized, placebo-controlled clinical trial to prove efficacy of botulinum toxin in chronic tension-type headache. Patients were randomly assigned to receive botulinum toxin (maximum 100 units) or placebo (saline) in muscles with increased tenderness. After 12 weeks there was no significant difference between the two treatment groups in decrease of headache intensity on VAS (-3.5 mm, 95% confidence interval (CI) -20 to +13), mean number of headache days (-7%; 95% CI -20 to +4), headache hours per day (-1.4%; 95% CI -3.9 to +1.1), days on which symptomatic treatment was taken (-1.9%; 95% CI -11 to +7) and number of analgesics taken per day (-0.01; 95% CI -0.25-0.22). There was no significant difference in patient's assessment of improvement after week 4, 8 and 12. Botulinum toxin was not proven effective in treatment of chronic tension-type headache. Increased muscle tenderness might not be as important in pathophysiology of chronic tension-type headache as hitherto believed.

Chronic Tension-Type Headache Treated with Acupuncture, Physical Training and Relaxation Training. Between-Group Differences

The aim of this study was to compare acupuncture, relaxation training and physical training in the treatment of chronic tension-type headache (CTTH). The study comprised 90 consecutive patients with CTTH who were randomly allocated to acupuncture, relaxation training or physical training. Headache intensity, headache-free days and headache-free periods were registered using a visual analogue scale and a headache diary. The measurements were made 4 weeks before, immediately after, and 3 and 6 months after the treatment period. Immediately after the last treatment, the number of headache-free periods and of headache-free days was higher in the relaxation group compared with the acupuncture group. There were no other significant differences between the groups at any time point. The clinical implications of our findings are that relaxation training induced the most pronounced effects directly after the treatment period, compared with acupuncture and physical training.

Rhinogenic and nonrhinogenic headaches

PURPOSE OF REVIEW

To review the present knowledge and the recent publications on the cause, characteristics, course and treatment of chronic and recurring facial pain and headaches. Facial pain is amongst the commonest complaints in ear, nose and throat clinics. Recent articles have presented important evidence-based approach to this common problem.

RECENT FINDINGS

Recent publications in the fields of otolaryngology and neurology have better defined the differences between rhinogenic and nonrhinogenic facial pain, and place this symptom in the context of rhinosinusitis. Although chronic facial pain has conventionally been considered to be due to sinusitis because of anatomical proximity, there is increasing evidence to support the contrary. Published literature has identified that only 16-20% of patients with sinusitis (purulent or with polyposis) confirmed by nasal endoscopy actually declared symptoms of facial pain. More pertinently, surgical series have shown that up to 40% of patients had persistent postoperative facial pain despite resolution of sinusitis on nasal endoscopy and computed tomography (CT). Rhinogenic pain is generally unilateral, severe, located on the same side and related to rhinogenic symptoms, and almost always accompanied by endoscopic and CT abnormalities. Incidental CT mucosal disease can be noted in 30% of asymptomatic patients.

SUMMARY

Traditionally, facial pain has often been considered to be caused by chronic rhinosinusitis. Increasing evidence has shown that the commonest cause for chronic facial pain is of nonrhinogenic origin. As otorhinolaryngologists, we deal with facial pain on a daily basis and therefore need to be aware of the different causes for this common symptom.

Botulinum Toxin Type a as a Therapeutic Agent against Headache and Related Disorders

Botulinum neurotoxin A (BoNT/A) is a toxin produced by the naturally-occurring Clostridium botulinum that causes botulism. The potential of BoNT/A as a useful medical intervention was discovered by scientists developing a vaccine to protect against botulism. They found that, when injected into a muscle, BoNT/A causes a flaccid paralysis. Following this discovery, BoNT/A has been used for many years in the treatment of conditions of pathological muscle hyperactivity, like dystonias and spasticities. In parallel, the toxin has become a “glamour” drug due to its power to ward off facial wrinkles, particularly frontal, due to the activity of the mimic muscles. After the discovery that the drug also appeared to have a preventive effect on headache, scientists spent many efforts to study the potentially-therapeutic action of BoNT/A against pain. BoNT/A is effective at reducing pain in a number of disease states, including cervical dystonia, neuropathic pain, lower back pain, spasticity, myofascial pain and bladder pain. In 2010, regulatory approval for the treatment of chronic migraine with BoNT/A was given, notwithstanding the fact that the mechanism of action is still not completely elucidated. In the present review, we summarize experimental evidence that may help to clarify the mechanisms of action of BoNT/A in relation to the alleviation of headache pain, with particular emphasis on preclinical studies, both in animals and humans. Moreover, we summarize the latest clinical trials that show evidence on headache conditions that may obtain benefits from therapy with BoNT/A.

Atopic disorders are more common in childhood migraine and correlated headache phenotype

BACKGROUND

The supportive clinical and pathophysiological data about the correlation between migraine and atopic disorders are far from a coincidence. In order to determine and investigate the correlates of atopic disorders in a specific dataset, we performed this retrospective cross-sectional clinical-based study.

METHODS

The dataset was composed from three tertiary center web-based databases (http://www.childhoodheadache.org). Headache diagnosis and differential diagnosis were made according to the International Classification of Headache Disorders, 2nd version and the Diagnostic Statistical Manual of Mental Disorders, 5th edition. Migraine with aura, migraine without aura, chronic migraine and episodic and chronic tension type headache (TTH) patients were included. All other causes of headache disorders, including comorbid headache disorders like migraine plus TTH or "possible" causes of headache, were excluded.

RESULTS

The study included 438 patients with migraine and 357 patients with TTH, whose age and sex distribution were identical. After descriptive statistics accordingly, 80 migraine (18.2%) and 23 TTH (6.4%) patients were found to have specific atopic disorders (P < 0.001). Atopic disorders are more commonly reported in patients with migraine with aura (21.6%) than those with migraine without aura and TTH (P < 0.001). The most common atopic disorders were seasonal rhinitis, conjunctivitis and asthma. There was also a close correlation between TTH with atopic disorders and psychiatric comorbid disorders of the patients.

CONCLUSIONS

Although the International Classification of Headache Disorders, 2nd version, does not specify, atopic disorders should be suspected in all migraine patients and their relatives, not only for accurate diagnosis but also for planning prophylactic medications, such as β-blockers.

OnabotulinumtoxinA for the treatment of headache

Botulinum toxin, a potent muscle relaxant, has been found to have analgesic effects in patients with various pain syndromes. Both in vitro and in vivo studies showed the ability of the toxin to block the release of pain neurotransmitters, such as substance P, glutamate, and calcitonin gene-related peptide. The effect of the toxin, and specifically of one of its serotypes, botulinum neurotoxin type A, on headaches, has been extensively studied. This serotype is available in the United States in 3 forms, including as onabotulinumtoxinA. Data from clinical trials confirmed the efficacy, safety, and tolerability of onabotulinumtoxinA in the prophylactic treatment of chronic migraine, the most severe and debilitating type of migraine, in adults. The drug was approved by the Food and Drug Administration for this indication in 2010. The drug was not found to be effective for episodic migraine or tension-type headache. Noncontrolled studies suggest the efficacy of the toxin for headache associated with craniocervical dystonia. Proper injection technique and appropriate patient selection are essential for achieving positive results after treatment with onabotulinumtoxinA. The recommended injection paradigm combines a fixed site/fixed dose and follow the pain approaches, with the toxin injected to multiple sites of the head and neck, at a total dose of 155U-195U. The treatment is given at intervals of 12 weeks on average. The efficacy of onabotulinumtoxinA for some headaches, its long duration of action, and its favorable adverse effect profile make it a viable treatment option for the appropriate headache patients. The drug may be particularly suitable for patients who cannot tolerate, or are not compliant with, the daily intake of oral headache preventive drugs.

Diagnosis and treatment of headache in the ambulatory care setting: a review of classic presentations and new considerations in diagnosis and management

Headaches represent the most common constellation of neurologic disorders and are a very common cause of morbidity, lost work time, and decreased quality of life among sufferers. In this article, the diagnostic features, workup, and treatment of common, nuanced, and difficult-to-diagnose headache conditions were addressed. The future will hold a number of changes, with respect to both the diagnosis and treatment of headache disorders. As the aging population continues to grow, primary care providers will need to become increasingly familiar with differentiating between benign primary and more serious secondary headache disorders and will need to be able to treat the headache disorders unique to the elderly. With respect to therapeutic options, the future for treatment of the various headache disorders is promising. With the rise in popularity of complementary medical practices, there is likely to be more research on the roles of acupuncture, herbal and alternative remedies, massage therapy, and mind-body techniques. Further, new research is suggesting that neurostimulation may be useful in certain chronic, intractable headache conditions. Finally, the pathophysiology of headache disorders is still poorly understood and there is great hope that better understanding of the underlying mechanics of headache might contribute to improved treatment modalities and better quality of life for patients.

Intranasal contact points as a cause of facial pain or headache: a systematic review

BACKGROUND

There is a body of opinion in the clinical literature advocating the removal of intranasal contact points to treat facial pain.

OBJECTIVES

To review the evidence that intranasal mucosal contact points cause facial pain or headache and their removal is therapeutic.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A systematic search of the available literature was performed using MEDLINE, EMBASE, Cochrane library and NHS Evidence from inception to September 2011. Terms used include facial pain and contact point (3628), rhinologic headache (6) contact point and surgery/endoscopy (38).

EVALUATION METHOD

Inclusion criteria applied. Assessment of papers were undertaken by one reviewer and checked by the second. A narrative review of each study was performed and results recorded in tables.

RESULTS

In one study, 973 consecutive patients with a provisional diagnosis of rhinosinusitis were divided into groups with (42%) and without facial pain. There was a 4% prevalence of nasal contact in both groups, which was unrelated to the presence of facial pain. In another study of 100 patient's coronal paranasal sinus CT scans, 29% had headache and 55% had a contact point but their presence was inversely related to the presence of pain.(1) In a further study, ten healthy volunteers had palpation, adrenaline, substance P and placebo applied to different areas throughout the nasal cavity and none of these stimuli caused facial pain. Nineteen studies were identified where nasal mucosal contact points had been removed surgically for the treatment of facial pain. They were small case series, not randomised and subject to selection bias, had no control group, a limited follow-up and were open to observer bias with level IV evidence. Seven studies had a statistically significant improvement in pain postoperatively compared with preoperative questionnaire results but the majority had residual facial pain.

CONCLUSION

The majority of people with contact points experience no facial pain. The presence of a contact point is not a good predictor of facial pain. The removal of a contact point rarely results in the total elimination of facial pain making the theory that a contact point is responsible unlikely. The improvement in postoperative symptoms following the removal of contact points in some patients may be explained by cognitive dissonance or neuroplasticity. A randomised, controlled and blinded trial with a followed up period of over 12 months is needed to assess the place of surgery in the removal of a contact point for the treatment of facial pain.

Efficacy of psychological treatment for headaches: an overview of systematic reviews and analysis of potential modifiers of treatment efficacy

OBJECTIVES

A variety of psychological treatments exist for headaches (HAs). Their efficacy has been evaluated through systematic reviews with meta-analysis. Our goal was to evaluate the scope of these reviews and reevaluate the efficacy of treatments considering potential sources of variation systematically. These findings should help guide clinical practice and will provide guidance to researchers planning to address the efficacy of psychological treatments for HAs.

MATERIALS AND METHODS

Two systematic reviews were conducted: one searched for systematic reviews with meta-analysis exploring the efficacy of psychological treatments for HA in Cochrane Database, DARE, EMBASE, ISI Web of Knowledge, Medline, and PsychINFO from inception to December 2011. Two independent reviewers screened, evaluated quality, and extracted data. The second review searched for primary studies from the included reviews estimating the efficacy of psychological treatments for a clinically significant change.

RESULTS

Eighteen reviews met a priori criteria for inclusion. The broad scope of research on efficacy of psychological treatments for HA is reflected by variation in clinical and methodological characteristics of the reviews. These variations were explored through meta-analysis and subgroup analysis of 41 primary studies and showed that some of these variations, including time of assessment, treatment type, age, HA diagnosis, and study quality, can impact the magnitude of treatment effect.

DISCUSSION

There is substantial evidence in favor of psychological treatments for HA management. Further investigation, especially in specific treatments (cognitive-behavioral or autogenic treatment) for HA disorders, is needed. The assessment of these systematic reviews highlighted key areas where improvement should be made to increase the quality of evidence.

Efficacy and gastrointestinal risk of aspirin used for the treatment of pain and cold

AIMS

To analyse major sources of evidence-based information on the efficacy and gastrointestinal tolerability of aspirin, used short-term, in over-the-counter (OTC) doses, to relieve acute pain and cold symptoms, including associated feverishness.

METHODS

Evidence was largely collected from published meta-analyses and systematic reviews that focused on randomised, controlled, double-blind clinical trials, in which aspirin was compared to placebo and, in some cases also, to active comparators such as OTC doses of paracetamol or ibuprofen.

RESULTS

Across a large number of comparisons, aspirin was superior to placebo in treating pain, cold or fever. Efficacy was essentially similar to that of comparators used in equivalent doses. There was no serious GI adverse event attributed to ASA in any study, but mild-to-moderate dyspepsia in small percentages of cases was commonly reported.

CONCLUSION

OTC aspirin is safe and effective. Safety concerns should not limit brief use to relieve acute pain, cold or fever.

Application of ICHD-II criteria for headaches in a TMJ and orofacial pain clinic

The aim of this study was to identify and diagnose headache in a temporomandibular joint and orofacial pain clinic population using the second edition of The International Classification of Headache Disorder criteria. In 502 temporomandibular disorder and orofacial pain patients, 246 patients (49%) were diagnosed with tension-type headache (TTH), followed by migraine without aura (14.5%), probable migraine (12.9%), migraine with aura (7%), probable TTH (4.8%) and cluster headache (0.2%). The prevalence of headaches was compared between male and female patients, and the prevalence of migraine was found to be higher in women than in men. In evaluating by age, the prevalence of migraine was highest in patients in their 20s and 30s and declined as age increased above 40. TTH showed the highest rate throughout all age groups, but it also decreased as age increased. In this study, the prevalence of migraine was lower than that reported in Dr Kim et al.'s study, and the prevalence of TTH much higher than that reported in the previous study. Of the headache patients, 81.1% presented with masseter muscle pain and 47.8% with temporal muscle pain. This finding suggests that pericranial muscle pain may be an inducing factor of primary headache.

Sinus headaches: avoiding over- and mis-diagnosis

'Sinus headache' is a term used by many patients and primary-care physicians and, contrary to popular belief, sinus headaches are uncommon. Headaches that are due to sinusitis are confined to a minority of patients who have acute frontal sinusitis or sphenoiditis. The International Headache Society classification is robust in qualifying the term sinus headache and says that "chronic sinusitis is not validated as a cause of headache and facial pain unless relapsing into an acute stage". The vast majority of people who present with a symmetrical frontal or temporal headache, sometimes with an occipital component, have tension-type headache. Unilateral, episodic headaches are often vascular in origin. The idea that sinusitis can trigger migraine is misplaced, as the whole symptom complex is vascular and coexisting nasal congestion is due to vasodilation of the nasal mucosa that is sometimes part of the vascular event. The use of nasal endoscopy and imaging of the paranasal sinuses have advanced our appreciation that these patients are suffering from a vascular event. When these patients are asked to attend a clinic when they are symptomatic, the vast majority are found not to have a sinus infection. Sinusitis rarely causes headache, let alone facial pain, except when there is an acute bacterial infection when the sinus in question cannot drain, and it is usually unilateral due to increased pressure and inflammation caused by pus trapped within the sinus cavity. These patients usually have a history of a viral upper respiratory infection immediately before this and they have pyrexia with unilateral nasal obstruction. The vast majority of patients with acute sinusitis respond to antibiotics. Recurrent bacterial sinusitis is rare and anyone with more than two episodes of genuine bacterial sinusitis in 1 year should be investigated for evidence of poor immunity. Patients with chronic bacterial sinusitis rarely have any pain unless the sinus ostia are blocked and their symptoms are then the same as in acute sinusitis. Within the medical literature, there are texts that report that sphenoid sinusitis can cause headaches and, as with other acute sinus infections, intracranial or ophthalmolgical complications can occur. First, acute sphenoid sinusitis is rare and second, most of these patients respond to antibiotics. Batotrauma can cause short-lived pain in the sinus involved but there is always a clear history associated with diving or flying and, as the pressure within the sinus equalizes, the pain resolves within a few hours. Headaches are rarely due to sinusitis.

Therapeutic uses of botulinum toxin: from facial palsy to autonomic disorders

BACKGROUND

The therapeutic uses of botulinum toxin have been expanding due to deeper knowledge of its molecular behaviour and different mechanisms of action.

OBJECTIVE

To present suggested doses of Botox and Dysport for controlling the muscle hyperkinetic activity in facial palsy in the perioral area and to review other uses.

METHODS

An extensive updated literature review on the success and limits of the botulinum neurotoxin (BoNT) therapeutic treatments.

RESULTS/CONCLUSION

BoNT can be considered to be the preferred single method for many disorders; it has substituted for some conventional surgical methods and it can be associated with other therapies to increase overall treatment performance. Depending on the disorder, the lack of permanent effect causes no major inconvenience.

Pericranial injection of botulinum toxin type A (Dysport) for tension-type headache - a multicentre, double-blind, randomized, placebo-controlled study

Increasingly, botulinum type A toxin is used to influence pathologically increased muscle activity in conditions such as dystonia and spasticity. Studies have also assessed its efficacy in tension-type headache, where muscle tenderness may be increased. We undertook a prospective, multicentre, randomized, double-blind, placebo-controlled trial. Patients received injections of Dysport (total dose of 420 or 210 units) or saline placebo in 18 sites on the head and neck. Of 125 patients treated, 118 were included in the intention-to-treat dataset. No significant differences between each verum group and placebo were seen for the primary efficacy parameter - change in the number of headache-free days at 4-8 weeks after injection compared with 4 weeks before injection. The groups receiving 420 or 210 units of Dysport experienced 2.60 and 2.87 more headache-free days respectively, compared with 1.93 more headache-free days for the placebo group (P = 0.66 versus 420 units; P = 0.52 versus 210 units). Treatment with 420 units of Dysport was associated with significant improvements compared with placebo for two secondary efficacy parameters: mean change in headache duration from baseline to weeks 8-12 (P < 0.05) and improved global physician and patient assessment scores (P < 0.05). Further studies should address the possible value of multiple injections with extended observation periods, dose optimization, and whether duration of headache history and number of previous treatments are predictors of patient response.

Headache in the elderly

Headache in an elderly patient can be a sign of serious, potentially life-threatening disorders. All patients require a full assessment, including a complete neurologic examination. Particular emphasis should be placed on excluding subarachnoid hemorrhage, subdural hematoma, giant cell arteritis, intracranial neoplasm, cerebrovascular accident, acute-angle-closure glaucoma, and infectious etiologies such as meningitis and encephalitis. Once life-threatening disorders are excluded, the geriatrician can focus on more benign etiologies such as migraine, tension headache, and medication withdrawal. Treatment depends on the underlying etiology. This article discusses headaches that require emergent treatment and then describes more benign etiologies of headaches.

Multi-center randomized control trial of etizolam plus NSAID combination for tension-type headache

OBJECTIVE

Benzodiazepines are commonly used for the treatment of tension-type headache (TTH), however, there are few randomized controlled trials recommending the use of these drugs in Japan. This study was undertaken to evaluate the efficacy of etizolam, a thienodiazepine derivative, in combination with a non-steroidal anti-inflammatory drug (NSAID) as an acute treatment for TTH.

METHODS

The study design was a multi-center randomized control trial and included 144 patients. The diagnosis of TTH was based on the criteria of the International Classification of Headache Disorders-1 and all patients were diagnosed with episodic tension-type headache (ETTH). Changes in the severity of headache and shoulder pain were graded using a Visual Analogue Scale (VAS) before and after administration of drugs. Patients were randomized into NSAID alone (NSAID, mefenamic acid, 250 mg) group and NSAID (mefenamic acid, 250 mg) plus etizolam (0.5 mg) (NSAID-ET) group prior to treatment.

RESULTS

Although both groups showed a significant drop in VAS for headache and shoulder pain (p<0.01), there was no overall significant difference between the NSAID-ET and NSAID groups. However, headache was improved significantly in female patients (p<0.05), and shoulder pain was improved in young and female patients (p<0.05, p<0.04) in the NSAID-ET group.

CONCLUSION

This study indicates that the combination treatment of etizolam and NSAID is useful in young or female patients.

Botulinum toxin: Clinical use

Since its development for the use of blepharospasm and strabismus more than 2.5 decades ago, botulinum neurotoxin (BoNT) has become a versatile drug in various fields of medicine. It is the standard of care in different disorders such as cervical dystonia, hemifacial spasm, focal spasticity, hyperhidrosis, ophthalmological and otolaryngeal disorders. It has also found widespread use in cosmetic applications. Many other indications are currently under investigation, including gastroenterologic and urologic indications, analgesic management and migraine. This paper is an extensive review of the spectrum of BoNT clinical applications.

Botulinum toxin therapy of migraine and tension-type headache: comparing different botulinum toxin preparations

Most of the initial reports on botulinum toxin in tension-type headache (TTH) and in migraine were positive. Unfortunately, these results were not reproduced in well-designed, randomized controlled trials. So far, doses from 20 U (Botox) to 500 U (Dysport) have been studied in patients with chronic TTH, and doses from 16 to 200 U (Botox) in patients with migraine. Overall, there is no evidence for a beneficial effect of botulinum toxin, although trends favoring botulinum toxin were reported. Experience with botulinum toxin type B (Myobloc/NeuroBloc) is limited and similar to the experience with the type A. Thus, a widespread use of botulinum toxin therapy in headache can currently not be recommended.

Headache and coping in a female working population

Tension-type headache is a common disorder amongst working people and, because of its very high prevalence, represents one of the most costly ailments in modern society. To study the frequency of tension-type headache in a working female population and to investigate how females who have experienced tension-type headache cope with pain compared with the way healthy pain-free subjects cope with stress. A total of 400 females working at a university hospital in Sweden were asked about their experience of headache in the previous 3 months. Instruments used were a specific Headache Questionnaire, the Jalowiec Stress-coping Questionnaire and Coping Strategy Questionnaire. Before the study, approval from the board of directors and the employees' council was obtained. About 257 females (64.3%) answered the questionnaire and 78% of them (n = 199) reported that they had experienced headache in the previous 3 months. About 90% of the participants had never had an appointment with a doctor concerning headache and 57% reported a relationship between stress and headache. Regarding pain-coping strategy, increased pain behaviour was the most frequent strategy used. With regard to stress-coping style, a significant difference in the use of emotive style was found between females reporting headache and females not reporting headache. The results indicate that prevention programmes emphasizing stress management and coping may influence the experience of tension-type headache.

Sinogenic Facial Pain: Diagnosis and Management

Most patients who present to an otorhinolaryngology clinic with facial pain and headaches believe they have sinusitis. There is an increasing awareness that neurologic causes are responsible for a large proportion of patients with headache and facial pain. If facial pain and pressure is the primary symptom, it is unlikely to be caused by sinus disease in the absence of any nasal symptoms or signs. Patients with facial pain who have no objective evidence of sinus disease are unlikely to be helped by surgery. Most patients with pain caused by sinusitis respond to medical therapy.

Greater occipital nerve block is ineffective in chronic tension type headache

Patients with primary headache syndromes often describe a pain distribution, that does not respect the trigeminal innervation of the head. In addition to pain in frontal areas, innervated by the first (ophthalmic) division of the trigeminal nerve, the pain often occurs in occipital parts of the head, innervated by the greater occipital nerve, a branch of the C2 spinal nerve root. Anatomical and neurophysiological studies in animals suggest a convergence of cervical and trigeminal input in the trigeminal nucleus caudalis. Modulation of this pathway has been discussed to be of potential benefit in headache disorders. We investigated in an open pilot study the effect of bilateral block of the greater occipital nerve with 50 mg prilocaine and 4 mg dexamethasone in patients with chronic tension type headache. From 15 patients, only one patient described a headache relief after initial exacerbation of headache for 2 days. Headache intensity was unchanged in 11 patients. In further three patients, the headache worsened in the first hours or days after injection. No serious adverse events were observed. One patient showed a bradycardia (36/min) after the first injection during palpation of the muscles of the neck. Three patients suffered pain on the injection site for a few days. Our results indicate that block of the greater occipital nerve is not effective in the treatment of chronic tension type headache. If at all, rather a 'pro-nociceptive' effect was observed.

Etiology of primary headaches: the importance of genes and environment

Results from twin studies show that genes play an important role for susceptibility to migraine. The propensity for migraine to run in some families but not in others arises predominantly from alleles shared by family members and not the shared family environment, and that environmental influences on migraine are unique to the affected family member. The main genetic and environmental architecture for the other two major primary headaches, tension-type and cluster, remains to be elucidated. This review focuses on recent advances in twin studies of primary headaches and the future prospects are outlined.

New developments in the pharmacotherapy of tension-type headaches

The first International Headache Society classification defined tension-type headaches (TTHs) by itemising those characteristics of migraines TTHs did not possess [1]. As a result, TTHs, both episodic and chronic, remain the most nonspecific of all the commonly observed primary headaches. Until recently, there has been little impetus on the part of the pharmaceutical industry to investigate TTHs; many of the potentially useful drugs are now generic and unprofitable. In addition, few investigators have pursued the study of TTHs in lieu of its more glamorous neighbour, migraine. As a result, there are few well-designed studies on the pharmacotherapy of TTHs. The few studies that exist support the use of age-old standard drug classes, the tricyclic antidepressants and the NSAIDs. New research is now emerging that points to the potential utility of botulinum toxin type A, NMDA-receptor antagonists including Mg(2+) and nitric oxide synthase inhibitors. More scientifically rigorous clinical studies are needed.

Local inflammation as a mediator of migraine and tension-type headache

OBJECTIVE

To demonstrate the relationship of migraine and tension-type headache to a localized maxillary gingival inflammation.

BACKGROUND

Intraoral tenderness has been observed consistently in the most common types of primary headache disorders. The laterality and degree of tenderness is related to laterality and severity of reported symptoms, both during headache and in the interictal state.

METHODS

Bilateral posterior maxillary palpation and local temperature recordings were performed during unilateral migraine and tension-type headache. Local anti-inflammatory techniques, ie, local chilling and a topical anti-inflammatory gel, were used in these tender areas in episodic migraine and tension-type headache patients.

RESULTS

Ipsilateral intraoral tenderness and increased local temperature were consistently observed during unilateral migraine and tension-type headache, suggesting local inflammation. Intraoral chilling and topical application of a nonsteroidal anti-inflammatory drug were highly effective for the treatment of migraine and tension-type headache, both in the acute phase and for headache prevention.

CONCLUSION

These results suggest that a local intraoral inflammation may be associated with the pathogenesis of these common headaches.

Temperament and character profiles of patients with tension-type headache and migraine

The aim of this present study was to evaluate the temperament and character profiles of persons with tension-type headache (TTH) and migraine, and to compare the results with those of healthy controls. The study population consisted of 81 patients with TTH (60 female, 21 male) and 56 patients with migraine (34 female, 17 male) aged 18-50 years, according to the criteria of the International Headache Society with age and gender - matched healthy control subjects (54 female, 28 male). All participants were instructed to complete a self-administered 240-item temperament and character inventory (TCI) questionnaire and Beck Depression Inventory (BDI). The TCI assesses four dimensions of temperament, namely, novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (P), and three dimensions of character, being self-directedness (SD), cooperativeness (C) and self-transcendence (ST). According to the TCI biosocial model, the temperament dimension HA is suggested to indicate central serotonergic turnover, which is further correlated with depressive state. It was found that mean BDI scores were significantly higher in patients with TTH and migraine than in those of the controls. The BDI scores were positively correlated with HA scores (r = 0.295, P < 0.001) and negatively correlated with SD (r = -0.386, P < 0.001) and C scores (r = -0.164, P= 0.016). Multivariate analysis showed that BDI scores had significant covariation for HA, SD and C. Despite using the BDI score as a covariate, TTH patients had higher HA scores (P = 0.01) than did the control subjects. No significant differences were found between the groups regarding main NS, RD, P, SD, C and ST scores. Based on the main results of this study, it is suggested that higher serotonergic activity related to HA scores in TTH patients and their relationship with depressive symptomatology supports the role of central serotonergic involvement in TTH.

[Headaches in the elderly]

ACCORDING TO AGE: It is generally thought that the prevalence of headaches decreases with ageing. However recent studies, with stricter epidemiology and methodology, clearly indicate that this decreases is less obvious than that perceived. PRIMARY AND SECONDARY HEADACHES: In elderly patients, primary headaches and notably migraine (often with altered presentation) are less frequent, even though new authentic cases may appear. However the other types of headache are clearly present. In particular, the incidence and prevalence of secondary headaches slightly increases and they represent up to 30% of all the headaches observed, compared with less than 10% in young or adult patients. The causes of such symptomatic headaches are multiple and it is important to be able to identify them since an aetiological treatment is often possible. REGARDING TREATMENT: The symptomatic treatment of headaches in the elderly follows the same principles as that of younger patients. However, the side effects and drug interactions related to pharmacological treatments can be disastrous in fragilised patients. It is therefore important to emphasize the interest of physical methods of analgesia, particularly adapted to the elderly. Some of these methods have demonstrated their efficacy and are recommended by international consensuses.

[A chronic problem-the chronic headache patient]

Chronic daily headache is a frequent problem which affects 3-5% of the population. Until the 2nd edition of the IHS headache classification, the diagnosis of chronic headache was synonymous with the diagnosis of chronic tension type headache. Now one has to differentiate, not only in symptomatic headache, but also between other primary headache syndromes, such as chronic migraine, hemicrania continua and acute persisting daily headache. Epidemiological studies point to a particular importance of chronic migraine and headache due to chronic analgetica use, since both types of headache are responsible for more than 60% of all cases with chronic headache. Although the mechanisms which cause chronification of headache are not well understood, the new headache classification prompts some direct therapeutical consequences: 1) the indication for drug withdrawal and 2) the indication for a migraine preventive therapy. In general, as with other chronic pain syndromes, there is increasing evidence that a multimodal therapy, consisting of patient education, behavioral therapy and pharmacological therapy, is more successful than a singular therapy.

Midfacial segment pain: implications for rhinitis and sinusitis

During the past decade, studies on facial pain have shown that there is a distinct group of patients who have a form of facial neuralgia that has all the characteristics of tension-type headache, except that it affects the midface; it is called midfacial segment pain. The pain is described as a feeling of pressure, although some patients might feel that their nose is blocked when they have no nasal airway obstruction. Midfacial segment pain is symmetric, and it might involve areas of the nasion (the root of the nose), under the bridge of the nose, on either side of the nose, the peri- or retro-orbital regions, or across the cheeks. There might be hyperesthesia of the skin and soft tissues over the affected area. Nasal endoscopy and CT scans are typically normal. Most patients with this condition respond to low-dose amitriptyline, but noticeable improvement might require up to 6 weeks.

Ponytail Headache: A Pure Extracranial Headache

Fifty of 93 females experienced headache from wearing a ponytail. Pain was experienced only at the site of the hair tie in 10 subjects, extending in others, forwards to the vertex (n = 5) or forehead (n = 7), laterally to the parietal region (n = 8) or temples (n = 3), downwards to the neck (n = 5), or to other areas (n = 12). Loosening the hair relieved pain immediately in 4 subjects, within half an hour in 32, and within an hour in 5 subjects; the remaining 9 subjects were uncertain of pain duration. This headache was preventable by wearing the ponytail more loosely tied. Ponytail headache, well known to females, is not described in the medical literature because the remedy is obvious, therefore those affected do not seek medical advice. This seemingly common headache provides an example of a pure extracranial headache arising from pericranial muscle fascia and tendon traction. Males almost certainly have similar experiences, but were not questioned in this study. Distinguishing intracranial from extracranial headache is essential in diagnosis and treatment. Further research on ponytail and other extracranial headaches could shed light on the mechanism of tension-type headache.

Treatment of chronic tension-type headache with botulinum toxin A: a randomized, double-blind, placebo-controlled multicenter study

A beneficial effect of botulinum toxin on tension-type headache was reported in open-label studies but scientifically rigorous clinical studies are lacking. Therefore we conducted a prospective, multicenter, randomized, double-blind, placebo-controlled trial. Multiple pericranial muscles of 112 patients with chronic tension-type headache were treated either with 500 mouse units of botulinum toxin (Dysport) or with placebo. The diagnoses were made strictly following the International Headache Society criteria. Co-existence of migraine was an exclusion criterion. Injections were made following a fixed scheme and not adjusted to the patient's symptoms. Patients kept a headache diary that was used to calculate the area under the headache curve of 6 weeks before and 12 weeks after the treatment as the main effect measure. Secondary effect measures were the number of days with headache, the number of days with intake of analgesics, the duration of the nocturnal sleep, and the Beck Depression Inventory score. There were no significant differences between the verum group and the placebo group in any of these variables. Seven patients of the verum group had transient weakness of the eyelids, the neck, or both, indicating that a higher dose than used in this study does not seem sensible for the treatment of headache. The statistical power of the study was high enough to warrant the conclusion that there is no clinically significant effect of botulinum toxin A on chronic tension-type headache.

Botulinum toxin: application into acupuncture points for migraine

BACKGROUND

: Botulinum toxin has been employed in orthopedics, physiatrics, gastroenterology, gynecology, neurology, pediatrics, general surgery, plastic surgery, and several other specialties. We have applied this drug to treat hyperhidrosis and wrinkles in dermatology; it offers also a secondary benefit: relief for headaches.

OBJECTIVE

: We have performed studies based on acupuncture principles in order to develop new botulinum toxin application sites for the treatment of migraine. These additional sites are helpful when patients expect results for both their illness and their wrinkles; whereas some patients will show improvement with the classic treatment for wrinkles, additional sites may be required.

METHODS

: Ten patients suffering from migraine, as diagnosed through the criteria proposed by the Headache Classification Committee of the International Headache Society, were selected. We used easily recognizable acupuncture sites for the injection of botulinum toxin.

RESULTS

: There was significant improvement in patients with acupuncture site-guided botulinum toxin injection. It showed to be a safe and effective therapy for migraine.

CONCLUSION

: There are alternative sites besides those used for the treatment of expression lines, which bring forth an improvement of migraine.

Peripheral and central mechanisms in tension-type headache: an update

Despite the tremendous socioeconomic impact of tension-type headache surprisingly little is known about the underlying pathophysiology and treatment. Existing evidence and theories about the relation between central and peripheral mechanisms are discussed. Central sensitization is probably the most important key to understand this widespread disorder. An effective prevention or reversal of this central sensitization will probably be of major importance in future treatment strategies.

Low-dose diclofenac potassium in the treatment of episodic tension-type headache

BACKGROUND

Several clinical trials have demonstrated that low doses of non-steroidal anti-inflammatory drugs relieve episodic tension-type headache (ETH).

AIMS

The aims of this placebo-controlled study were to determine whether single doses of diclofenac-K 12.5 and 25mg effectively relieve ETH in adults and to compare it to ibuprofen 400mg.

METHODS

A single-dose multicentre, randomised, double-blind, double-dummy, clinical trial was conducted at 22 primary care centres in Germany. All subjects had a history of ETH according to the classification of the International Headache Society. Of 684 subjects randomised, 620 used the study drugs for an episode of tension headache occurring within one month after enrolment: diclofenac-K 12.5mg (n=160), diclofenac-K 25mg (n=156), ibuprofen 400mg (n=151) and placebo (n=153). The primary efficacy variable was total pain relief, calculated as the time-weighted sum of the pain relief assessments from baseline to the 3h evaluation time (TOTPAR-3).

RESULTS

For TOTPAR-3, all active treatments were superior to placebo; no statistically significant difference between the three active treatments could be detected. A similar pattern was also observed with regard to TOTPAR-6 (6h evaluation time), > or =50%maxTOTPAR at 3 and 6h, weighted pain intensity difference at 3 and 6h (SPID-3; SPID-6), percentage of patients with complete headache relief at 2h, end of study global evaluation and time to rescue medication. The number-needed-to-treat (NNT) at 6h was 4.5 (2.9-9.2) in the ibuprofen 400mg group, 4.0 (2.8-7.3) in the diclofenac-K 12.5mg group and 3.9 (2.7-7.1) in the diclofenac-K 25mg group. These differences were not statistically significant.

CONCLUSION

Diclofenac-K, administered as single doses of 12.5 and 25mg effectively relieves ETH and is comparable to ibuprofen 400mg.

Saints-protectors from headache - historical hints of suggestive therapy?

A short overview of several saints, venerated in Christian tradition as protectors from headache, is offered as an introduction to a more substantial debate on the possibility and value of analysing historical literary and iconographic sources and their interpretation. Headache of possible psychosomatic origin allows (auto) suggestive therapy obtained by the invocation of saints to have had considerable success. This possibility favours the opinion that historical material can be useful not only for cultural-anthropological, but also for modern medical considerations as well.

Pharmacotherapy of tension-type headaches

The first International Headache Society classification defined tension-type headaches by itemizing characteristics of migraines that tension-type headaches did not possess. As a result, tension-type headaches (episodic and chronic) remain the most nonspecific of all the commonly observed primary headaches. Until recently, there has been little impetus on the part of the pharmaceutical industry to investigate tension-type headaches; many of the potentially useful drugs are now generic and unprofitable. In addition, few investigators have pursued the study of tension-type headache because of its more glamorous neighbor, migraine. As a result, there are few well-designed studies on the pharmacotherapy of tension-type headaches. The few studies that exist support the use of age-old standard drug classes, the tricyclic antidepressants and the nonsteroidal anti-inflammatory drugs. New research is emerging that points to the potential use of botulinum toxin and nitric synthase inhibitors. More scientifically rigorous clinical studies are needed.

Nasal polyposis and facial pain

A cohort of 973 patients with symptoms of rhinosinusitis and/or facial pain was followed up for a mean of 2 years 2 months and, within this, was a group of 220 with nasal polyps. Only 39 (18%) had pain or pressure as a symptom. Out of the 220 with nasal polyps, 190 had polyps without any purulent secretions and, of these, only 5 (2.6%) had pain attributable to their paranasal sinus disease. Ten out of the 15 with pain and polyps without pus were found to have pain as a result of neurological or medical cause after endoscopic sinus surgery and a trial of medical nasal treatment and, where necessary, drugs to treat neurological conditions. Thirty patients (13.6%) had nasal polyposis and purulent secretions, and, within this subgroup, 24 (79%) had pain as well. Of the 24 with pain and purulent secretions, 19 (80%) responded to treatment for their paranasal sinus disease, a far higher proportion than with nasal polyps without pus. In conclusion, in patients who have nasal polyps without purulent secretions, be cautious about attributing any symptoms of facial pain or pressure as being due to their paranasal sinuses as it is more probable that it is coincidental and the result of a neurological cause.

Classification and diagnosis of facial pain

This is an interesting time to consider the classification of facial pain because of the emergence of new ideas that challenge our understanding of the mechanisms involved. The new hypotheses that have been proposed appear to be of clinical relevance.