Tension-Type Headache - The Normal and Most Prevalent Headache

Efficacy and safety of simple analgesics for acute treatment of episodic tension-type headache in adults: a network meta-analysis

OBJECTIVE

Tension-type headache is the most common type of primary headache and results in a huge socioeconomic burden. This network meta-analysis (NMA) aimed to compare the efficacy and safety of simple analgesics for the treatment of episodic tension-type headache (ETTH) in adults.

METHODS

We searched the Cochrane Library, PubMed, Web of Science, Embase, Chinese BioMedical Literature database and International Clinical Trials Registry Platform databases for eligible randomized clinical trials reporting the efficacy and/or safety of simple analgesics. A Bayesian NMA was performed to compare relative efficacy and safety. The surface under the cumulative ranking curve (SUCRA) was calculated to rank interventions. PROSPERO registration number: CRD42018090554.

RESULTS

We highlighted six studies including 3507 patients. For the 2 h pain-free rate, the SUCRA ranking was ibuprofen > diclofenac-K > ketoprofen > acetaminophen > naproxen > placebo. All drugs except naproxen reported a higher 2 h pain-free rate than placebo, with a risk ratio (RR) of 2.86 (95% credible interval, CrI: 1.62-5.42) for ibuprofen and 2.61 (1.53-4.88) for diclofenac-K. For adverse events rate, the SUCRA ranking was: metamizol > diclofenac-K > ibuprofen > lumiracoxib > placebo > aspirin > acetaminophen > naproxen > ketoprofen. The adverse event rates of all analgesics were no higher than those of placebo, except for ketoprofen. Moreover, all drugs were superior to placebo in the global assessment of efficacy. In particular, the RR of lumiracoxib was 2.47 (1.57-4.57). Global heterogeneity I2 between the studies was low.

CONCLUSIONS

Simple analgesics are considered more effective and safe as a placebo for ETTH in adults. Our results suggest that ibuprofen and diclofenac-K may be the two best treatment options for patients with ETTH from a comprehensive point of view (both high-quality evidence).

Headaches in SLE patients: a cross-sectional analysis of clinical, immunological, and Radiological Correlations

BACKGROUND

Systemic Lupus Erythematosus (SLE) is a multifaceted autoimmune disorder characterized by diverse clinical manifestations, including a significant prevalence of headaches. This cross-sectional study aimed to thoroughly explore the relationship between SLE and headaches by analysing their prevalence, types, and associated clinical, immunological, and radiological factors.

METHOD

A comparative analysis was conducted on 179 SLE patients, who were categorized into two groups: those with headaches and those without. Data collection encompassed demographic details, disease activity levels, neurological assessments, immunological profiles, and brain imaging results. Headaches were diagnosed and classified following the International Classification of Headache Disorders (ICHD-3). Disease activity was measured using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Statistical analyses were performed to identify significant associations and correlations.

RESULTS

Headaches were observed in 55% of the SLE patients, predominantly presenting as tension-type headaches (65%) and migraines (27%). Notably, no patients met the criteria for a lupus-specific headache. The Headache Group exhibited significantly higher disease activity (SLEDAI scores). Tension-type and migraine headaches were particularly associated with increased muco-cutaneous manifestations. The presence of antiphospholipid (aPL) antibodies was significantly linked to migraines and cluster headaches. While neurological disorders such as ischemic stroke and venous sinus thrombosis were more prevalent in the Headache Group, these findings were not statistically significant. Brain MRI abnormalities were detected in 9.4% of patients with headaches, including venous sinus thrombosis (2.3%), ischemic stroke (5.8%), and white matter hyperintensities (1.1%).

CONCLUSION

This study underscore es the complex relationship between SLE and headaches, suggesting that headaches may serve as an indicator of heightened SLE disease activity. Immunological factors, particularly aPL antibodies, show a strong association with specific headache types. MRI abnormalities further emphasize the intricate neurobiological aspects in SLE patients experiencing headaches. Continued research is essential to better understand biomarkers, genetic factors, and effective treatment strategies for managing headaches in SLE patients.

[Temporal trend of the global prevalence rate of tension-type headache in children and adolescents in 1990-2021]

OBJECTIVES

To investigate the prevalence of tension-type headache (TTH) in children and adolescents aged 0-19 years globally in 1990-2021, and to provide a basis for the prevention and treatment of TTH.

METHODS

Based on the Global Burden of Disease Study data, the age-standardized prevalence distribution of TTH and its changing trend were analyzed among the children and adolescents aged 0-19 years, with different sexes, age groups, sociodemographic index (SDI) regions and countries/territories.

RESULTS

The age-standardized prevalence rate (ASPR) of TTH in children and adolescents aged 0-19 globally in 2021 was 17 339.89/100 000, which was increased by 1.73% since 1990. The ASPR in females was slightly higher than that in males (1990: 17 707.65/100 000 vs 16 403.78/100 000; 2021: 17 946.29/100 000 vs 16 763.09/100 000). The ASPR in adolescence was significantly higher than that in school-aged and preschool periods (1990: 27 672.04/100 000 vs 10 134.16/100 000; 2021: 28 239.04/100 000 vs 10 059.39/100 000). Regions with high SDI exhibited a higher ASPR than the other regions, with significant differences in prevalence rates across different countries. From 1990 to 2021, there was a slight increase in global ASPR, with an average annual percentage change (AAPC) of 0.06%. Females experienced a smaller increase than males based on AAPC (0.04% vs 0.07%). There was reduction in ASPR in preschool and school-aged groups, with an AAPC of -0.02%, while there was a significant increase in ASPR in adolescence, with an AAPC of 0.07%. ASPR decreased in regions with low-middle and low levels of SDI, with an AAPC of -0.02% and -0.04%, respectively, while it increased in regions with middle SDI, with an AAPC of 0.24%.

CONCLUSIONS

There is a consistent increase in the ASPR of TTH in children and adolescents aged 0-19 years globally, with significant differences across sexes, age groups, SDI regions and countries/territories.

Durable effects of acupuncture for tension-type headache: A systematic review and meta-analysis

Background

Acupuncture may be effective in treating tension-type headache (TTH). The durability of its effects after treatment completion remains inconclusive.

Methods

We searched multiple databases and references from previous reviews for randomized controlled trials (RCTs) which investigated the effectiveness of acupuncture for TTH. We assessed the methodological quality of RCTs using the Cochrane Risk of Bias 2.0 (RoB 2) tool. Primary outcome was response rate, defined as the proportion of participants who reported at least a 50% reduction in monthly headache days from baseline after completion of treatment. Secondary outcomes included headache days, headache intensity, and analgesic use. Safety outcomes were also evaluated.

Results

A total of seven RCTs involving 3,221 participants with frequent episodic and chronic TTH were included. Individuals receiving acupuncture reported a significantly higher response rate versus sham acupuncture (SA) immediately and at 1-6 months after completion of treatment (P<0.05). Compared with SA, post-treatment results of headache days and headache intensity appeared consistent on the whole, showing associations favoring acupuncture. However, no significant reduction in analgesic use was found post-treatment. Acupuncture showed no superiority over physical training or relaxation training in headache days and headache intensity. Moreover, no serious adverse events associated with acupuncture were reported.

Conclusion

Limited evidence suggested that acupuncture might provide durable post-treatment effects in the management of frequent episodic and chronic TTH for up to 6 months compared with SA,with no severe treatment-related adverse events reported.

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.

The cervical spine in tension type headache

INTRODUCTION

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

PURPOSE

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

IMPLICATIONS

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

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.

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Acupuncture for tension-type headache: a systematic review and meta-analysis of randomized controlled trials

Background

Tension-type headache (TTH) is the most common neurologic disease worldwide. Acupuncture is commonly applied to treat TTH, but evidence of acupuncture for TTH is contradictory based on previous meta-analyses. Therefore, we conducted this systematic review and meta-analysis to update the evidence of acupuncture for TTH and aimed to provide a valuable reference for clinical application.

Methods

We searched 9 electronic databases from their inceptions to July 1, 2022 for randomized controlled trials (RCTs) of acupuncture for TTH. We also manually searched reference lists and relevant websites, and the experts in this field were consulted for possible eligible studies. Two independent reviewers conducted literature screening, data extraction, and risk of bias assessment. The revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias of included studies. Subgroup analyses were carried out based on frequency of acupuncture, total sessions, treatment duration, needle retention, types of acupuncture and categories of medication. Data synthesis was performed using Review Manager 5.3 and Stata 16. The Grading of Recommendations Assessment, Development and Evaluation Approach (GRADE) was used to evaluate the certainty of evidence of each outcome. Meanwhile, the Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) was used to assess the reporting quality of interventions in clinical trials of acupuncture.

Results

30 RCTs involving 2,742 participants were included. According to ROB 2, 4 studies were considered as low risk, and the rest studies were some concerns. After treatment, compared with sham acupuncture, acupuncture had greater effect in improvement of responder rate [3 RCTs, RR = 1.30, 95%CI (1.13, 1.50), I2 = 2%, moderate certainty] and headache frequency [5 RCTs, SMD = -0.85, 95%CI (-1.58, -0.12), I2 = 94%, very low certainty]. In contrast to medication, acupuncture was more effective to reduce pain intensity [9 RCTs, SMD = -0.62, 95%CI (-0.86, -0.38), I2 = 63%, low certainty]. Adverse events were evaluated in 16 trials, and no serious event associated with acupuncture occurred.

Conclusions

Acupuncture may be an effective and safe treatment for TTH patients. Due to low or very low certainty of evidence and high heterogeneity, more rigorous RCTs are needed to verify the effect and safety of acupuncture in the management of TTH.

Physical Therapy in Tension-Type Headache: A Systematic Review of Randomized Controlled Trials

(1) Objective: The aim of this study is to synthesize the effects of physical therapy on pain, frequency, or duration management in the short, medium, and long term in adult patients diagnosed with Tension-type headache (TTH). (2) Background: Tension-type headache (TTH) is the most common headache with migraine and its pathophysiology and treatment has been discussed for years without reaching a consensus. (3) Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review was registered in PROSPERO (CRD42020175020). The systematic search for clinical trials was performed in the databases PubMed, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, Scopus, SciELO and Dialnet. Articles were selected according to the inclusion and exclusion criteria, regarding the effectiveness of physical therapy interventions on adult patients with TTH published in the last 11 years with a score ≥ 6 in the PEDro Scale (Physiotherapy Evidence Database). (4) Results: In total, 120 articles were identified, of which 15 randomized controlled trials were finally included in order to determine the inclusion criteria. Changes in pain intensity, headache frequency or headache duration of individual studies were described (5) Conclusions: This systematic review shows that there is no standardized physical therapy protocol for the approach to tension headache, although all the techniques studied to date address in one way or another the cranio-cervical-mandibular region. The approach to the cranio-cervical-mandibular region reports significant effects in terms of decreasing the intensity of pain and frequency of headache episodes in the short and medium term. More long-term longitudinal studies are needed.

The effectiveness of botulinum toxin for chronic tension-type headache prophylaxis: A systematic review and meta-analysis

BACKGROUND

A systematic and meta-analysis was conducted to examine the evidence of the effects of botulinum toxin A on chronic tension-type headache.

METHODS

Cochrane, Embase, Ovid, ProQuest, PubMed, Scopus, Web-of-Science databases, and ClinicallTrials.gov registry were systematically searched for studies examining the effects of botulinum toxin A on tension-type headaches. The records were screened by two independent reviewers using pre-determined eligibility criteria. DerSimonian Liard random-effects meta-analyses were performed using the 'meta' package (5.2-0) in R (4.2.0). Risk of bias and quality of evidence were assessed using the Cochrane Collaboration's Tool RoB 2 and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Clinical significance was determined using pre-defined minimal clinically important differences.

RESULTS

Eleven controlled trials were included (390 botulinum toxin A, 297 controls). Botulinum toxin A was associated with significant improvements in standardized headache intensity (-0.502 standard deviations [-0.945, -0.058]), headache frequency (-2.830 days/month [-4.082, -1.578]), daily headache duration (-0.965 [-1.860, -0.069]) and the frequency of acute pain medication use (-2.200 days/month [-3.485, -0.915]) vs controls. Botulinum toxin A-associated improvements exceeded minimal clinically important differences for headache intensity, frequency, and acute pain medication use. A 79% (28%, 150%) greater response rate was observed for botulinum toxin A vs controls in improving chronic tension-type headache. Treatment of eight chronic tension-type headache patients was sufficient to elicit a therapeutic response in one patient.

CONCLUSIONS

Corroborating the current mechanistic evidence, our meta-analysis supports the utility of botulinum toxin A for managing chronic tension-type headaches. However, due to limitations in the quality of evidence, adequately-powered high-quality controlled trials examining the effects of Botulinum toxin A on chronic tension-type headache are warranted.

REGISTRATION

Protocol preregistered in PROSPERO International Prospective Register of Systematic Reviews (CRD42020178616).

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

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

Effects of diacutaneous fibrolysis in patients with tension-type headache: A randomized controlled trial

BACKGROUND

Manual therapy appears to be effective for the relief of tension-type headache (TTH), just as diacutaneous fibrolysis (DF) has shown to be a beneficial technique for the relief of symptoms in other dysfunctions. However, no studies have evaluated the potential beneficial effect of DF in TTH. The aim of this study is to analyze the effect of three sessions of DF in patients with TTH.

METHODS

Randomized controlled trial in 86 subjects (43 intervention/ 43 control group). The headache frequency, the headache intensity, the pressure pain thresholds (PPTs) at trapeziometacarpal joint, upper trapezius, suboccipital, frontal and temporal muscles, parietal sutures and the cervical mobility were measured at baseline, at the end of the third intervention and one-month after the last intervention.

RESULTS

Statistically significant differences with p values <0.05 were observed between groups in favor of the intervention group in the one-month follow-up in the following variables: headache frequency, headache intensity, flexion, extension, right and left side-bending, right and left rotation, PPTs in left trapeziometacarpal joint, right suboccipital muscle, right and left temporal muscle, left frontal muscle and right and left parietal.

CONCLUSIONS

DF provides a beneficial effect in reducing headache frequency, relieving pain, and improving cervical mobility in patients with TTH.

Prevalence, frequency, and disability of migraine headaches and tension headaches among the general population in the Eastern Region of Saudi Arabia

A tension-type headache (TTH) is a recurrent headache that is mild to moderate in intensity, unlike migraine (MH), which is accompanied by crippling effects of nausea, vomiting, photophobia, or phonophobia. TTH is more frequent than migraine, but it is less likely to cause severe pain and physical dysfunction. TTHs account for more lost workdays due to their prevalence. The study aimed to evaluate the prevalence, frequency, and disability of MHs and TTHs among the general population in the Eastern Region of Saudi Arabia. A cross-sectional study was employed using a validated questionnaire. The questionnaire implemented the HARDSHIP algorithm to diagnose MH and TTH and questions to correlate their prevalence to socio-demographic data, measurement of the level of disability, headache management, and treatment effectiveness using the chi-square test. The study reviewed 877 subjects (46.6% males vs. 53.4% females). 52.9% of the participants experienced headaches during the previous three months, and 35.6% experienced headaches recently. The most common type of headache was a probable MH (32.1%), followed by a TTH (26.9%), probable TTH (19.5%), and MH (15%). It was reported that some disability was attributed to 47% of MHs and 26% of TTHs. The most commonly used headache medication was paracetamol (53.5%). This study revealed that TTH and MH are common illnesses in Saudi Arabia's Eastern Region. TTH and MH are correlated with significant individual and social burdens, particularly for MH. Headache sufferers mostly manage their headaches using conventional over-the-counter methods.

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.

Primary headaches increase the risk of dementias: An 8-year nationwide cohort study

Background

Headache, a highly prevalent neurological disorder, has consistently been linked with an elevated risk of dementia. However, most studies are focused on the relationship with migraine in limited age groups. Therefore, the objective of this research was to look at the link between various type of headaches and dementias based on longitudinal population-based data.

Methods and results

Participants diagnosed with headache from 2002 to 2005 were selected and major covariates were collected. The diagnoses of Alzheimer’s disease, vascular dementia, and other dementias were observed from 2006 until 2013. The adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of dementias according to headache type were calculated by Cox proportional hazards regression. A number of 470,652 participants were observed for a mean of 7.6 years (standard deviation: 1.2), for approximately 3.6 million person-years. Both tension type headache (TTH) and migraine elevated the risk of all-cause dementias (TTH, aHR 1.18, 95% CI 1.13–2.24; migraine, aHR 1.18, 95% CI 1.13–2.24). Headaches had a greater influence in females and non-smokers as a risk factor of dementias. Patients with migraine who consumed alcohol had a higher risk of dementia, however this was not true with TTH patients. Among participants without comorbidities, TTH patients were more susceptible to dementia than migraine patients. Headache patients had a higher proportion of females regardless of headache type and approximately 1.5 times more individuals had three or more comorbidities compared to those without headache.

Conclusions

Headache could be an independent predictor for subsequent dementia risk. Future studies should focus on clarifying pathogenic pathways and possible dementia-related preventive measures in headache populations.

Increasing Collaboration between Headache Medicine and Plastic Surgery in the Surgical Management of Chronic Headache

Introduction

Chronic headache is one of the most disabling conditions afflicting humankind. The management of chronic headaches has, to date, been only partially successful. The goal of this paper is to highlight the importance of collaboration between surgeons and headache physicians in treating this condition.

Methods

We present a narrative review of migraine pathophysiology, its medical and surgical treatment options, and the important role of collaboration between headache physicians and surgeons.

Results

Migraine headaches can be treated with both medication-based regimens and surgery. Novel medications such monoclonal antibodies directed at the CGRP molecule or its receptor have recently been FDA approved as an effective treatment modality in chronic migraines. However, these medications are associated with a high cost, and there is a paucity in data regarding effectiveness compared to other treatment modalities. The pathophysiology of headache likely exists along a spectrum with peripheral - extracranial and meningeal - factors at one end and central - brain - factors at the other, with anatomic and physiologic connections between both ends. Recent evidence has clearly shown that surgical decompression of extracranial nerves improves headache outcomes. However, appropriate patient selection and preoperative diagnosis are of paramount importance to achieve excellent outcomes.

Conclusions

Surgeons and headache physicians who are interested in providing treatment for patients with chronic headache should strive to form a close collaboration with each other in order to provide the optimal plan for migraine/headache patients.

Repetitive Neuromuscular Magnetic Stimulation for Pediatric Headache Disorders: Muscular Effects and Factors Affecting Level of Response

Repetitive neuromuscular magnetic stimulation (rNMS) for pediatric headache disorders is feasible, safe, and alleviates headache symptoms. This study assesses muscular effects and factors affecting response to rNMS. A retrospective chart review included children with headaches receiving six rNMS sessions targeting the upper trapezius muscles. Pressure pain thresholds (PPT) were measured before and after rNMS, and at 3-month follow-up (FU). Mean headache frequency, duration, and intensity within the last 3 months were documented. In 20 patients (14.1 ± 2.7 years), PPT significantly increased from pre- to post-treatment (p < 0.001) sustaining until FU. PPT changes significantly differed between primary headache and post-traumatic headache (PTH) (p = 0.019−0.026). Change in headache frequency was significantly higher in patients with than without neck pain (p = 0.032). A total of 60% of patients with neck pain responded to rNMS (≥25%), while 20% of patients without neck pain responded (p = 0.048). 60% of patients receiving rNMS twice a week were responders, while 33% of patients receiving rNMS less or more frequently responded to treatment, respectively. Alleviation of muscular hyperalgesia was demonstrated sustaining for 3 months, which was emphasized in PTH. The rNMS sessions may positively modulate headache symptoms regardless of headache diagnosis. Patients with neck pain profit explicitly well. Two rNMS sessions per week led to the highest reduction in headache frequency.

Burden of tension-type headache in the Middle East and North Africa region, 1990-2019

Introduction

Tension-type headache (TTH) is the most prevalent neurological disorder. As there is a gap in the literature regarding the disease burden attributable to TTH in the Middle East and North Africa (MENA) region, the aim of the present study was to report the epidemiological indicators of TTH in MENA, from 1990 to 2019, by sex, age and socio-demographic index (SDI).

Methods

Publicly available data on the point prevalence, annual incidence and years lived with disability (YLDs) were retrieved from the global burden of disease (GBD) 2019 study for the 21 countries and territories in MENA, between 1990 and 2019. The results were presented with numbers and age-standardised rates per 100000 population, along with their corresponding 95% uncertainty intervals (UIs).

Results

In 2019, the age-standardised point prevalence and annual incidence rates for TTH in the MENA region were 24504.5 and 8680.1 per 100000, respectively, which represents a 2.0% and a 0.9% increase over 1990-2019, respectively. The age-standardised YLD rate of TTH in this region in 2019 was estimated to be 68.1 per 100000 population, which has increased 1.0% since 1990. Iran [29640.4] had the highest age-standardised point prevalence rate for TTH, while Turkey [21726.3] had the lowest. In 2019, the regional point prevalence of TTH was highest in the 35-39 and 70-74 age groups, for males and females, respectively. Furthermore, the number of prevalent cases was estimated to be highest in those aged 35-39 and 25-29 years, in both males and females, respectively. Moreover, the burden of TTH was not observed to have a clear association with SDI.

Conclusions

While the prevalence of TTH in the MENA region increased from 1990 to 2019, the incidence rate did not change. In addition, the burden of TTH in MENA was higher than at the global level for both sexes and all age groups. Therefore, prevention of TTH would help alleviate the attributable burden imposed on the hundreds of millions of people suffering from TTH around the region.

Repetitive neuromuscular magnetic stimulation in children with headache

INTRODUCTION

Repetitive neuromuscular magnetic stimulation (rNMS) was previously applied in adult patients with episodic migraine, showing beneficial effects on headache characteristics, high safety, and convincing satisfaction. This study aims to assess rNMS as a personalized intervention in pediatric headache.

METHODS

Retrospective chart review including patients with migraine, TTH, mixed type headache, or PTH, who had received at least one test rNMS session targeting the upper trapezius muscles (UTM).

RESULTS

33 patients (13.9 ± 2.5 years; 61% females) were included in the primary analysis, resulting in a total of 182 rNMS sessions. 43 adverse events were documented for 40 of those sessions (22%). Most common side effects were tingling (32.6%), muscle sore (25.5%), shoulder (9.3%) and back pain (9.3%). Secondly, in patients (n = 20) undergoing the intervention, headache frequency (p = 0.017) and minimum and maximum intensities (p = 0.017; p = 0.023) significantly decreased from baseline to 3-month after intervention. 11 patients (44%) were classified as ≥25% responders, with 7 patients (28%) experiencing a ≥75% reduction of headache days. After 73% of interventions, patients reported rNMS helped very well or well. A majority of patients would repeat (88.5%) and recommend rNMS (96.2%) to other patients.

CONCLUSION

rNMS seems to meet the criteria of safety, feasibility, and acceptance among children and adolescents with three age-typical headache disorders. A significant reduction in headache frequency and intensity during a 3 months follow-up was documented. Larger, prospective, randomized, sham-controlled studies are urgently needed to confirm if rNMS may become a new valuable non-invasive, non-pharmacological treatment option for pediatric headache disorders.

The bidirectional relation of migraine and affective disorders

No abstract

Is calcitonin gene-related peptide a reliable biochemical marker of migraine?

PURPOSE OF REVIEW

The aim of this study was to provide an overview of clinical studies on calcitonin gene-related peptide (CGRP) measurements in body fluids of migraine patients and to discuss the validity of CGRP measurement as a clinical biomarker of migraine.

RECENT FINDINGS

Several studies have reported increased CGRP levels in venous blood, saliva and tear fluid of migraine patients compared with healthy controls and in migraine patients during attacks compared with the interictal state, suggesting that CGRP may be a feasible biomarker of migraine. However, the findings of studies investigating CGRP levels in migraine patients are generally conflicting and measurements of CGRP levels are challenged by several methodological issues. Reported differences in CGRP levels between patients with chronic migraine relative to episodic migraine have also been inconsistent. There is also a well documented involvement of CGRP in several nonmigraine pain disorders, including cluster headache and common pain conditions such as osteoarthritis.

SUMMARY

Current evidence does not justify the usage of CGRP levels as a biomarker for diagnosing migraine or for determining the severity of the disease in individual patients. However, CGRP measurements could prove useful in the future as clinically relevant biomarkers for predicting the response to therapy, including anti-CGRP migraine drugs.

Treatment experiences and clinical characteristics in migraine and tension-type headache patients before the first visit to a tertiary headache center

OBJECTIVES

To investigate previous treatment and clinical characteristics in migraine and tension-type headache patients at their first visit to a tertiary headache center.

METHODS

This was a cross-sectional study using data obtained from electronic questionnaires and medical charts. Migraine and tension-type headache patients were investigated at their first visit to the Danish Headache Center.

RESULTS

Out of 382 patients the main diagnoses of primary headaches were: 36% with episodic migraine, 43% with chronic migraine, 3% with episodic tension-type headache and 17% with chronic tension-type headache. The majority had attempted non-pharmacological treatment options such as physiotherapy (episodic migraine: 53%, chronic migraine: 68%, episodic tension-type headache: 50%, chronic tension-type headache: 65%) and acupuncture: (episodic migraine: 45%, chronic migraine: 62%, episodic tension-type headache: 17%, chronic tension-type headache: 51%). The majority of migraine patients had tried no more than one triptan (episodic migraine: 71%, chronic migraine: 66%). In total, 35% of episodic migraine and 19% of chronic migraine patients as well as 50% of episodic tension-type headache and 41% of chronic tension-type headache patients had never tried preventive medication. The headache under-response to treatment (HURT) questionnaire score was higher in chronic migraine (score 15) and chronic tension-type headache (score 16) patients than the episodic forms (P < 0.004).

CONCLUSIONS

Headache patients had attempted several non-pharmacological treatments prior to their first visit at a tertiary headache center in Denmark. The limited use of acute and preventive treatment before the first visit demonstrates a need for better treatment at the primary and secondary care level.

Assessment of the head, cervical spine, thoracic spine and shoulder girdle postures in people with and without chronic headache

Background/Aims

Cervical dysfunction is one of the common symptoms of chronic headaches. This study was conducted to assess the posture of the head, cervical and thoracic spine and the shoulder girdle in people with and without cervicogenic and migraine headaches.

Methods

The postural angles of the head, cervical and thoracic spine and the shoulder girdle in frontal and sagittal planes, as well as thoracic spine curvature, were measured on 90 people who were split into three groups: 20 people with cervicogenic headache, 20 people with migraine and 50 people as the control group.

Results

There were significant differences among the three groups in the craniovertebral angle, coronal head tilt angle and scapular upward rotation angle (P<0.05). There was no relationship between postural angles.

Conclusions

The results of this study revealed that forward head posture was evident in people with cervicogenic and migraine headache. Decreased scapular upward rotation seen in the migraine headache group highlights the importance of shoulder girdle-related dysfunctions in people with chronic headaches.

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.

Development of an automated tool to score the Headache Screening Questionnaire: Agreement between automated and manual scoring

BACKGROUND

Migraines and tension-type headaches (TTH) are primary headaches that can be screened with the Headache Screening Questionnaire (HSQ). However, the HSQ scoring algorithms rely on manual calculation, which is laborious and carries a risk of human error.

OBJECTIVE

To develop an automated tool to calculate the output of the HSQ scoring algorithm and to determine the agreement between the automated and manual calculation.

DESIGN

A cross-sectional design was used.

METHODS

The automated tool was developed as a Microsoft Excel spreadsheet that was tested with all possible answers for the HSQ. An experienced researcher had access to answers to the HSQ from 163 people with headaches and manually applied the migraine and TTH algorithms to obtain the final scores and classifications. After that, the same answers were uploaded into the spreadsheet and scored by the automated algorithm. The agreement between manual and automated scoring was calculated for the total score using Intraclass Correlation Coefficients (ICC_2,1), Standard Error of Measurement (SEM), and Limits of Agreement. The agreement between the classification obtained by the automated tool and the classification obtained by manual calculation for migraine and TTH was calculated using weighted Kappas (k-values).

RESULTS

The total score showed excellent agreement for migraine (ICC = 0.97, 95% CI = 0.96-0.98, SEM = 0.36) and good agreement for TTH (ICC = 0.87, 95% CI = 0.82-0.90, SEM = 0.55). The classification demonstrated excellent agreement for migraine (k-value = 0.93, 95% CI = 0.89-0.97) and for TTH (k-value = 0.78, 95% CI = 0.70-0.86).

CONCLUSION

Implementation of the automated tool in clinical practice is suggested when using the HSQ to screen patients with primary headaches.

Diagnostic criteria for acute headache attributed to ischemic stroke and for sentinel headache before ischemic stroke

Background

Defining the relationship between a headache and stroke is essential. The current diagnostic criteria of the ICHD-3 for acute headache attributed to ischemic stroke are based primarily on the opinion of experts rather than on published clinical evidence based on extensive case-control studies in patients with first-ever stroke. Diagnostic criteria for sentinel headache before ischemic stroke do not exist. The present study aimed to develop explicit diagnostic criteria for headache attributed to ischemic stroke and for sentinel headache.

Methods

This prospective case-control study included 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke and 192 control patients (mean age 58.7, 36% males) admitted to the emergency room without any acute neurological deficits or severe disorders. Standardized semi-structured interview forms were used to evaluate past and present headaches during face-to-face interviews by a neurologist on admission to the emergency room in both groups of patients. All headaches were diagnosed according to the ICHD-3. We tabulated the onset of different headaches before a first-ever ischemic stroke and at the time of onset of stroke. We divided them into three groups: a new type of headache, the previous headache with altered characteristics and previous unaltered headaches. The same was done for headaches in control patients within one week before admission to the hospital and at the time of entry. These data were used to create and test diagnostic criteria for acute headache attributed to stroke and sentinel headache.

Results

Our previous studies showed that headache at onset of ischemic stroke was present in 82 (14.9%) of 550 patients, and 81 (14.7%) patients had sentinel headache within the last week before a stroke. Only 60% of the headaches at stroke onset fulfilled the diagnostic criteria of ICHD-3. Therefore, we proposed alternative criteria with a sensitivity of 100% and specificity of 97%. Besides, we developed diagnostic criteria for sentinel headache for the first time with a specificity of 98% and a sensitivity of 100%.

Conclusions

We suggest alternative diagnostic criteria for acute headache attributed to ischemic stroke and new diagnostic criteria for sentinel headache with high sensitivity and specificity.

Association between primary headaches and temporomandibular disorders: A systematic review and meta-analysis

BACKGROUND

The primary objective of this systematic review was to answer the following question systematically: Is there any association between primary headaches (PHs) and temporomandibular disorders (TMDs) in adults?

TYPES OF STUDIES REVIEWED

The protocol was registered with the International Prospective Register of Systematic Reviews. The authors performed the search in 7 main databases and 3 gray literature sources. The included articles had to have adult samples. PHs must have been diagnosed using the International Classification of Headache Disorders, and TMDs must have been diagnosed using Research Diagnostic Criteria for Temporomandibular Disorders, Diagnostic Criteria for Temporomandibular Disorders, or International Classification of Orofacial Pain. Risk of bias was evaluated using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument tools. The meta-analysis was performed using Review Manager software, Version 5.4. Certainty of evidence was screened according to Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Eight of 2,574 articles reviewed met the inclusion criteria for qualitative analysis and, of these, 6 met the inclusion criteria for quantitative analysis. Odds ratios (ORs) for painful TMD and tension-type headache (OR, 3.16; 95% CI, 1.80 to 5.54 to OR, 13.06; 95% CI, 2.79 to 61.12), migraines (OR, 5.35; 95% CI, 3.04 to 9.40 to OR, 6.22; 95% CI, 3.81 to 10.14), and chronic headaches (OR, 40.40; 95% CI, 8.67 to 188.15 to OR, 95.93; 95% CI, 12.53 to 734.27) were calculated. Articular TMDs without pain were evaluated in only 1 article, in which ORs of 1.78 (95% CI, 0.90 to 3.51) for migraines and 1.04 (95% CI, 0.53 to 2.06) for tension-type headache were reported. Three studies were classified as moderate risk of bias and 5 as low risk of bias. The certainty of evidence varied between very low and low.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Recognizing the positive association between painful TMD and PHs can help dentists and physicians treat the pain and avoid it, or recommend the patient to a specialist.

Physical inactivity and headache disorders: Cross-sectional analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

BACKGROUND

Physical inactivity has been linked to headache disorders but estimates based on the current World Health Organization physical activity guidelines are unknown.

OBJECTIVE

To test the associations between headache disorders and physical inactivity in the ELSA-Brasil cohort.

METHODS

In a cross-sectional analysis, linear (continuous variables) and logistic regression models (categorical variables) tested the associations of physical activity levels in the leisure time, commuting time, and combined leisure time physical activity + commuting time physical activity domains with headache disorders, adjusted for the effects of sociodemographic data, cardiovascular risk variables, psychiatric disorders, and migraine prophylaxis medication.

RESULTS

Of 15,105 participants, 14,847 (54.4% women) provided data on physical activity levels and headache. Higher physical activity levels (continuous values) in the leisure time physical activity domain associated with lower migraine and tension-type headache occurrence and lower headache attack frequency, while in the commuting time physical activity domain it associated with more frequent headache attacks. Compared to people who met World Health Organization physical activity levels in the leisure time physical activity or combining leisure time physical activity + commuting time physical activity domains (i.e. ≥150 min.wk^-1 of moderate and/or ≥75 min.wk^-1 of vigorous physical activity), physical inactivity associated with higher migraine occurrence, while somewhat active (i.e. not meeting World Health Organization recommendations) associated with higher migraine and tension-type headache occurrence. Physical inactivity in the commuting time physical activity domain associated with higher tension-type headache in men and lower migraine in women. Physical inactivity within vigorous leisure time physical activity intensity, but not moderate leisure time physical activity, associated with higher migraine, mostly in women. Finally, physical inactivity associated with higher headache attack frequency regardless headache subtype.

CONCLUSION

Physical inactivity and unmet World Health Organization physical activity levels associate with primary headaches, with heterogeneous associations regarding headache subtype, sex, physical activity domain/intensity, and headache frequency in the ELSA-Brasil study.

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.

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

Objectives

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

Materials and methods

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

Results

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

Conclusion

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

Clinical relevance

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

Recent advancements in tension-type headache: a narrative review

INTRODUCTION

Tension-type headache (TTH) is the most common primary headache disorder with a prevalence of up to 78% in general population and huge expenses in terms of health service. Despite its high incidence and impact on life's quality the knowledge on the pathophysiology and efficacious treatment of TTH was still limited.

AREAS COVERED

In recent years, a series of studies highlighted the heterogeneous nature of this pathology that seems to be determined by a complex interaction between genetic, environmental, and neuromuscular factors, which result in nociceptive system activation. In this setting, alongside the simple analgesic therapies used during the acute attack, a series of therapeutic options based on newly acquired experiences have taken hold.

EXPERT REVIEW

Not having a single substrate or a typical site of pathophysiology, TTH must be analyzed in a global and multidisciplinary way. Herein, we perform a narrative review of the most recent advancement stimulating the concept of this disease as the tip of the iceberg of a more complex individual malaise secondary to different alterations. Strategies based solely on symptomatic drugs should therefore be avoided by experienced personnel and treatment should aim at taking charge of the patient considering the processes behind this complex pathology.

Endogenous melatonin levels and therapeutic use of exogenous melatonin in tension type headache: A systematic review

BACKGROUND-PURPOSE

A bidirectional relationship appears to connect tension-type headache (TTH) and circadian dysregulation. The present systematic review examined the published evidence for melatonin (MT) supplementation in the prophylaxis of TTH. Initially, we reviewed case-control studies investigating nocturnal MT or 6-sulphatoxymelatonin (aMT6s, a urine-discarded metabolite) in TTH individuals and healthy controls (HC). Secondly, we reviewed studies appraising the use of MT in the prevention of TTH.

METHODS

The search strategy involved MEDLINE EMBASE, CENTRAL, PsycINFO, trial registries, Google Scholar and OpenGrey. Case-control studies were appraised according to the Newcastle-Ottawa-Scale, whereas randomised controlled trials were assessed based on the risk-of-bias Cochrane tool. Infrequent, as well as frequent, episodic, and chronic TTH patients were evaluated separately in children and adults.

RESULTS

Our search strategy yielded two case-control studies. One (high-quality) did not reveal any difference in morning salivary MT concentration between children with frequent episodic TTH and HC. The second (moderate-quality) was indicative of a disturbed nocturnal secretion pattern in adults with chronic TTH. For the second part, five uncontrolled studies were retrieved. In total, 94 adults with chronic TTH were assessed and results were suggestive of a beneficial effect of MT on headache frequency, intensity, induced disability, and induced analgesic consumption. However, the uncontrolled-unblinded designs may have induced an important placebo effect. Non-adult populations and frequent TTH were substantially understudied.

CONCLUSIONS

There are not enough studies to designate the role of MT in the prevention of TTH. Given the disease's background, additional relevant research is warranted for chronic TTH.

Advances in the Understanding of Pathophysiology of TTH and its Management

Background

Tension-type headache (TTH) is the most common form of primary headache.

Objective

The aim of this study was to document and summarize the advances in the understanding of TTH in terms of pathogenesis and management.

Material and Methods

We reviewed the available literature on the pathogenesis and management of TTH by searches of PubMed between 1969 and October 2020, and references from relevant articles. The search terms "tension-type headache", "episodic tension-type headache", chronic tension-type headache, "pathophysiology", and "treatment" were used.

Results

TTH occurs in two forms: episodic TTH (ETTH) and chronic TTH (CTTH). Unlike chronic migraine, CTTH has been less thoroughly studied and is a more difficult headache to treat. Frequent ETTH and CTTH are associated with significant disability. The pathogenesis of TTH is multifactorial and varies between the subtypes. Peripheral mechanism (myofascial nociception) and environmental factors are possibly more important in ETTH, whereas genetic and central factors (sensitization and inadequate endogenous pain control) may play a significant role in the chronic variety. The treatment of TTH consists of pharmacologic and non-pharmacologic approaches. Simple analgesics like NSAIDs are the mainstays for acute management of ETTH. CTTH requires a multimodal approach. Preventive drugs like amitriptyline or mirtazapine and non-pharmacologic measures like relaxation and stress management techniques and physical therapies are often combined. Despite these measures, the outcome remains unsatisfactory in many patients.

Conclusion

There is clearly an urgent need to understand the pathophysiology and improve the management of TTH patients, especially the chronic form.

Factors associated with headache and neck pain among telecommuters - a five days follow-up

BACKGROUND

The current sanitary crisis brought on by the COVID-19 recently forced a large proportion of workers to adopt telecommuting with limited time to plan transition. Given that several work-related risk factors are associated with headache and neck pain, it seems important to determine those associated with headache and neck pain in telecommuters. The main objective of this study was to identify which telecommuting and individual associated factors are related with headache and neck pain occurrence in telecommuters over a five days follow-up. The second objective was to evaluate the impact of wearing a headset on headache and neck pain intensity in telecommuters.

METHODS

One hundred and sixty-two participants in telecommuting situation were recruited. Baseline assessment included sociodemographic data, headache and neck pain-related disability (6-item Headache Impact Test (HIT-6) and Neck Bournemouth Questionnaire (NBQ)), headache and neck pain frequency and intensity as well as questions about the wearing of a headset (headset wearing, headset type and headset wearing hours). A prospective data collection of headache, neck pain and headset wearing was conducted using daily e-mail over a 5-day follow-up. A stepwise multivariate regression model was performed to determine associated factors of headache or neck pain occurrence during the follow-up. A t-test was conducted to assess the impact of headset wearing on headache and neck pain intensity during the follow-up.

RESULTS

Regarding headache, the stepwise multivariate regression model showed that the HIT-6 score was associated with future headache occurrence in telecommuters (OR (95% CI) = 1.094 (1.042-1.148); R² = 0.094; p <  0.001). For neck pain, the stepwise multivariate regression showed that the NBQ score was related to future neck pain occurrence in telecommuters (OR (95% CI) = 1.182 (1.102-1.269); R² = 0.182; p <  0.001). T-test showed no difference between participants that wore a headset and participant that did not wore a headset on mean headache (p = 0.94) and neck pain (p = 0.56) intensity during the five days follow-up.

CONCLUSION

Although several work-related risk factors are associated with headache and neck pain in workers, telecommuting did not present the same risks. Working set-up did not have a significant impact on headache and neck pain as headache-related disability was the only associated factor of future headache episodes and neck-pain related disability was the only associated factor of future neck pain episodes. Also, wearing a headset had no impact on headache and neck pain in telecommuters.

Temporomandibular-disorder-related pain as a predictor of severe headaches

OBJECTIVE

The current study aimed to investigate the association of temporomandibular disorders (TMD)-related pain with the presence of migraine or tension-type headaches (TTH) over a follow-up period of 11 years.

METHODS

Data sets from Finnish national health surveys, the Health 2000 Survey (baseline), and the Health 2011 Survey (follow-up) were utilized. Study participants are undergoing clinical TMD examination at baseline and answering questions related to the presence of migraine and TTH at follow-up were included in the study (n = 530). For analyses, the study sample was divided into two data sets: One with those excluded suffering from migraine at baseline (Data set I, n = 345), and the other excluding those having TTH at baseline (Data set II, n = 464).

RESULTS

Based on logistic regression modelling, no consistent association between TMD-related pain and the presence of migraine was observed, although jTMD associated with elevated estimates for migraine. However, participants with muscle-related TMD pain (mTMD) at baseline had markedly higher odds for having TTH at follow-up than participants without mTMD at baseline (OR 2.1, 95% CI 1.2-3.8). Joint-related TMD pain (jTMD) at baseline was inversely associated with the presence of TTH at follow-up (OR 0.4, 95% CI 0.1-1.3).

CONCLUSION

Contrasting patterns of the associations of TMD-related pain with different severe headaches point towards a more thorough and systematic research approach are needed to understand the mechanisms behind these associations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PROTOCOL REGISTRATION NUMBER

INPLASY202130088.

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.

Sinus, disabling tension-type, and temporomandibular joint headaches

PURPOSE OF REVIEW

Clinicians frequently face questions from headache patients regarding the roles played by sinus issues, muscle tension, and temporomandibular joint (TMJ) problems. This review highlights new concepts regarding the diagnosis and management of these headache conditions and their differentiation from migraine.

RECENT FINDINGS

Recent research has clarified the roles played by pathology in the paranasal sinuses and TMJ in patients reporting headache. Additional information from physiologic studies in patients with tension-type headache (TTH) has improved the understanding of this condition.

SUMMARY

Improved understanding of sinus headache, disabling TTH, and TMJ headache and their differentiation from migraine will lead to reductions in unnecessary diagnostic procedures and unwarranted medical and surgical procedures. More expedient recognition of the origin of headache should lead to improved therapeutic outcomes.

The Role of Myofascial Release in Treating Patients with Tension-Type Headaches: A Critically Appraised Topic

Clinical Question: What is the efficacy of myofascial release, combined with trigger point therapy, in treating pain in patients with tension-type headaches? Clinical Bottom Line: There is significant evidence to support the use of myofascial release and trigger point therapy in patients with pain from tension-type headaches.

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.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Manual therapy associated with topical heat reduces pain and self-medication in patients with tension-type headache

ABSTRACT Tension-type headache (TTH) is a significant public health problem. The myofascial trigger points in the masticatory and cervical muscles are related to pain located in the temporomandibular joint, face, and cranium according to specific patterns. Thus, therapeutic procedures should be directed to myofascial trigger points rather than to the area of referred pain. For this purpose, the massage therapy combined with the topical heat can provide effective results due to the increase of the local microcirculation, improving tissue perfusion and promoting muscle relaxation. In this study we investigated the effects of manual therapy associated with topical heat therapy in TTH pain. This is a single-arm study composed of 13 participants with TTH (females), which were submitted to a three-month research protocol. In the first month , they filled out a pain diary and then they were evaluated. In the following month, the treatment protocol was applied (8 sessions of 45 minutes, twice a week, involving massage for skin desensitization, myofascial trigger point deactivation and stretching (friction massage) on masticatory and trapezius muscles after the topical heat). Then, in the third month (follow-up period), the participants were instructed to fill out the pain diary once again. We observed a significant decrease in pain intensity in TTH episodes, and medication intake after treatment and it keeps decreasing in follow-up. We conclude that the combination of manual therapy protocol and topical heat reduced pain and episodes related to TTH, and self-medication use in our sample.

Patient Profiling Based on Spectral Clustering for an Enhanced Classification of Patients with Tension-Type Headache

Profiling groups of patients in clusters can provide meaningful insights into the features of the population, thus helping to identify people at risk of chronification and the development of specific therapeutic strategies. Our aim was to determine if spectral clustering is able to distinguish subgroups (clusters) of tension-type headache (TTH) patients, identify the profile of each group, and argue about potential different therapeutic interventions. A total of 208 patients (n = 208) with TTH participated. Headache intensity, frequency, and duration were collected with a 4-week diary. Anxiety and depressive levels, headache-related burden, sleep quality, health-related quality of life, pressure pain thresholds (PPTs), dynamic pressure thresholds (DPT) and evoked-pain, and the number of trigger points (TrPs) were evaluated. Spectral clustering was used to identify clusters of patients without any previous assumption. A total of three clusters of patients based on a main difference on headache frequency were identified: one cluster including patients with chronic TTH (cluster 2) and two clusters including patients with episodic TTH (clusters 0–1). Patients in cluster 2 showed worse scores in all outcomes than those in clusters 0–1. A subgroup of patients with episodic TTH exhibited pressure pain hypersensitivity (cluster 0) similarly to those with chronic TTH (cluster 2). Spectral clustering was able to confirm subgrouping of patients with TTH by headache frequency and to identify a group of patients with episodic TTH with higher sensitization, which may need particular attention and specific therapeutic programs for avoiding potential chronification.

Chinese Herbal Formula Xuefu Zhuyu for Tension-Type Headache with Qi-Stagnation and Blood-Stasis Pattern (CheruXTH): Study Protocol for a Randomized Controlled Trial

Background

Tension-type headache (TTH) is the most common headache disorder. Current treatments for TTH have been reported to be associated with insufficient long-term benefits and unwanted adverse events (AEs). The Chinese herbal formula Xuefu Zhuyu (XFZY) has been utilized in TTH treatment, but the evidence supporting its efficacy remains unclear. This study will evaluate the efficacy and safety of XFZY for TTH.

Methods

This multicenter, double-blind, randomized, placebo-controlled trial will be undertaken in China. A total of 174 eligible participants will be randomly assigned to either an XFZY group or a placebo group (20 ml each dose, three times daily for 4 weeks) at a ratio of 1 : 1. The primary outcome is the change in mean headache intensity measured by a 10 cm visual analogue scale (VAS). Secondary outcomes include the area-under-the headache curve (AUC), headache frequency, rescue medication use, qi-stagnation and blood-stasis pattern measurement, quality of life measured by the EuroQol-5-Dimensions-5-Level (EQ-5D-5L), global evaluation of medication, and health economic indexes. Discussion. The results of the study are expected to provide evidence of high methodological and reporting quality on the efficacy and safety of XFZY for TTH. This trail is registered with ChiCTR1900026716 (registered on 19 October, 2019).

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

OBJECTIVE

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

DATABASES AND DATA TREATMENT

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

RESULTS

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

CONCLUSION

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

Headaches in hypermobility syndromes: A pain in the neck?

Headache and neck pain (cervicalgia) are frequently reported among patients with joint hypermobility but the prevalence and scope of these symptoms has not been studied in the era of contemporary Ehlers-Danlos and hypermobility disorder nosology. We performed a single-center retrospective study on the incidence of head and neck symptoms in 140 patients with hypermobility disorders over a 2-year period. Overall, 93 patients (66%) reported either headache or neck pain with 49 of those (53%) reporting both. Migraine (83%) was the most common headache type among those with headache disorders and cervical spondylosis (61%) the most common pathology among those with neck symptoms. Fifty-nine percent of spondylosis patients who underwent cervical facet procedures reported significant improvement in neck and head symptoms. Of patients with both head and neck complaints, 82% had both migraine and spondylosis, which, when combined with the high response rate to injections raises the possibility of cervicogenic headache. In this large multidisciplinary retrospective study of patients with hypermobility disorders, head and neck symptoms were highly prevalent, with migraine and cervical spondylosis common, often coexisting, and frequently responsive to targeted therapy for the cervical spine suggesting that degenerative spinal pathology may cause or contribute to headache symptoms in some patients with hypermobility disorders.