Does neck pain determine the outcome of adolescent headache?

Poor prognosis of child and adolescent musculoskeletal pain: a systematic literature review

OBJECTIVES

To identify baseline patient characteristics that are (1) associated with a poor outcome on follow-up regardless of which treatment was provided (prognosis) or (2) associated with a successful outcome to a specific treatment (treatment effect modifiers).

DESIGN

Systematic literature review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

DATA SOURCES

Medline, Embase, Cinahl, Web of Science, Cochrane, SportDiscus, OT Seeker and PsychInfo were searched for prospective cohort studies up to February 2019 without limitation in publication date.

ELIGIBILITY CRITERIA

Prospective cohort studies reporting either prognostic factors or treatment effect modifiers on persistent musculoskeletal pain in 0-year-old to 19-year-old children and adolescents. Pain caused by tumours, fractures, infections, systemic and neurological conditions were excluded.

OUTCOME MEASURES

Our primary outcome was musculoskeletal pain at follow-up and identification of any baseline characteristics that were associated with this outcome (prognostic factors). No secondary outcomes were declared.

METHOD

Two reviewers independently screened abstracts and titles. We included prospective cohort studies investigating the prognosis or treatment effect modifiers of 0-year-old to 19-year-old children and adolescents with self-reported musculoskeletal pain. Risk of bias assessment was conducted with the Quality in Prognostic Studies tool.

RESULTS

Twenty-six studies yielding a total of 111 unique prognostic factors were included. Female sex and psychological symptoms were the most frequent investigated prognostic factors. Increasing age, generalised pain, longer pain duration and smoking were other identified prognostic factors. No treatment effect modifiers were identified.

CONCLUSION

Several prognostic factors are associated with a poor prognosis in children and adolescents with musculoskeletal pain. These prognostic factors may help guide clinical practice and shared decision-making. None of the included studies was conducted within a general practice setting which highlights an area in need of research.

PROSPERO REGISTRATION NUMBER

CRD42016041378.

Characteristics of Neck Pain Associated With Adolescent Headache

The objective of the study was to find out what kind of neck pain (NP) is associated with headache (HA) and with various headache variables: frequency, type, intensity, disturbance, and relief with analgesics. A population-based sample of 12-year-olds with and without HA ( n = 304) was followed for 4 years. At the age of 16 years, NP was evaluated on the basis of self-reported symptoms and a thorough physical examination of the neck region. Both self-reported and measured NP were associated with HA variables. Co-occurrent NP was found in adolescents with migraine as often as in those with tension-type HA. Especially, muscle pain and intensive, frequent NP were associated with disturbing HA unresponsive to analgesics. The study indicates that concomitant NP should be considered in adolescent HA sufferers, and a thorough cervical and muscle evaluation is recommended when planning the treatment of HA.

Influence of temporomandibular disorder on temporal and masseter muscles and occlusal contacts in adolescents: an electromyographic study

Background

The aim of the present study was to analyse the influence of temporomandibular disorder (TMD) on electromyographic activity in the masseter and temporal muscles of adolescents and investigate a possible association with the number of occlusal contacts.

Methods

The Helkimo Index was administered for the diagnosis of TMD and classification of the adolescents into three groups: without TMD; with mild TMD; and with moderate/severe TMD. Carbon paper was used for the determination of occlusal contact points. A standardised electromyographic evaluation was performed on the masticatory muscles at rest, during habitual chewing and during maximum voluntary clenching. The readings were normalised to maximum voluntary clenching. Statistical analysis involved the chi-squared test and Fisher’s exact test. The Kruskal-Wallis test and one-way analysis of variance with Dunn’s post hoc test were used to compare differences between groups. Pearson’s correlation coefficients (r) were calculated for the determination of correlations between the number of occlusal contacts and RMS values.

Results

Electromyography revealed significant differences in the right and left masseter and temporal muscles at rest and during chewing among the three groups. These differences were not observed during maximum voluntary clenching. No statistically significant differences were found between the groups with and without TMD regarding the number of occlusal contacts.

Conclusion

Electromyographic activity in the masseter and temporal muscles was greater among adolescents with moderate to severe TMD.

Self-reported neck pain is associated with migraine but not with tension-type headache in adolescents

Aim

The aim of the present analysis is to confirm or refute the association of neck pain to migraine or tension-type headache and to assess whether this association is independent of other risk factors for headache.

Methods

Secondary school students were invited to complete a questionnaire on headache and lifestyle factors in a cross-sectional study. Neck pain was assessed via (a) a screening question concerning neck pain and (b) denoting affected areas in schematic drawings of the human body.

Results

Absolute increment in prevalence of headache with pain in the shoulder-neck region was between 7.5% and 9.6%. Gender, grade, stress and lifestyle factors were assessed as potential confounding factors. Nearly all factors were associated with shoulder-neck pain and most with headache. After adjustment for confounders, the association of neck pain with headache was almost completely confined to migraine (OR 2.39; 95% CI 1.48–3.85) and migraine + tension-type headache (OR 2.12; 95% CI 1.50–2.99), whereas the association with isolated tension-type headache was negligible (OR 1.22, 95% CI 0.87–1.69).

Conclusion

Neck pain is associated with migraine but not with tension-type headache. A possible link between migraine and neck pain may be the cervico-trigeminal convergence of neck and meningeal sensory afferents or a disturbed descending inhibition in migraine.

Adolescent cervical disc degeneration in MRI does not predict adult headache or neck pain: A 5-year follow-up of adolescents with and without headache

AIM

The impact of early degenerative changes of the cervical spine on pain in adulthood is unknown. The objective was to determine whether degeneration in adolescence predicts headache or neck pain in young adulthood.

METHODS

As part of a follow-up of schoolchildren with and without headache, 17-year-old adolescents with headache at least three times a month (N = 47) and adolescents with no headache (N = 22) participated in a magnetic resonance imaging (MRI) study of the cervical spine. The same adolescents were re-examined by phone interview at the age of 22 years (N = 60/69, 87%).

RESULTS

Mild disc degeneration at the age of 17 years was common, but was not associated with either frequent or intensive headache or neck pain at the age of 22 years. Conclusion: Mild degenerative changes of the cervical spine in 17-year-old adolescents cannot be regarded as a cause of future headache or neck pain.

Are occlusal characteristics, headache, parafunctional habits and clicking sounds associated with the signs and symptoms of temporomandibular disorder in adolescents?

[Purpose] To assess the association between the oclusal characteristics, headache, parafunctional habits and clicking sounds and signs/symptoms of TMD in adolescents. [Subjects] Adolescents between 14 and 18 years of age. [Methods] The participants were evaluated using the Helkimo Index and a clinical examination to track clicking sounds, parafunctional habits and other signs/symptoms of temporomandibular disorder (TMD). Subjects were classified according to the presence or absence of headache, type of occlusion, facial pattern and type of bite. In statistical analyse we used the chi-square test and Fisher's exact test, with a level of significance of 5%. [Results] The sample was made up of 81 adolescents with a mean age of 15.64 years; 51.9% were male. The prevalence of signals/symptoms of TMD was 74.1%, predominantly affecting females. Signals/symptoms of TMD were significantly associated with clicking sounds, headache and nail biting. No associations were found between signals/symptoms of TMD and angle classification, type of bite and facial pattern. [Conclusion] Headache is one of the most closely associated symptoms of TMD. Clicking sounds were found in the majority of cases. Therefore, the sum of two or more factors may be necessary for the onset and perpetuation of TMD.

Sex-specific predictor analyses for the incidence of recurrent headaches in German schoolchildren

Objective: The aim of the present study was to identify psychosocial risk factors for the incidence of recurrent headache (HA) in children/adolescents (8–15 years).

Method: In 2003 (Wave 1) a representative, population-based sample of 8800 parents was mailed a questionnaire. Those who took part were asked to participate again one year later (Wave 2). Of the parents originally contacted, 47.3% participated in both surveys. Potential risk factors concerning the areas ‘school’ and ‘emotional and behavioural problems’ were collected in Wave 1. Binary logistic regression analyses were performed to assess their predictive value for HA in Wave 2.

Results: Univariable regression analyses showed that for boys and girls most of the predictor variables influenced the incidence of recurrent HA, but only to a very low extent. When all variables were assessed jointly in a multivariable model, these factors lost their predictive power for boys. For girls, ‘academic problems’ and ‘dysfunctional stress coping’ were shown to increase the chance for the incidence of recurrent HA.

Discussion: In contrast to previous findings, school-related factors and emotional and behavioural problems failed to predict HA in boys, and only two factors appeared relevant with regard to girls. This might be due to the strict unidirectional design, which focussed exclusively on the incidence of HA.

Self-reported muscle pain in adolescents with migraine and tension-type headache

AIM

To identify possible associations between muscular pain and headache in adolescents in a large population-based sample.

METHODS

Grammar school students were invited to fill in a questionnaire on headache and associated lifestyle factors. Headache was classified according to the German version of the International Classification of Headache Disorders (2nd edition). Muscular pain was assessed via denoting affected areas in schematic drawings of a body and via provoked muscular pain on controlled movements of head, neck and shoulder regions.

RESULTS

Prevalence of any headache within the previous 6 months exceeded 80%. In all subjects muscular pain or pain on movement was most prominent in the neck and shoulder region, ranging from 9% to 27% in the non-headache population to up to 63% for individuals with migraine or mixed migraine and tension-type headache (TTH). Frequency of muscular pain increased significantly with growing chronicity of TTH.

INTERPRETATION

A strong association between muscle pain in the neck/shoulder region and headache was observed, pointing to the importance of muscular pain for headache in adolescents. Also, in this age group muscular pain appears to be of particular importance in chronic TTH and - unexpectedly - in migraine, which is the most important new finding in our study.

Estudo do impacto da enxaqueca na severidade da dor miofascial da musculatura mastigatória

OBJETIVO: comparar a severidade da dor subjetiva e objetiva, além de outras características associadas entre pacientes com dor miofascial com e sem o diagnóstico adicional de enxaqueca. MÉTODOS: foram selecionados 203 pacientes, com idade média de 40,3 anos (89,2% do sexo feminino), que se apresentaram à Clínica de Dor Orofacial da Universidade da Califórnia, Los Angeles, EUA - todos com diagnóstico primário de dor miofascial. Pacientes com diagnóstico secundário de enxaqueca foram incluídos (n=83) e formaram o grupo 2. O teste de Mann-Whitney foi utilizado para comparar o grupo 1 (dor miofascial) com o 2 (dor miofascial + enxaqueca) quanto à intensidade de dor à palpação e subjetiva, através de Escalas Analógicas Visuais (EAV). Também com o auxílio de EAV, foram comparados estado de humor, problemas com a função, qualidade do sono e incapacidade. Em todos os testes foi adotado um nível de significância de 5%. RESULTADOS: o grupo 2 apresentou níveis de dor à palpação muscular estatisticamente maiores que o grupo 1 (p<0,05). Ao se analisar a intensidade de dor subjetiva obtida através da EAV, o grupo 2 apresentou níveis maiores de dor subjetiva (EAV) em todas as medições, com significância estatística para "dor no momento" e "dor máxima" (p<0,05). Da mesma maneira, o grupo 2 mostrou níveis maiores, obtidos através da EAV, de problemas com humor, incapacidade, problemas com a função mandibular e problemas com sono/descanso, sendo que apenas o último apresentou significância estatística (p<0,05). CONCLUSÕES: a comorbidade enxaqueca exerce forte impacto na severidade da dor e na qualidade de vida de pacientes que apresentam diagnóstico primário de dor miofascial.

Restricted neck mobility in children with chronic tension type headache: a blinded, controlled study

The main purpose of this study was to analyze the differences in neck mobility between children with chronic tension type headache (CTTH) and healthy children, and to determine the influence of cervical mobility on headache intensity, frequency and duration. Fifty children, 13 boys and 37 girls (mean age 8.5 ± 1.6 years) with CTTH associated to peri-cranial tenderness (IHS 2.3.1) and 50 age- and sex matched children without headache (13 boys, 37 girls, mean age 8.5 ± 1.8 years, P = 0.955) participated. Cervical range of motion (CROM) was objectively assessed with a cervical goniometer by an assessor blinded to the children’s condition. Children completed a headache diary for 4 weeks to confirm the diagnosis. Children with CTTH showed decreased CROM as compared to children without headache for flexion (z = −6.170; P < 0.001), extension (z = −4.230; P < 0.001), right (z = −4.505; P < 0.001) and left (z = −4.768; P < 0.001) lateral-flexions, but not for rotation (right z = −0.802; P = 0.425; left z = −1.254; P = 0.213) and also for total range of motion for flexion-extension (z = −4.267; P < 0.001) and lateral-flexion (z = −4.801; P < 0.001), but not for rotation (z = −1.058; P = 0.293). Within CTTH children, CROM was not correlated with headache intensity, frequency or duration. Additionally, age (P > 0.125) or gender (P > 0.250) did not influence CROM in either children with CTTH or without headache. Current results support the hypothesis that the cervical spine should be explored in children with headache. Further research is also needed to clearly define the potential role of the cervical spine in the genesis or maintenance of CTTH.

Chronic pain disorders and headache chronification

It is estimated that nearly half of the global adult population suffers from an active headache disorder, most of whom experience attacks on an episodic basis. The transition from episodic to chronic headache is a poorly understood process. Epidemiological findings demonstrating comorbidity and common risk factors suggest that headache progression or prognosis may be related to the presence of other chronic pain disorders. This review highlights findings from population-based studies on headache and other pain disorders and how they relate to each other, with a focus on understanding headache chronification. We also consider the limitations and methodological challenges in understanding how two different chronic pain disorders may be related.

One-year course of paediatric headache in children and adolescents aged 8-15 years

The aims of the present study were the assessment of headache (HA) prevalence in German children and adolescents in the second year of a 4-year longitudinal study and the analysis of headache status change from year 1 to year 2. The original sample consisted of 8800 households with a child aged 7-14 years. A total of 4159 households responded in both year 1 and year 2, yielding 3984 valid parent questionnaires. Data regarding various aspects of the child's HA history and general health were gathered via mailed questionnaires from the parents. Of the households returning valid parent questionnaires at survey 2, 48.9% reported their child to have experienced headaches during the previous 6 months (53% at survey 1). Weekly HA was reported for 6.5% of the children, monthly or less frequent HA for 16.5% and 25.9%, respectively. With regard to headache diagnosis, 55.0% of the children and adolescents with HA experienced tension-type HA (TTH) and 11.3% migraine with or without aura (M). For more than half of the children and adolescents with HA (57.0%) the frequency of head pain remained stable over the period of 1 year (i.e. same frequency category in years 1 and 2). Improved and worsened HA status regarding frequency of occurrence was found in 22.3% and 20.7% of the subjects, respectively. Thus, there was no definite trend towards an increase of HA episodes over the course of 1 year regarding the individual child or adolescent. The most stable type of HA was TTH.

Are Signs of Temporomandibular Disorders Stable and Predictable in Adolescents With Headache?

The aim of the present study was to study changes in signs and symptoms of temporomandibular disorders (TMD) and factors predicting TMD signs in adolescents with and without headache. A population-based sample ( n = 212) of 13-year-olds with and without headache was re-examined at the age of 16. The study included a questionnaire, face-to-face interview and somatic examination. In addition, a neurological examination, a muscle evaluation and a stomatognathic examination were performed. Significant changes were seen in TMD signs during the follow-up, but TMD signs at the end of the follow-up could not be predicted by baseline headache, sleeping difficulties, depression or muscle pain. TMD signs at the age of 16 were associated with female gender and muscle pain. We conclude that considerable changes in TMD signs occur in the follow-up of adolescents with and without headache. Headache-related TMD are not predictable in adolescents with and without headache.