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Embaby E, Khalil AA, Mansour A, Hamdy HA. The relationship between myofascial trigger points sensitivity, cervical postural abnormality, and clinical tension-type headache parameters. J Man Manip Ther 2024; 32:390-399. [PMID: 38163855 PMCID: PMC11257008 DOI: 10.1080/10669817.2023.2299186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Myofascial Trigger Points (MTrPs) play a significant role in the pathogenesis of Tension Type Headache (TTH). Abnormal cranio-cervical posture has been linked to various types of headaches. However, the correlation between MTrPs sensitivity, cervical postural alignment, and clinical measures of headache has not been extensively studied in patients with TTH. OBJECTIVES To investigate the relationship between MTrPs sensitivity in cervical and pericranial muscles, cervical postural abnormality, and clinical headache parameters in patients with TTH. Furthermore, to investigate the effect of sex on the examined variables and their association with headache type (episodic vs chronic TTH). METHODS A total of 72 patients with TTH of both sexes were enrolled in this study. Headache frequency and disability as clinical measures of headache, pressure pain threshold (PPT) of bilateral upper trapezius (UT) and suboccipital (SUB) muscles, cervical lordosis angle (CA), and anterior head translation (AHT) were measured. RESULTS Pericranial MTrPs sensitivity did not demonstrate any correlation with clinical headache parameters or cervical postural abnormality. However, there was a significant correlation between the frequency of headaches and the level of disability (r = 0.32, P < 0.05). In addition, episodic TTH was more prevalent in females who exhibited greater AHT and MTrPs sensitivity of both bilateral UT and right SUB muscles than males. CONCLUSIONS There was no correlation found between the frequency of headaches and the level of disability with measures of cervical posture alignment or MTrPs sensitivity in individuals with TTH.. Based on findings, Clinicians should consider sex differences when assessing patients with TTH.
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Affiliation(s)
- Eman Embaby
- Basic science department, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Aya A Khalil
- Biomechanics Department, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Abdallah Mansour
- 5 year undergraduate student, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Hend A Hamdy
- Basic science department, Faculty of Physical Therapy, Cairo University, Giza, Egypt
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2
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Monti-Ballano S, Márquez-Gonzalvo S, Lucha-López MO, Ferrández-Laliena L, Vicente-Pina L, Sánchez-Rodríguez R, Tricás-Vidal HJ, Tricás-Moreno JM. Effects of Dry Needling on Active Myofascial Trigger Points and Pain Intensity in Tension-Type Headache: A Randomized Controlled Study. J Pers Med 2024; 14:332. [PMID: 38672959 PMCID: PMC11051369 DOI: 10.3390/jpm14040332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/12/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024] Open
Abstract
Tension-type headache is the most prevalent type of headache and is commonly associated with myofascial pain syndrome and the presence of active myofascial trigger points. This randomized controlled trial aimed to assess the impact of dry needling on the total number of active trigger points, pain intensity, and perceived clinical change in tension-type headache subjects. Thirty-two subjects were randomly assigned to the control and dry needling groups. The presence of active trigger points in 15 head and neck muscles, the headache intensity, and the perceived clinical change were evaluated. A single dry needling technique was administered at each active trigger point across three sessions. Significant differences were observed in the post-treatment measures favouring the dry needling group, including reductions in the headache intensity scores (p = 0.034) and the total number of active trigger points (p = 0.039). Moreover, significant differences in the perception of clinical change were found between the control and treatment groups (p = 0.000). Dry needling demonstrated positive effects in reducing the number of active trigger points and improving the short-term headache intensity in tension-type headache patients. A single dry needling session applied in the cranio-cervical area resulted in a self-perceived improvement compared to the control subjects.
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Affiliation(s)
| | - Sergio Márquez-Gonzalvo
- Unidad de Investigación en Fisioterapia, Spin off Centro Clínico OMT-E Fisioterapia SLP, Universidad de Zaragoza, Domingo Miral s/n, 50009 Zaragoza, Spain; (S.M.-B.); (L.F.-L.); (L.V.-P.); (R.S.-R.); (H.J.T.-V.); (J.M.T.-M.)
| | - María Orosia Lucha-López
- Unidad de Investigación en Fisioterapia, Spin off Centro Clínico OMT-E Fisioterapia SLP, Universidad de Zaragoza, Domingo Miral s/n, 50009 Zaragoza, Spain; (S.M.-B.); (L.F.-L.); (L.V.-P.); (R.S.-R.); (H.J.T.-V.); (J.M.T.-M.)
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3
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Repiso-Guardeño Á, Moreno-Morales N, Labajos-Manzanares MT, Rodríguez-Martínez MC, Armenta-Peinado JA. Does Tension Headache Have a Central or Peripheral Origin? Current State of Affairs. Curr Pain Headache Rep 2023; 27:801-810. [PMID: 37889466 PMCID: PMC10713699 DOI: 10.1007/s11916-023-01179-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW The aim of this narrative review is to analyze the evidence about a peripheral or central origin of a tension headache attack in order to provide a further clarification for an appropriate approach. RECENT FINDINGS Tension headache is a complex and multifactorial pathology, in which both peripheral and central factors could play an important role in the initiation of an attack. Although the exact origin of a tension headache attack has not been conclusively established, correlations have been identified between certain structural parameters of the craniomandibular region and craniocervical muscle activity. Future research should focus on improving our understanding of the pathology with the ultimate goal of improving diagnosis. The pathogenesis of tension-type headache involves both central and peripheral mechanisms, being the perpetuation over time of the headache attacks what would favor the evolution of an episodic tension-type headache to a chronic tension-type headache. The unresolved question is what factors would be involved in the initial activation in a tension headache attack. The evidence that favors a peripheral origin of the tension headache attacks, that is, the initial events occur outside the brain barrier, which suggests the action of vascular and musculoskeletal factors at the beginning of a tension headache attack, factors that would favor the sensitization of the peripheral nervous system as a result of sustained sensory input.
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Affiliation(s)
- Ángela Repiso-Guardeño
- Department of Physiotherapy, Faculty of Health Sciences, University of Málaga, C/ Arquitecto Francisco Peñalosa, 3, 29071, Málaga, Spain
| | - Noelia Moreno-Morales
- Department of Physiotherapy, Faculty of Health Sciences, University of Málaga, C/ Arquitecto Francisco Peñalosa, 3, 29071, Málaga, Spain
- Biomedical Research Institute of Malaga-Nanomedicine Platform (IBIMA-BIONAND Platform), 29590, Málaga, Spain
| | - María Teresa Labajos-Manzanares
- Department of Physiotherapy, Faculty of Health Sciences, University of Málaga, C/ Arquitecto Francisco Peñalosa, 3, 29071, Málaga, Spain
- Biomedical Research Institute of Malaga-Nanomedicine Platform (IBIMA-BIONAND Platform), 29590, Málaga, Spain
| | - María Carmen Rodríguez-Martínez
- Department of Physiotherapy, Faculty of Health Sciences, University of Málaga, C/ Arquitecto Francisco Peñalosa, 3, 29071, Málaga, Spain.
- Biomedical Research Institute of Malaga-Nanomedicine Platform (IBIMA-BIONAND Platform), 29590, Málaga, Spain.
| | - Juan Antonio Armenta-Peinado
- Department of Physiotherapy, Faculty of Health Sciences, University of Málaga, C/ Arquitecto Francisco Peñalosa, 3, 29071, Málaga, Spain
- Biomedical Research Institute of Malaga-Nanomedicine Platform (IBIMA-BIONAND Platform), 29590, Málaga, Spain
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4
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Azhdari N, Kamali F, Vosooghi O, Petramfar P, Rahimijaberi A. The effect of manual therapies on tension-type headache in patients who do not respond to drug therapy: a randomized clinical trial. J Man Manip Ther 2023; 31:246-252. [PMID: 36052499 PMCID: PMC10324431 DOI: 10.1080/10669817.2022.2107446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
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.
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Affiliation(s)
- Negar Azhdari
- PhD Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fahimeh Kamali
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Omid Vosooghi
- Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Payman Petramfar
- Department of Neurology, School of Medicine Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abbas Rahimijaberi
- Department of Neurology, School of Medicine Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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Pillai S, Zhang N. The Role of Manual Therapies in the Treatment of Headache Disorders. Curr Neurol Neurosci Rep 2023:10.1007/s11910-023-01279-x. [PMID: 37354308 DOI: 10.1007/s11910-023-01279-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE OF REVIEW A comprehensive headache treatment plan typically requires both medication and non-medication treatment strategies. Manual therapies offer another therapeutic approach to headache treatment. This article reviews the evidence for manual therapies in the treatment of headache disorders. RECENT FINDINGS Current evidence shows potential benefit from myofascial trigger point injections, myofascial release, and massage for the treatment of various headache types. There is also evidence for strain counterstrain technique, ischemic compression, and spinal manipulative therapies for cervicogenic headache. Although larger randomized clinical trials are necessary for many of these modalities, recent findings show that manual therapies could be an important tool for the treatment of some headache disorders.
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Affiliation(s)
- Sheena Pillai
- Department of Physical Medicine & Rehabilitation, Stanford University School of Medicine, 450 Broadway, MC 6342, Redwood City, CA, 94063, USA.
| | - Niushen Zhang
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
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Liew BXW, Palacios-Ceña M, Scutari M, Fuensalida-Novo S, Guerrero-Peral A, Ordás-Bandera C, Pareja JA, Fernández-de-Las-Peñas C. Path Analysis Models Integrating Psychological, Psycho-physical and Clinical Variables in Individuals With Tension-Type Headache. THE JOURNAL OF PAIN 2023; 24:426-436. [PMID: 36244659 DOI: 10.1016/j.jpain.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
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 (modeltheory) and a data-driven (modelBN) latent variable model. The modelBN (root mean square error of approximation [RMSEA] = 0.035) provided a better statistical fit than modeltheory (RMSEA = 0.094). The only path common between modelbn and modeltheory was the influence of years with pain on TrPs. The modelBN 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.
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Affiliation(s)
- Bernard X W Liew
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, United Kingdom
| | - María Palacios-Ceña
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Marco Scutari
- Istituto Dalle Molle di Studi Sull'Intelligenza Artificiale (IDSIA), Lugano, Switzerland
| | - Stella Fuensalida-Novo
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
| | | | | | - Juan A Pareja
- Department of Neurology, Hospital Quirón Pozuelo, Madrid, Spain
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain.
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7
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Geri T, Botticchio A, Rossettini G, Pournajaf S, Pellicciari L, Di Antonio S, Castaldo M. Pressure Pain Threshold of the Upper Trapezius Trigger Point: A Systematic Review with Meta-Analysis of Baseline Values and Their Modification after Physical Therapy. J Clin Med 2022; 11:7243. [PMID: 36498817 PMCID: PMC9739431 DOI: 10.3390/jcm11237243] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Myofascial trigger points (TrP) are diagnosed upon the presence of clinical signs among which hypersensitivity is considered one of the most important. The detection of the pressure pain threshold (PPT) is used to quantify the degree of hypersensitivity. However, there is a lack of normative data about how hypersensitive a TrP is. Therefore, the objective was to quantify the PPT for myofascial TrP in the upper trapezius muscle and its modification after manual or instrumental physical therapy interventions. METHODS A systematic review and meta-analysis were conducted among three databases (MEDLINE, Cochrane Library, and PEDro). Two independent reviewers conducted the electronic search and assessed the methodological quality of the included studies. RESULTS Eleven studies with a high-risk bias indicated that the PPT at TrP sites was 105.11 kPa lower (95% CI: -148.93; -61.28) at active TrP sites (Chi-squared = 1.07, df = 1 (p = 0.30), I2 = 7%) compared to the PPT of the upper trapezius muscles of healthy subjects. In addition, the PPT of TrP was also lower than the reference values coming from the pain-free population. Moreover, the PPT increased after both manual and instrumental treatment by 28.36 kPa (95% CI: 10.75; 45.96) and 75.49 kPa (95% CI: 18.02; 132.95), respectively. CONCLUSIONS The results of the present study show that TrP has a decreased PPT when compared to healthy muscles and that physical therapy may increase the PPT. However, the clinical relevance of this decreased PPT needs to be further elucidated. Further, the high risk of bias in all the retrieved studies undermines the validity of the results.
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Affiliation(s)
| | | | | | - Sanaz Pournajaf
- Neurorehabilitation Research Laboratory, Department of Neurological and Rehabilitation Sciences, IRCCS San Raffaele Roma, 00163 Rome, Italy
| | | | - Stefano Di Antonio
- Center for Pain and Neuroplasticity (CNAP), Department of Health Science and Technology, School of Medicine, Aalborg University, 9220 Aalborg, Denmark
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, University of Genoa, 16132 Genoa, Italy
- Poliambulatorio FisioCare, 16035 Rapallo, Italy
| | - Matteo Castaldo
- Center for Pain and Neuroplasticity (CNAP), Department of Health Science and Technology, School of Medicine, Aalborg University, 9220 Aalborg, Denmark
- Sport Physiotherapy, University of Siena, 53100 Siena, Italy
- Department of Physical Therapy, Poliambulatorio Fisiocenter, 43044 Collecchio, Italy
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8
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The Role of the Autonomic Nervous System in Headache: Biomarkers and Treatment. Curr Pain Headache Rep 2022; 26:767-774. [PMID: 36063265 PMCID: PMC9442588 DOI: 10.1007/s11916-022-01079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 11/30/2022]
Abstract
Purpose of Review In this review, the role of the autonomic nervous system in tension-type headache and migraine is reviewed. Recent Findings A pathophysiological model for tension-type headache is proposed that is compatible with most physiological and behavioral literature. Summary A treatment protocol is described that follows from this model. For migraine, incorporating autonomic factors into the pathophysiology offers rationales for behavioral interventions that have been shown to be useful in migraine treatment and a biofeedback protocol is proposed.
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9
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Di Antonio S, Arendt-Nielsen L, Ponzano M, Bovis F, Torelli P, Finocchi C, Castaldo M. Cervical musculoskeletal impairments in the 4 phases of the migraine cycle in episodic migraine patients. Cephalalgia 2022; 42:827-845. [PMID: 35332826 DOI: 10.1177/03331024221082506] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess cervical musculoskeletal impairments during the 4 phases of a migraine cycle in episodic migraine patients, controlling for the presence of concomitant neck pain. METHODS Differences in cervical musculoskeletal impairments were assessed during the 4 migraine phases in episodic migraine patients and compared with healthy controls controlling for concomitant neck pain. Cervical musculoskeletal impairments were assessed as follow: cervical active range of motion; flexion rotation test; craniocervical flexion test and calculation of activation pressure score; the total number of myofascial trigger points in head/neck muscles; the number of positivevertebral segments (headache's reproduction) during passive accessory intervertebral movement; pressure pain thresholds over C1, C2, C4, C6 vertebral segments bilaterally, trigeminal area, hand, and leg. Signs of pain sensitization were assessed by evaluating mechanical pain threshold over trigeminal area and hand, pressure pain thresholds, and the wind-up ratio. The Bonferroni-corrected p-value (05/4 = 0.013) was adopted to assess the difference between groups, while a p-value of 0.05 was considered significant for the correlation analysis. RESULTS A total of 159 patients and 52 controls were included. Flexion rotation test and craniocervical flexion test were reduced in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). The number of myofascial trigger points and positive vertebral segments was increased in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). Flexion, extension, and total cervical active range of motion and cervical pressure pain thresholds were reduced in episodic migraine in the ictal phase versus controls (p < 0.007) with no other significant differences. Outside the ictal phase, the total cervical active range of motion was positively correlated with trigeminal and leg pressure pain threshold (p < 0.026), the number of active myofascial trigger points and positive positive vertebral segments were positively correlated with higher headache frequency (p=0.045), longer headache duration (p < 0.008), and with headache-related disability (p = 0.031). Cervical pressure pain thresholds were positively correlated with trigeminal, hand, and leg pressure pain threshold (p < 0.001), and trigeminal and leg mechanical pain thresholds (p < 0.005), and negatively correlated with the wind-up ratio (p < 0.004). CONCLUSION In all phases of the migraine cycle, independent of the presence of concomitant neck pain, episodic migraine patients showed reduced flexion rotation test and craniocervical flexion test and an increased number of myofascial trigger points and passive accessory vertebral segments. These impairments are correlated with enhanced headache duration, headache-related disability, and signs of widespread pain sensitization. Reduction in active cervical movement and increased mechanical hyperalgesia of the cervical was consistent in ictal episodic migraine patients and the subgroups of episodic migraine patients with more pronounced widespread sensitization.
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Affiliation(s)
- Stefano Di Antonio
- Department of Health Science and Technology, Center for Pain and Neuroplasticity (CNAP), School of Medicine, Aalborg University, Denmark.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, Genoa, Italy
| | - Lars Arendt-Nielsen
- Department of Health Science and Technology, Center for Pain and Neuroplasticity (CNAP), School of Medicine, Aalborg University, Denmark.,Department of Medical Gastroenterology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Marta Ponzano
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genoa, Italy
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genoa, Italy
| | - Paola Torelli
- Headache Centre, Department of Medicine and Surgery, University of Parma, Italy
| | - Cinzia Finocchi
- Headache Centre, IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Castaldo
- Department of Health Science and Technology, Center for Pain and Neuroplasticity (CNAP), School of Medicine, Aalborg University, Denmark
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Fernández-de-Las-Peñas C, Palacios-Ceña M, Valera-Calero JA, Cuadrado ML, Guerrero-Peral A, Pareja JA, Arendt-Nielsen L, Varol U. Understanding the interaction between clinical, emotional and psychophysical outcomes underlying tension-type headache: a network analysis approach. J Neurol 2022; 269:4525-4534. [PMID: 35229190 DOI: 10.1007/s00415-022-11039-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. .,Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Faculty of Medicine, SMI, Aalborg University, Aalborg, Denmark. .,Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922, Alcorcón, Madrid, Spain.
| | - María Palacios-Ceña
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.,Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Faculty of Medicine, SMI, Aalborg University, Aalborg, Denmark
| | - Juan A Valera-Calero
- Department of Physiotherapy, Faculty of Health, Camilo José Cela University, Villanueva de la Cañada, Madrid, Spain.,VALTRADOFI Research Group, Department of Physiotherapy, Faculty of Health, Camilo Jose Cela University, Madrid, Spain
| | - Maria L Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Juan A Pareja
- Department of Neurology, Hospital Quirón Pozuelo, Madrid, Spain
| | - Lars Arendt-Nielsen
- Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Faculty of Medicine, SMI, Aalborg University, Aalborg, Denmark.,Department of Medical Gastroenterology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Umut Varol
- VALTRADOFI Research Group, Department of Physiotherapy, Faculty of Health, Camilo Jose Cela University, Madrid, Spain
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11
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Steel SJ, Robertson CE, Whealy MA. Current Understanding of the Pathophysiology and Approach to Tension-Type Headache. Curr Neurol Neurosci Rep 2021; 21:56. [PMID: 34599406 DOI: 10.1007/s11910-021-01138-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Description of headache dates back thousands of years, and to date, tension-type headache (TTH) remains the most common form of headache. We will review the history and current understanding of the pathophysiology of TTH and discuss the recommended clinical evaluation and management for this syndrome. RECENT FINDINGS Despite being the most prevalent headache disorder, TTH pathophysiology remains poorly understood. Patients with TTH tend to have muscles that are harder, more tender to palpation, and may have more frequent trigger points of tenderness than patients without headache. However, cause and effect of these muscular findings are unclear. Studies support both peripheral and central mechanisms contributing to the pain of TTH. Diagnosis is based on clinical presentation, while the focus of evaluation is to rule out possible secondary causes of headache. Treatment options have remained similar over the course of the past decade, with some additional studies supportive of both pharmacological and non-pharmacological options. An approach to TTH has been outlined including historical context, evolution over time, and the best evidence regarding our current understanding of the complex pathophysiology and treatment of this disease.
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Affiliation(s)
- Stephanie J Steel
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Carrie E Robertson
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Mark A Whealy
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Karamanlioglu DS, Geler Kulcu D, Ozturk G, Akpinar P, Unlu Ozkan F, Aktas I. Effectiveness of pregabalin treatment for trigger points in patients with comorbid myofascial pain syndrome and fibromyalgia syndrome: a randomized controlled trial. Somatosens Mot Res 2021; 38:327-332. [PMID: 34544324 DOI: 10.1080/08990220.2021.1977265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM OF THE STUDY Myofascial pain syndrome (MPS) is a common problem in the general population. MPS should not be a local/peripheral painful syndrome and considered to be a syndrome of central sensitivity. We aimed to investigate the effect of pregabalin in patients with MPS in this study. MATERIALS AND METHODS We randomized 40 patients into two groups, and 17 patients per group completed the study. Female patients in group I received pregabalin and exercise therapy, whereas those in group II received exercise therapy alone. All patients were evaluated as follows: for pain by visual analog scale (VAS); trigger-point pressure pain threshold-(PPT) by algometry; neuropathic pain using the Douleur Neuropathique en 4 Questions (DN4) and quality of life with the Short Form-36 (SF36). Evaluations were performed pre-treatment and at the end of the first and third months of treatment. Clinical trial ID: NCT04600037, retrospectively registered 20/10/2020. RESULTS In group I, significant improvements were observed in VAS, trigger-point-PPT, physical component summary-SF-36, at the first and third months. In group II, statistically significant improvements were observed in VAS, trigger-point-PPT after the first and third months. Group I showed statistically better improvements in VAS, trigger points-PPT, physical component summary-SF36 compared with group II by the third month. CONCLUSION Pregabalin treatment is effective for controlling trigger points. Pregabalin treatment is also more effective than exercise treatment at improving quality of life in patients with MPS.
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Affiliation(s)
- Duygu Silte Karamanlioglu
- Physical Medicine and Rehabilitation, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Duygu Geler Kulcu
- Istsanbul Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Gulcan Ozturk
- Physical Medicine and Rehabilitation, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Pinar Akpinar
- Physical Medicine and Rehabilitation, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Feyza Unlu Ozkan
- Physical Medicine and Rehabilitation, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Ilknur Aktas
- Physical Medicine and Rehabilitation, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
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Abstract
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.
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Lee E, Lee S. Impact of Cervical Sensory Feedback for Forward Head Posture on Headache Severity and Physiological Factors in Patients with Tension-type Headache: A Randomized, Single-Blind, Controlled Trial. Med Sci Monit 2019; 25:9572-9584. [PMID: 31838486 PMCID: PMC6929546 DOI: 10.12659/msm.918595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/06/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Tension-type headache (TTH) decreases the ability to concentrate and function during daily activities in affected patients. As most patients with TTH exhibit forward head posture (FHP). Various interventions have been proposed to resolve TTH. However, research regarding the efficacy of these interventions remains lacking. The present study aimed to investigate the association between FHP and TTH, and to evaluate the efficacy of various intervention methods on headache symptoms and other clinical variables in patients with TTH induced by FHP. MATERIAL AND METHODS Participants were randomly allocated to 3 groups: biofeedback (BF, n₁=21), manual therapy (MT, n₂=20) and, stretching (ST, n₃=21). Interventions were conducted 3 times per week for 4 weeks. Craniovertebral angle (CVA), electroencephalographic findings for attention, stress, and pressure-pain threshold (PPT), headache on activities of daily living (Henry Ford Headache Disability Inventory, HDI), and quality of life (QoL) assessments were obtained pre-intervention, post-intervention, and at the 2-week follow-up. RESULTS The correlation between CVA and HDI after intervention (R²=0.324, P<0.001), and at 2-week follow-up (R²=0.115, P<0.01) are significant. BF was associated with significant improvements in CVA (F₂,₅₉=3.393, P<0.001, η^2/P=0.130), attention (F₂,₅₉=5.186, P<0.01, η^2/P=0.150), stress [skin temperature (F₂,₅₉=6.005, P<0.001, η^2/P=0.169) and skin conductance (F₂,₅₉=4.900, P<0.01, η^2/P=0.142)], PPT (F₂,₅₉=5.050, P<0.01, η^2/P=0.146), HDI (F₂,₅₉=3.303, P<0.01, η^2/P=0.101), and QoL (F₂,₅₉=3.409, P<0.05, η^2/P=0.104). CONCLUSIONS Our findings indicate that BF was more effective than MT and ST in the treatment of TTH due to FHP. Such findings highlight the need to develop and promote a controlled exercise program to facilitate a return to normal daily activities in patients with TTH due to FHP.
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Affiliation(s)
- Eunsang Lee
- Department of Physical Therapy, The Graduate School of Sahmyook University, Seoul, Republic of Korea
| | - Seungwon Lee
- Department of Physical Therapy, College of Health and Welfare, Sahmyook University, Seoul, Republic of Korea
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San-Antolín M, Rodríguez-Sanz D, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, Casado-Hernández I, López-López D, Calvo-Lobo C. Central Sensitization and Catastrophism Symptoms Are Associated with Chronic Myofascial Pain in the Gastrocnemius of Athletes. PAIN MEDICINE 2019; 21:1616-1625. [DOI: 10.1093/pm/pnz296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Objective
To compare central sensitization symptoms, presence of central sensitivity syndrome (CSS), catastrophism, rumination, magnification, and helplessness symptoms between athletes with gastrocnemius myofascial pain and healthy athletes. Furthermore, to predict central sensitization symptoms based on sociodemographic and descriptive data, catastrophism features, and presence of gastrocnemius myofascial pain in athletes.
Design
Case–control study.
Setting
Outpatient clinic.
Subjects
Fifty matched paired athletes were recruited and divided into patients with chronic (more than three months) gastrocnemius myofascial pain (N = 25) and healthy subjects (N = 25).
Methods
Central sensitization symptoms and CSS presence (≥40 points) were determined by the Central Sensitization Questionnaire (CSQ). Catastrophism symptoms and rumination, magnification, and helplessness domains were measured by the Pain Catastrophizing Scale (PCS). Statistical significance was set at P < 0.01 for a 99% confidence interval.
Results
Statistically significant differences (P ≤ 0.001) with a large effect size (d = 1.05–1.19) were shown for higher CSQ scores and PCS total and domain scores in athletes with gastrocnemius myofascial pain vs healthy athletes. Nevertheless, CSS presence (CSQ ≥ 40 points) did not show statistically significant differences (P = 0.050) between groups. A linear regression model (R2 = 0.560, P < 0.01) predicted higher CSQ scores based on PCS total score (R2 = 0.390), female sex (R2 = 0.095), and myofascial pain presence (R2 = 0.075).
Conclusions
Greater symptoms of central sensitization, catastrophism, rumination, magnification, and helplessness were shown in athletes with gastrocnemius myofascial pain compared with healthy athletes. Nevertheless, there was not a statistically significant presence of CSS comparing both groups. Greater central sensitization symptoms were predicted by catastrophism symptoms, female sex, and presence of gastrocnemius myofascial pain in athletes.
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Affiliation(s)
- Marta San-Antolín
- Department of Psychology, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - David Rodríguez-Sanz
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain
| | | | | | | | - Daniel López-López
- Research, Health and Podiatry Unit, Department of Health Sciences, Faculty of Nursing and Podiatry, Universidade da Coruña, Ferrol, Spain
| | - César Calvo-Lobo
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain
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Cigarán‐Méndez M, Jiménez‐Antona C, Parás‐Bravo P, Fuensalida‐Novo S, Rodríguez‐Jiménez J, Fernández‐de‐las‐Peñas C. Active Trigger Points Are Associated With Anxiety and Widespread Pressure Pain Sensitivity in Women, but not Men, With Tension Type Headache. Pain Pract 2019; 19:522-529. [DOI: 10.1111/papr.12775] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - Carmen Jiménez‐Antona
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine Universidad Rey Juan Carlos AlcorcónSpain
| | - Paula Parás‐Bravo
- Department of Nursing Universidad de Cantabria Cantabria Spain
- Nursing Group IDIVAL Santander Cantabria Spain
| | - Stella Fuensalida‐Novo
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine Universidad Rey Juan Carlos AlcorcónSpain
| | - Jorge Rodríguez‐Jiménez
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine Universidad Rey Juan Carlos AlcorcónSpain
| | - César Fernández‐de‐las‐Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine Universidad Rey Juan Carlos AlcorcónSpain
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Ortega-Santiago R, Maestre-Lerga M, Fernández-de-las-Peñas C, Cleland JA, Plaza-Manzano G. Widespread Pressure Pain Sensitivity and Referred Pain from Trigger Points in Patients with Upper Thoracic Spine Pain. PAIN MEDICINE 2019; 20:1379-1386. [DOI: 10.1093/pm/pnz020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Objectives
The presence of trigger points (MTrPs) and pressure pain sensitivity has been well documented in subjects with neck and back pain; however, it has yet to be examined in people with upper thoracic spine pain. The purpose of this study was to investigate the presence of MTrPs and mechanical pain sensitivity in individuals with upper thoracic spine pain.
Methods
Seventeen subjects with upper thoracic spine pain and 17 pain-free controls without spine pain participated. MTrPs were examined bilaterally in the upper trapezius, rhomboid, iliocostalis thoracic, levator scapulae, infraspinatus, and anterior and middle scalene muscles. Pressure pain thresholds (PPTs) were assessed over T2, the C5-C6 zygapophyseal joint, the second metacarpal, and the tibialis anterior.
Results
The numbers of MTrPs between both groups were significantly different (P < 0.001) between patients and controls. The number of MTrPs for each patient with upper thoracic spine pain was 12.4 ± 2.8 (5.7 ± 4.0 active TrPs, 6.7 ± 3.4 latent TrPs). The distribution of MTrPs was significantly different between groups, and active MTrPs within the rhomboid (75%), anterior scalene (65%), and middle scalene (47%) were the most prevalent in patients with upper thoracic spine pain. A higher number of active MTrPs was associated with greater pain intensity and longer duration of pain history.
Conclusions
This study identified active MTrPs and widespread pain hypersensitivity in subjects with upper thoracic spine pain compared with asymptomatic people. Identifying proper treatment strategies might be able to reduce pain and improve function in individuals with upper thoracic spine pain. However, future studies are needed to examine this.
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Affiliation(s)
- Ricardo Ortega-Santiago
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
- Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | | | - César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
- Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Joshua A Cleland
- Rehabilitation Services, Concord Hospital, Concord, New Hampshire
- Manual Therapy Fellowship Program, Regis University, Denver, Colorado
- Department of Physical Therapy, Franklin Pierce University, Manchester, New Hampshire, USA
| | - Gustavo Plaza-Manzano
- Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
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Do TP, Heldarskard GF, Kolding LT, Hvedstrup J, Schytz HW. Myofascial trigger points in migraine and tension-type headache. J Headache Pain 2018; 19:84. [PMID: 30203398 PMCID: PMC6134706 DOI: 10.1186/s10194-018-0913-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/03/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A myofascial trigger point is defined as a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. It has been suggested that myofascial trigger points take part in chronic pain conditions including primary headache disorders. The aim of this narrative review is to present an overview of the current imaging modalities used for the detection of myofascial trigger points and to review studies of myofascial trigger points in migraine and tension-type headache. FINDINGS Different modalities have been used to assess myofascial trigger points including ultrasound, microdialysis, electromyography, infrared thermography, and magnetic resonance imaging. Ultrasound is the most promising of these modalities and may be used to identify MTrPs if specific methods are used, but there is no precise description of a gold standard using these techniques, and they have yet to be evaluated in headache patients. Active myofascial trigger points are prevalent in migraine patients. Manual palpation can trigger migraine attacks. All intervention studies aiming at trigger points are positive, but this needs to be further verified in placebo-controlled environments. These findings may imply a causal bottom-up association, but studies of migraine patients with comorbid fibromyalgia syndrome suggest otherwise. Whether myofascial trigger points contribute to an increased migraine burden in terms of frequency and intensity is unclear. Active myofascial trigger points are prevalent in tension-type headache coherent with the hypothesis that peripheral mechanisms are involved in the pathophysiology of this headache disorder. Active myofascial trigger points in pericranial muscles in tension-type headache patients are correlated with generalized lower pain pressure thresholds indicating they may contribute to a central sensitization. However, the number of active myofascial trigger points is higher in adults compared with adolescents regardless of no significant association with headache parameters. This suggests myofascial trigger points are accumulated over time as a consequence of TTH rather than contributing to the pathophysiology. CONCLUSIONS Myofascial trigger points are prevalent in both migraine and tension-type headache, but the role they play in the pathophysiology of each disorder and to which degree is unclarified. In the future, ultrasound elastography may be an acceptable diagnostic test.
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Affiliation(s)
- Thien Phu Do
- Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - Gerda Ferja Heldarskard
- Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - Lærke Tørring Kolding
- Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - Jeppe Hvedstrup
- Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - Henrik Winther Schytz
- Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
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Quantitative sensory testing in patients with migraine: a systematic review and meta-analysis. Pain 2018; 159:1202-1223. [DOI: 10.1097/j.pain.0000000000001231] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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20
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Fernández-De-Las-Peñas C, Arendt-Nielsen L. Improving understanding of trigger points and widespread pressure pain sensitivity in tension-type headache patients: clinical implications. Expert Rev Neurother 2017; 17:933-939. [DOI: 10.1080/14737175.2017.1359088] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- César Fernández-De-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Spain
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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