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

Calcitonin Gene-Related Peptide Levels in Children and Adolescents With Primary Headache Disorder

ObjectiveThis study aimed to investigate calcitonin gene-related peptide (CGRP) levels in children and adolescents with primary headache.MethodsAll patients underwent blood sampling regardless of their headache state (ictal or interictal) on the day of examination. The patients were grouped based on their headache diagnosis (migraine, tension-type headache, or mixed).ResultsNinety-two patients aged 5-18 years were included (29 diagnosed with migraine and 31 with tension-type headache). In the comparisons between the patients with migraine and the patients with tension-type headache, interictal CGRP levels in blood from the cubital vein showed no significant difference. Ictal samples were collected in the tension-type headache group only, and no significant difference was observed between the ictal and interictal phases. Variables such as headache diagnosis, sex, age, family history with primary headache, headache frequency, time since last headache, medication usage, and body mass index did not significantly influence CGRP levels.ConclusionNo significant difference in interictal CGRP levels between patients with migraine and patients with tension-type headache were found. In patients with tension-type headache, there were no significant differences between CGRP levels in the ictal and interictal state. We were not able to draw conclusions about differences in ictal levels of CGRP in patients with migraine compared with patients with tension-type headache, or in differences between ictal and interictal levels in patients with migraine. Future studies should aim to replicate these results in a larger study cohort.

German translation, transcultural adaptation and test-retest reliability of the headache screening questionnaire

INTRODUCTION

Tension-type headache (TTH) and migraines are frequent headache types. For appropriate treatment, physiotherapists need to be able to recognize these two headache types. The Dutch Headache Screening Questionnaire (HSQ-DV) is the only screening questionnaire designed specifically for migraines and TTH, based on the latest International Classification of Headache Disorders and supporting evidence. The aim of this study is to translate the HSQ-DV into German and evaluate its test-retest reliability.

METHODS

A cross-sectional and prospective cohort study was conducted to answer the research questions. The HSQ-DV was translated according to the COMSIN checklist for patient-reported outcome measurement instruments. Test-retest reliability was assessed with a retest after two weeks. Weighted kappa values, intraclass-correlation coefficients (ICCs) and standard error of the measurements (SEMs) were calculated separately for migraines and THH, based on point scale ranging from 0 to 8.

RESULTS

The HSQ-DV was translated and culturally adapted into German. An introductory clarification was added to guide participants with multiple headaches, which headache type to consider. Sixty-one subjects were included in the reliability study. For migraine, the weighted kappa was 0.70 (95% Confidence Interval (CI) 0.52 to 0.87), the ICC was 0.84 (95% CI: 0.71 to 0.91), and the SEM was 0.39 points. For TTH, the weighted kappa was 0.73 (95% CI: 0.57 to 0.90), the ICC was 0.85 (95% CI: 0.74 to 0.92), and the SEM was 0.29 points.

CONCLUSION

The HSQ-GV is a reliable screening questionnaire for migraines and TTH in physiotherapy settings, demonstrating substantial to nearly perfect reliability.

Physical-functional alterations in women with chronic migraine

BACKGROUND

Migraine is a prevalent neurological disorder that significantly impacts quality of life. Despite its considerable burden, the underlying pathophysiology remains poorly understood.

OBJECTIVES

To identify physical-functional alterations in women with chronic migraine.

METHODS

Twenty-four women (39.2 ± 7.7 years) with chronic migraine were assessed using tools selected for this study. We analyzed pain intensity and perception (Visual Analog Scale - VAS and McGill Pain Questionnaire), motion sickness (Dizziness Handicap Inventory - DHI), panic and agoraphobia (Panic and Agoraphobia Scale - PAS), postural stability (modified Clinical Test of Sensory Integration and Balance - mCTSIB and Dynamic Gait Index - DGI), and quality of life (WHOQOL-BREF).

RESULTS

The prevalence of pain is widely reported, with a mean intensity score of 6.7 ± 1.7, and when assessed using the McGill scale, the total pain index was 60.6 ± 14.7. The DHI showed a score with a median of 34 points, while the PAS scored with a median of 4 points. In the WHOQOL, the Physical and Psychological domains had the worst scores (53.3 ± 17.8 and 58.9 ± 18.7, respectively). The mean DGI score was 21.5 ± 2.3, where 12.5 % of the participants presented a deficit, whose score indicates gait impairment and risk of falls. In the mCTSIB, the mean score was 5.3 ± 1.1. When correlating the uni or multidimensional aspects of pain with quality of life, the pain scores by VAS are significantly associated with the score of total quality of life.

CONCLUSION

Chronic migraine can alter physical-functional conditions in women.

Natural subgroups of tension-type headache: A population-based study

OBJECTIVE

To identify natural subtypes of tension-type headache (TTH) based on clinical characteristics.

BACKGROUND

Tension-type headache is generally recognized as a bilateral, non-pulsating headache of mild-to-moderate intensity, with minimal accompanying symptoms. However, diverse symptomatology can be present with current diagnostic criteria.

METHODS

This study was a cross-sectional, secondary analysis of data previously collected from a nationwide population-based web survey data on headache and sleep, conducted in South Korea in October 2020. Categorical variables for TTH diagnostic criteria according to the third edition of the International Classification of Headache Disorders were analyzed to determine the natural subtypes of TTH.

RESULTS

Of 3030 participants, 954 were identified with TTH. A four-class model was selected as optimal, revealing subtypes named "classic TTH," "severe TTH," "unilateral TTH," and "TTH with photophobia," comprising 413 (43.3%), 66 (6.9%), 376 (39.4%), and 99 (10.4%) individuals, respectively. The most common, "classic TTH," featured typical bilateral (413/413 [100.0%]), non-pulsatile headaches (220/413 [53.3%]) of mild-to-moderate intensity (400/413 [96.9%]). The "severe TTH" class exhibited the highest headache intensity (moderate headache intensity, 35/66 [53.0%]), and the greatest impact of headache (mean [± standard deviation, SD] six-item Headache Impact Test [HIT-6] score, 55.1 [6.0]). The "unilateral TTH" class was primarily mild headache intensity (277/376 [73.7%]) and lowest impact of headache (mean [SD] HIT-6 score 48.8 [8.3]). "TTH with photophobia" involved exclusive photophobia (99/99 [100%]) and was second to "severe TTH" in headache intensity (moderate intensity, 43/99 [43.4%]) and impact of headache (mean [SD] HIT-6 score 53.2 [8.1]). Of 954 total TTH participants, 56.7% were not "classic TTH" subtype and 51.4% had unilateral headache.

CONCLUSION

We identified four TTH subgroups, each with unique clinical features, providing additional insights into TTH subtypes.

Burden of migraine among Egyptian people: prevalence and comorbidities

INTRODUCTION

Migraine is a prevalent debilitating neurological illness that stands among the top causes of disability and significantly impacts the quality of life. Migraine-related functional impairment involves physical, emotional, and economic consequences that frequently impact occupational, academic, social, and familial aspects of life. Depression, anxiety, and sleep disturbances are among the most common comorbid conditions associated with migraine.

OBJECTIVE

This study aimed to assess the prevalence of migraine among the Egyptian population and associated comorbidities.

METHODS

we conducted a cross-sectional study using a validated Arabic self-administered questionnaire distributed to the general population. The questionnaire was used to collect data on sociodemographic characteristics, migraine frequency, characteristic associated disability, insomnia, and psychological factors. Convenience snowball sampling method was utilized. Univariate and multivariate regression analyzes were applied.

RESULTS

A total of 2,533 participants were included in the final analysis from five Egyptian regions. Females represent 57%. More than one-half of participants (59.1%) aged 20-30 years. The prevalence of migraine was 20.9%. The most common triggers were sleep disorders (76.9%), followed by perceived noise (65%), and anxiety (59%). Among the participants diagnosed with migraine, 46.7% had a severe disability, 22% had clinical insomnia of moderate severity, 20.5% had severe depression, 29% had severe anxiety, and 20.6% had severe stress. Females, older age, and urban residents were the key predictors of migraine. Lifestyle factors including regular physical activity and good hydration were linked to reduced migraine risk. Comorbid conditions including insomnia, stress, and anxiety significantly impacted migraine severity.

CONCLUSION

Our results showed a 20.9% prevalence of migraine, with nearly one-half of cases associated with severe disability, along with comorbidities like depression, anxiety, and insomnia. Female gender, older age, and urban residence are key predictors, while lifestyle factors such as physical exercise and good hydration reduce the risk of migraine.

Guidelines to minimize risk when dry needling the rectus capitus posterior major muscle

BACKGROUND

Headache disorders are prevalent often leading to disability. The rectus capitus posterior major muscle (RCPMaj) may contribute to headache symptoms via nociceptive convergence and myodural bridging.

OBJECTIVES

To establish guidelines for needle length and needle angle to mitigate risks during dry needling RCPMaj.

DESIGN

Cadaveric investigation.

METHODS

Twenty-five cadavers (mean age: 80.1 ± 13.2 years) were placed in prone. Depth measurements from the skin to the C2 spinous process were taken following midline incision. Dissection continued exposing the RCPMaj for three measures including: 1) posterior angle from the frontal plane, 2) lateral angle from midline, and 3) distance from the external occipital protuberance to the lateral most RCPMaj.

RESULTS

Mean values for tissue thickness overlying C2 spinous process (37 ± 7.3 mm), RCPMaj posterior angle from the frontal plane (65.2° ±10°), RCPMaj lateral angle from midline (34.7° ±12.9°), and distance from the external occipital protuberance to the lateral most RCPMaj (30.6 mm ± 9.3 mm) were used to calculate a needle inclination of ≤45° and a needle length <40 mm to reach the occipital portion of RCPMaj with an a priori insertion point of midway between the C2 spinous process and the C1 transverse process.

CONCLUSION

Inserting a dry needle <40 mm in length midway between the C2 spinous process and the C1 transverse process with a cranial angle of ≤45° relative to the frontal plane would increase the likelihood of reaching the RCPMaj and mitigate penetrating deeper structures.

Associations of comorbid headache disorders and depression with leisure-time physical activity among 14,088 adults in The Brazilian Longitudinal Study of Adult Health

BACKGROUND

While headache disorders are linked to low physical activity levels, the impact of depression on this relationship is unclear.

OBJECTIVE

To assess how single and comorbid diagnoses of migraine and tension-type headache (TTH) interact with depression and leisure-time physical activity (LTPA) levels in The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

METHODS

In this cross-sectional analysis based on the ELSA-Brasil baseline data, the relationship of migraine, TTH (both assessed with the International Classification of Headache Disorders, Second Edition), and depression (assessed with the Clinical Interview Schedule-Revised) with LTPA levels (International Physical Activity Questionnaire) was investigated by employing linear regression models. Models were adjusted for sociodemographic, lifestyle, and clinical covariates, and interaction terms were created to examine additive effects of comorbid conditions.

RESULTS

Among 14,088 participants, 54.4% (7668/14,088) were female, prevalence rates were: TTH = 39.6% (5573/14,088), migraine = 27.0% (3806/14,088), depression = 0.7% (94/14,088), depression + TTH = 1.1% (148/14,088), and depression + migraine = 2.5% (356/14,088). The mean (standard deviation) LTPA levels across the groups were: no headache + no depression = 148.7 (183.0) min/week, TTH = 133.5 (170.1) min/week, migraine = 110.3 (154.8) min/week, depression = 76.5 (146.3) min/week, depression + TTH = 84.5 (127.7) min/week, and depression + migraine = 64.3 (123.2) min/week. Negative associations were found for depression (β = -55.1, 95% confidence interval [CI] -93.6 to -17.0; p = 0.005), migraine (β = -24.7, 95% CI -33.2 to -15.4; p < 0.001), and TTH (β = -15.5, 95% CI -23.1 to -7.6; p < 0.001) with LTPA. No interaction effect was observed for depression + TTH (β = 36.0, 95% CI -12.6 to 84.6; p = 0.147) and depression + migraine (β = 31.7, 95% CI -11.3 to 74.7; p = 0.149), indicating no additive effect of comorbid conditions on LTPA levels. After adjusting for headache attack frequency, only depression + migraine remained negatively associated with LTPA (β = -38.7, 95% CI -71.6 to -5.8; p = 0.021).

CONCLUSIONS

Headache disorders and depression were independently and inversely associated with LTPA, with the strongest effects seen in depression alone or comorbid with migraine.

Single-centre, randomised and double-blind clinical trial on the efficacy of transcutaneous auricular vagus nerve stimulation in preventing and treating primary headache in children and adolescents: a study protocol

INTRODUCTION

Primary headaches pose a significant burden on children and adolescents, highlighting the need for effective non-pharmacological interventions. Transcutaneous auricular vagus nerve stimulation (taVNS) is a non-invasive modality that has demonstrated efficacy in adult populations with primary headaches and has shown safety in adolescents with mental health disorders. However, its effectiveness in managing acute headache episodes and preventing recurrences in paediatric populations remains underexplored. This study aims to evaluate the immediate analgesic effects of taVNS during acute headache episodes and its preventive efficacy over a 4-week period. Additionally, we will investigate potential biomarkers associated with primary headaches and elucidate the underlying mechanisms of taVNS through electromyography (EMG) and electrocardiography (ECG) assessments.

METHODS AND ANALYSIS

This study will employ a double-blind, randomised clinical trial design involving 288 children and adolescent participants diagnosed with primary headaches. The study will consist of two substudies: the acute period (AP) study and the preventive period (PP) study. Participants will be randomly allocated to receive either taVNS or sham stimulation. The primary outcome for the AP study will be the reduction of pain intensity 2 hours after treatment, as measured by the visual analogue scale, while the PP study will assess the change in the headache attack days over the treatment period. Secondary outcomes will include EMG and ECG parameters.

ETHICS AND DISSEMINATION

The study will adhere to the principles outlined in the Declaration of Helsinki and has received ethical approval from the Medical Ethics Committee of Nanfang Hospital, Southern Medical University (NFEC-2024-057), on 2 January 2024. Informed consent will be obtained from all participants or their guardians. The findings will be disseminated through peer-reviewed journals and presented at relevant scientific conferences.

TRIAL REGISTRATION NUMBER

NCT06277063.

The efficacy of physiotherapy approaches in chronic tension-type headache: a systematic review and meta-analysis

BACKGROUND

Although pharmacologic therapies are considered the first choice for the treatment of chronic tension-type headache (CTTH), physiotherapy and rehabilitation approaches are also used in the management of patients with CTTH. This study aimed to investigate the efficacy of physiotherapy approaches in CTTH through a systematic review and meta-analysis.

METHODS

The following electronic databases were searched, PubMed and Web of Science databases. Common primary outcomes from randomized controlled trials (RCTs) were changes in the intensity and duration of headaches, headache frequency, disability and headache impact. The methodologic quality (completeness of reporting and risk of bias) of trial reports included in systematic reviews was assessed using the Physiotherapy Evidence Database scale ratings. We also performed data synthesis and quantitative analysis of the eligible data.

RESULTS

Nine RCTs were included in the review. Seven studies related to intensity of headache (IH), three on headache frequency (HF), three on headache duration (HD), and two on headache impact were eligible for quantitative analysis. Analysis of the data showed that neck-shoulder strength exercises, electroacupuncture, and approaches targeting muscle relaxation improved the IH (-1.17 (-1.86, -0.49) p < 0.01) and reduced the HD (-0.71 (-1.31, -0.12), p = 0.02); the approaches targeting muscle relaxation and neck-shoulder strength exercises induced a significant decrease in the HF (-1.36 (-2.47, -0.26), p = 0.02) in patients with CTTH in comparison with the control groups.

CONCLUSIONS

Neck-shoulder strength exercises and muscle relaxation are effective in reducing the intensity, duration, and frequency of headaches and electroacupuncture causes significant improvement in the duration and intensity of headaches in patients with CTTH.

THE PROSPERO REGISTRATION

PROSPERO number is CRD42023457085.

Chronic Stress and Headaches: The Role of the HPA Axis and Autonomic Nervous System

Chronic stress significantly influences the pathogenesis of headache disorders, affecting millions worldwide. This review explores the intricate relationship between stress and headaches, focusing on the dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system (ANS). Persistent stress could lead to neuroinflammation, increased pain sensitivity, and vascular changes that could contribute to headache development and progression. The bidirectional nature of this relationship creates a vicious cycle, with recurrent headaches becoming a source of additional stress. Dysregulation of the HPA axis and ANS imbalance could amplify susceptibility to headaches, intensifying their frequency and severity. While pharmacological interventions remain common, non-pharmacological approaches targeting stress reduction, such as cognitive-behavioral therapy, biofeedback, and relaxation techniques, offer promising avenues for comprehensive headache management. By addressing the underlying stress-related mechanisms, these approaches provide a sustainable strategy to reduce headache frequency and improve patients' quality of life.

Association between internet use and primary headache severity among Hungarian university students: a cross-sectional study

Background

Recent studies suggest that increased digital technology usage could be a factor in the rising occurrence and severity of headache episodes. The purpose of this cross-sectional study was to determine whether the severity of primary headaches (migraine and tension-type headache) is associated with problematic internet use taking many covariates into account.

Methods

We conducted an online cross-sectional survey using a quantitative, descriptive questionnaire, targeting university students enrolled in correspondence courses, aged 18 to 65. The survey included socio-demographic parameters, risk factors, concomitant diseases, medical history of headaches, and details of online activities. Psychometric measurements contained the Problematic Internet Use Questionnaire, the 9-item short version of the Beck Depression Inventory (BDI-SF), and the Athens Insomnia Questionnaire.

Results

A total of 550 responders (n = 480 female; n = 70 male) completed the online questionnaire package. Among the participants, 202 individuals (36.7%) reported experiencing headaches, 74 had migraines and 119 had tension-type headache. Internet addiction was detected in 46 (8.4%) participants. Multivariate analysis of variance (MANOVA) showed that significant risk factors of all primary headaches severity included being <30 years (p = 0.044, OR = 3.439), not having children (p = 0.014, OR = 2.493), being married (p = 0.035, OR = 2.528), spending more than 4 h per day on the internet (p = 0.021, OR = 1.088), experiencing mood disturbances (p = 0.033, OR = 1.345) and the presence of insomnia (p = 0.048, OR = 1.667). Furthermore, a slight positive correlation was identified between the amount of time individuals spent on the Internet and the severity of headaches (r = 0.138, r2 = 0.019, ß = 1.068, p = 0.049). Patients with migraine or tension-type headache showed different predecessors, internet use was only associated with the severity of tension-type headache (night-time internet use, OR = 3.075, p = 0.043, and internet addiction, OR = 1.221, p = 0.003).

Conclusion

This research marks one of the initial epidemiological investigations in Hungary concentrating on the possible adverse impact of online activities on the severity of headache. Although our study could find slight correlation between the role of online activities and internet addiction on the severity of primary headaches, the topic merits further investigation.

Gender-specific inflammatory burden and headache risk in youth: a NHANES analysis

BACKGROUND

Headaches are a common and often debilitating condition among youth. The Inflammatory Burden Index (IBI), a simple surrogate marker of systemic inflammation, has been linked to various diseases. However, evidence for its relationship with headaches, particularly in youth, is lacking. This study aimed to investigate the association between IBI and persistent headache in youth, with a focus on evaluating gender-specific responses to IBI exposure.

METHODS

We analyzed data from 2,210 young people in the 2001-2004 National Health and Nutrition Examination Survey (NHANES). The association between IBI and frequent or severe headaches in the past year was investigated using weighted logistic regression models. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated, and threshold effect analyses were performed.

RESULTS

Youths in the highest IBI quartile (Q4) had a 46% higher risk of severe headaches compared to the lowest quartile (Q1) (OR: 1.46, 95% CI: 1.12-1.91, P = 0.0051). Gender-stratified analysis revealed a significant association between high IBI and headache risk in females (OR: 1.48; 95% CI: 1.03-2.11, P = 0.0324), but not in males. Threshold effect analysis identified an IBI breakpoint of 3.78, below which the headache risk increased significantly in females under 18 years (OR: 1.12, 95% CI: 1.01-1.25, P = 0.0385).

CONCLUSIONS

Our findings demonstrate a significant association between elevated IBI and increased headache risk in youth, particularly in females. This gender-specific effect suggests that inflammatory processes may play a more prominent role in headache pathophysiology among female youth. These results underscore the importance of considering inflammatory markers in the early identification and prevention of youth headaches, especially in females.

Non-Migraine Head Pain and Botulinum Toxin

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

Unravelling Migraine Stigma: A Comprehensive Review of Its Impact and Strategies for Change

Migraine-related stigma is a pervasive issue impacting nearly half of chronic migraine patients, with significant consequences for their quality of life, disability and mental health. Despite its profound effects, migraine stigma remains under-recognised in both clinical practice and research. This narrative review explores the three primary types of stigmas affecting migraine patients: public, structural and internalised. Public stigma involves negative societal attitudes and stereotypes that trivialise the condition. Structural stigma is reflected in policies that restrict access to necessary care and resources. Internalised stigma occurs when patients absorb these negative views, leading to self-blame and diminished self-worth. Addressing these different types of stigmas is crucial for improving the understanding, diagnosis and treatment of migraine. Educational efforts, advocacy and policy reform are essential strategies in this context. A deep understanding of stigma is vital for developing effective interventions that enhance clinical management and patient quality of life. Ultimately, reducing stigma can lead to better health outcomes and a more comprehensive approach to migraine care.

Transverse Sinus Stenosis as an Underdiagnosed Cause of Chronic Headache: A Case Report

Transverse sinus stenosis (TSS) is an abnormality in the cerebral venous system in which the narrowing of the transverse sinus of the brain leads to obstructed cerebral venous outflow. It is an infrequent, incidental radiological finding. However, it is not uncommon among patients with chronic headaches of unclear cause, particularly those that remain unexplained after initial evaluation or those that are refractory to medical treatment. Its diagnosis frequently eludes the initial workup, and a high degree of suspicion should be maintained since its identification can lead to potentially curative treatment. This report describes the case of a 36-year-old female with a history of chronic headache who was found to have TSS. This paper discusses its etiology, pathophysiology, clinical presentation, radiological findings, and management.

The relationship between myofascial trigger points sensitivity, cervical postural abnormality, and clinical tension-type headache parameters

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.

Systematic review and meta-analysis of Neck Disability Index and Numeric Pain Rating Scale in patients with migraine and tension-type headache

BACKGROUND

The present study aimed to assess the burden of neck pain in adults with migraine and tension-type headache (TTH), utilizing the Neck Disability Index (NDI) and Numeric Pain Rating Scale (NPRS).

METHODS

A systematic literature search was conducted on PubMed and Embase to identify observational studies assessing NDI and NPRS in populations with migraine or TTH. The screening of articles was independently performed by two investigators (HMA and ZA). Pooled mean estimates were calculated through random-effects meta-analysis. The I2 statistic assessed between-study heterogeneity, and meta-regression further explored heterogeneity factors.

RESULTS

Thirty-three clinic-based studies met the inclusion criteria. For participants with migraine, the pooled mean NDI score was 16.2 (95% confidence interval (CI) = 13.2-19.2, I2 = 99%). Additionally, the mean NDI was 5.5 (95% CI = 4.11-6.8, p < 0.001) scores higher in participants with chronic compared to episodic migraine. The pooled mean NDI score for participants with TTH was 13.7 (95% CI = 4.9-22.4, I2 = 99%). In addition, the meta-analysis revealed a mean NPRS score of 5.7 (95% CI = 5.1-6.2, I2 = 95%) across all participants with migraine.

CONCLUSIONS

This systematic review and meta-analysis shows a greater degree of neck pain-related disability in migraine compared to TTH. Nevertheless, the generalizability of these findings is constrained by methodological variations identified in the current literature.

Therapeutic Patient Education as Part of the Physiotherapy Management of Adults with Headache: A Scoping Review

PURPOSE OF REVIEW

Physiotherapy interventions for headache mostly include exercise and manual therapy. Yet, the complex nature of headache, sometimes characterized by symptoms of facilitated central pain mechanisms, demands an individualized approach in which therapeutic patient education could be supportive. This scoping review aimed to summarize the position of therapeutic patient education within the physiotherapy management of adults with headache. PubMed, EMBASE, Web of Science, and Scopus were searched. The search-query comprised terminology relating to "headache", "education", and "physiotherapy". Eligibility criteria were: adults with headache, interventions including education within the domain of physiotherapy, reviews, clinical trials, cohort, case report, case-control studies.

RECENT FINDINGS

Eleven publications were included from the 281 retrieved publications. These publications were clinical trials (n = 4), reviews (n = 4), case-reports (n = 2), and a guideline (n = 1). Type of headaches studied were migraine (n = 3), post-traumatic headache (n = 2), tension-type headache (n = 2), cervicogenic headache (n = 1), primary headaches (n = 1), chronic daily headache (n = 1), and mixed migraine-cervicogenic headache (n = 1). Education seems an umbrella-term for postural education, lifestyle advice, and pain education. Three themes emerged across the publications: handling headache triggers (migraine, post-traumatic headache), promoting active lifestyle (post-traumatic headache, chronic daily headache, migraine), evaluating posture (post-traumatic headache, chronic daily headache, tension-type headache, cervicogenic headache). All publications recommended education in the management of headache. Only one (of the 11 included) publication described the educational program and determined its efficacy. Based on this scoping review, therapeutic patient education seems supported within physiotherapy management of headache. However, it is unclear how such education is tailored to the specific needs of the individual, the headache subtype, or when it should be added to physiotherapy management of headache.

Sleep Bruxism and Obstructive Sleep Apnea Are Not Risk Factors for Tension-Type Headache (TTH): A Polysomnographic Study

Background: Tension-type headache (TTH) is the most common primary headache. Obstructive sleep apnea (OSA) and sleep bruxism (SB) are two of the most common sleep disorders; however, the relationship between TTH, OSA, and SB has not been conclusively proved in the literature. The objective of our study was to estimate potential associations with OSA and SB in TTH subjects. Methods: 108 adult individuals who underwent polysomnography (vPSG) were included, and the group was divided into two subgroups: TTH (n = 34) and control (n = 74). The International Classification of Headache Disorders (ICHD-3) guidelines were used to diagnose TTH. OSA and SB diagnoses were based on vPSG examination with electromyographic (EMG) recordings and the American Academy of Sleep Medicine (AASM) criteria. The results were analyzed, where p < 0.05 was considered to be statistically significant. Results: In the TTH group, the incidence of SB was more than two times lower than the control (OR = 0.41, 95% CI: 0.17-0.96, p < 0.05). However, the incidence of severe SB (BEI > 4) was similar in the TTH and control groups (OR = 0.54, 95% CI: 0.21-1.35, p > 0.05). Additionally, phasic and tonic SB episodes were less frequent in the TTH group compared to the controls (p < 0.05). The mean apnea-hypopnea index (AHI) was not significantly different between the TTH and control groups (p > 0.05). The sleep architecture and respiratory disturbances did not differ between the examined groups (p > 0.05). Conclusions: SB is not a risk factor for TTH. Moreover, severe SB is not connected with TTH. OSA is not a risk factor for TTH. Sleep quality did not differ between both groups during PSG; therefore, TTH may not change sleep structure. The mechanism of these findings is still unclear, and further studies should explain in detail the association between TTH and OSA.

Alternative Treatments for Emotional Experiencing and Processing in People with Migraine or Tension-Type Headache: A Scoping Review

This narrative review aims to summarize the use of alternative treatments (e.g., relaxation training, meditation, written intervention) for emotional expression, processing, control, or management in patients with migraine and tension-type headaches, which the previous literature has shown to be related to migraine pain perception and headache symptoms. Online databases including PubMed, Scopus, Web of Science, PsycINFO, and Medline were searched to identify studies published between 2000 and 2023. A descriptive synthesis of the included studies was conducted. We included seven articles after screening 1.173 records. A total of 610 patients with a diagnosis of migraine or tension-type headache, and an average age of 19-45.5 years (68-90.4% females) were recruited in the selected studies. Overall, the results show that alternative approaches to headache treatment contribute to the management, reduction, or control of negative emotions and at the same time have a positive impact on pain perception and headache symptoms. However, in some cases, the effects are more promising than others, depending on the peculiarities or limitations of each approach considered. This review provides useful insights from a methodological point of view for future studies on the management or control of negative emotions in patients with migraine and tension-type headache.

Migraine and Epilepsy in Children: A Narrative Review of Comorbidity and Similar Treatment Option

Migraine and epilepsy belong to the category of chronic paroxysmal neurological disorders and share numerous clinical features, as well as potential treatment options. This narrative review emphasizes the similarities between pediatric migraine and epilepsy, exploring epidemiology, pathophysiology, genetics, clinical presentation, and pharmacology. Although various syndromes exhibit symptoms common to both conditions, further research is needed to clarify the underlying pathophysiological and genetic connections contributing to their coexistence. Prophylactic medications used in the management of both migraines and epilepsy exhibit similar pharmacological characteristics. The review assesses treatment strategies for epilepsy and migraines, emphasizing antiseizure medications alongside nonpharmacological interventions like ketogenic diet, supplements, and vagal nerve stimulation. It aims to highlight how these interventions, originally targeted for epilepsy, may also show promise in preventing migraines. The urgent need for further randomized, controlled clinical trials investigating both pharmacological and nonpharmacological interventions for treating both disorders is emphasized, aiming to pave the way for innovative therapeutic strategies.

sEMG Biofeedback for Episodic Migraines: A Pilot Randomized Clinical Trial

The aim of this study was to assess the feasibility and potential effectiveness of a 6-week virtual sEMG biofeedback intervention for patients with episodic migraines. Patients with episodic migraines were randomized to treatment with a novel surface EMG (sEMG) at-home biofeedback device or a treatment as usual control group; they completed validated baseline and post-intervention assessments of migraine related disability (migraine-specific quality of life, anxiety and depression). Participants also underwent a series of Quantitative Sensory Testing (QST) procedures referring to several different tests that quantitatively assess responses to mechanical stimuli during two separate visits (baseline and post intervention). No adverse events were reported during the study. Compared to the treatment as usual comparison group, patients in the sEMG biofeedback group reported lower migraine disability (p < 0.05). Compared to baseline, participants in the sEMG biofeedback group demonstrated statistically significant reductions in anxiety (p < 0.01), and significant increases in quality of life (p < 0.001), and significant decreases in temporal summation (p < 0.05) assessed by QST. No significant changes were observed in any of the outcomes in the control comparison group (p > 0.05). No significant changes were observed in migraine frequency in either of the two groups (p > 0.05). In addition, mediation analyses revealed that changes in migraine related quality of life mediated group effects on changes in migraine disability. Virtual sEMG biofeedback shows promise as a potential therapy for reducing disability, anxiety and depression and improving quality of life in individuals with episodic migraines. These results demonstrate the feasibility of a digital intervention for migraines and set the basis for conducting a future, larger scale randomized controlled trial to confirm these preliminary findings.

Trigeminal neuralgia

Trigeminal neuralgia (TN) is a facial pain disorder characterized by intense and paroxysmal pain that profoundly affects quality of life and presents complex challenges in diagnosis and treatment. TN can be categorized as classical, secondary and idiopathic. Epidemiological studies show variable incidence rates and an increased prevalence in women and in the elderly, with familial cases suggesting genetic factors. The pathophysiology of TN is multifactorial and involves genetic predisposition, anatomical changes, and neurophysiological factors, leading to hyperexcitable neuronal states, central sensitization and widespread neural plasticity changes. Neurovascular compression of the trigeminal root, which undergoes major morphological changes, and focal demyelination of primary trigeminal afferents are key aetiological factors in TN. Structural and functional brain imaging studies in patients with TN demonstrated abnormalities in brain regions responsible for pain modulation and emotional processing of pain. Treatment of TN involves a multifaceted approach that considers patient-specific factors, including the type of TN, with initial pharmacotherapy followed by surgical options if necessary. First-line pharmacological treatments include carbamazepine and oxcarbazepine. Surgical interventions, including microvascular decompression and percutaneous neuroablative procedures, can be considered at an early stage if pharmacotherapy is not sufficient for pain control or has intolerable adverse effects or contraindications.

Prevalence, Characteristics, and Treatment Pattern of Menstrual-Related Headache Among Undergraduate Health Sciences Students at Addis Ababa University, Ethiopia

Background

Menstrual-related headache (MRH) is the most prevalent health condition among young females that limits productivity and social life. However, the magnitude of the problem and its characteristics have not been studied in Ethiopia.

Objective

This study aimed to assess the prevalence, characteristics, and treatment of MRH among undergraduate female students at the College of Health Sciences, Addis Ababa University, Ethiopia.

Methods

A cross-sectional study was conducted among undergraduate female students from May to June 2023. A random sample of 1000 females were approached who fulfilled the eligibility criteria using the online electronic method. Descriptive statistics were used to summarize participant characteristics. Multivariate logistic regression analysis was performed to identify factors associated with the severity of pain. All statistical analyses were performed using SPSS version 26. A p-value ≤ 0.05 was considered statistically significant.

Results

Of the 1000 students who approached online, 757 were included in the final analyses. The prevalence of MRH was (86, 11.4%) and 32.6% of them has experienced the headache before two to three days of menses. The median number of days of missed social activities and reduced productivity was three and one day, respectively. Being single was 6.24 times more likely to have severe MRH (AOR = 6.24, 95% CI: 2.73-14.26, p=0.001) and pharmacy students were less likely (AOR = 0.31, 95% CI: 0.16-0.61, p = 0.001) to have severe pain.

Conclusion

Our findings illustrated that MRH among young female students adversely affects students' productivity and social life. This demands interventions to reduce the impact and should pay attention in the future, particularly to create awareness to enhance screening and rendering various treatment options for the target population.

Ultrasonographic examination of masticatory muscles in patients with TMJ arthralgia and headache attributed to temporomandibular disorders

This study used ultrasonography to compare the thickness and cross-sectional area of the masticatory muscles in patients with temporomandibular joint arthralgia and investigated the differences according to sex and the co-occurrence of headache attributed to temporomandibular disorders (HATMD). The observational study comprised 100 consecutive patients with TMJ arthralgia (71 females and 29 males; mean age, 40.01 ± 17.67 years) divided into two groups: Group 1, including 86 patients with arthralgia alone (60 females; 41.15 ± 17.65 years); and Group 2, including 14 patients with concurrent arthralgia and HATMD (11 females; 33.00 ± 16.72 years). The diagnosis of TMJ arthralgia was based on the diagnostic criteria for temporomandibular disorders. The parameters of the masticatory muscles examined by ultrasonography were subjected to statistical analysis. The pain area (2.23 ± 1.75 vs. 5.79 ± 2.39, p-value = 0.002) and visual analog scale (VAS) score (3.41 ± 1.82 vs. 5.57 ± 12.14, p-value = 0.002) were significantly higher in Group 2 than in Group 1. Muscle thickness (12.58 ± 4.24 mm) and cross-sectional area (4.46 ± 2.57 cm2) were larger in the masseter muscle than in the other three masticatory muscles (p-value < 0.001). When examining sex-based differences, the thickness and area of the masseter and lower temporalis muscles were significantly larger in males (all p-value < 0.05). The area of the masseter muscle (4.67 ± 2.69 vs. 3.18 ± 0.92, p-value = 0.004) and lower temporalis muscle (3.76 ± 0.95 vs. 3.21 ± 1.02, p-value = 0.049) was significantly smaller in Group 2 than in Group 1. An increase in VAS was significantly negatively correlated with the thickness of the masseter (r =  - 0.268) and lower temporalis (r =  - 0.215), and the cross-sectional area of the masseter (r =  - 0.329) and lower temporalis (r =  - 0.293). The masseter and lower temporalis muscles were significantly thinner in females than in males, and their volumes were smaller in patients with TMJ arthralgia and HATMD than in those with TMJ arthralgia alone. HATMD and decreased masseter and lower temporalis muscle volume were associated with increased pain intensity.

Association of mental health symptoms with the migraine-tension-type headache spectrum in the Brazilian longitudinal study of adult health

OBJECTIVE

To investigate the relationship between mental health symptoms and the migraine-tension-type headache (TTH) spectrum in middle-aged adults from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil study).

METHODS

In this cross-sectional analysis (baseline data: 2008-2010), it was evaluated the relationship between each mental health symptom assessed by the Clinical Interview Schedule-Revised (CIS-R) questionnaire and headache subtypes (migraine and TTH) according to international criteria. It was performed binary logistic regression models, with estimated odds ratios (OR) with their respective 95% confidence intervals (CI) adjusted for confounders including migraine attack frequency.

RESULTS

Among 13,916 participants, 70.1% reported any major primary headache subtype within the last year. The most common subtype was definite TTH (33.4%), followed by probable migraine (21.0%), definite migraine (8.5%), and probable TTH (7.2%). Our main findings indicated positive associations between anxiety-related symptoms and the migraine-tension type headache (TTH) spectrum with a clear trend toward definite migraine more than tension-type headache. The presence of somatic symptoms presented a high likelihood for the associations with headaches, mainly definite migraine (OR: 7.9, 95% CI: 6.4-9.8), probable migraine (OR: 4.5, 95% CI 3.7-5.4) and probable TTH (OR: 3.0, 95% CI: 2.3-3.8). Other symptoms associated with headache disorders included fatigue, panic, irritability, anxiety symptoms, concentration problems, forgetfulness, depressive symptoms, and worry. The effect of associations remained significant after controlling for headache attack frequency.

CONCLUSION

This study provides evidence of consistent associations between mental health symptoms and primary headache disorders, with a higher burden of anxiety-based symptoms observed in people with migraine than those with TTH.

Pediatric Migraine and Visual Cortical Excitability: A Prospective Observational Study with Sound-Induced Flash Illusions

The pathophysiological mechanisms underlying migraine are more difficult to investigate in children than in the adult population. Abnormal cortical excitability turns out to be one of the most peculiar aspects of migraine, accounting for the manifestations of migraine attacks. Recently, visual cortical excitability has been explored effectively in adult migraineurs with a technique based on cross-modal audio-visual illusions (with sound-induced flash illusions (SIFIs) being reduced in migraineurs compared to non-migraineur subjects). On such a basis, in this study, we investigated visual cortical excitability in children with migraine using SIFIs using combinations of visual and sound stimuli presented randomly. We evaluated 26 children with migraine without aura and 16 healthy children. Migraineurs did not differ from the age-matched healthy subjects regarding fission or fusion illusions but perceived more flashes in trials of multiple flashes with or without beeps. The higher number of SIFIs in migraineur children compared to adults may be due to a greater propensity of visual stimulation to be driven by auditory stimuli (i.e., acoustic dominance). The increased ability to perceive flashes reveals a hyperfunctional visual cortex, demonstrating that the use of SIFIs is a valid tool for assessing visual cortical responsiveness even in pediatric migraine.

Effects of Dry Needling on Active Myofascial Trigger Points and Pain Intensity in Tension-Type Headache: A Randomized Controlled Study

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.

Cervical impairments in subjects with migraine or tension type headache: an observational study

Objective

The aim of this investigation was to compare the thickness of the deep local muscles in the neck region, as well as local and widespread sensitivity and functionality, between individuals with migraine, Tension-Type Headache (TTH), and healthy controls. To date, we know that the onset of migraine and TTH share similar pathophysiological pathways. Nevertheless, there may be some anatomical and functional differences which would explain why clinicians may obtain variable results when treating both pathological entities with similar or equal approaches.

Methods

An observational study was conducted in accordance with STROBE guidelines. The flexor longus colli and multifidus, two neck-stabilizing muscles, were measured using B-mode ultrasound imaging. The upper trapezius, masseter, temporalis, tibialis anterior, and median nerve all underwent bilateral pressure-pain threshold (PPT) assessments.

Results

Ninety participants were enrolled in the study. All subjects were equally divided into TTH, migraine and control groups. The PPT values exhibited lower thresholds in patients with TTH than both migraine and healthy participants. Specifically, in the temporal muscle on both sides, patients with TTH exhibited a significantly lower threshold (p < 0.001)than both migraine and healthy participants. Patients with TTH displayed significantly lower thresholds in both upper trapezius muscles (right: p < 0.001; left: p = 0.001). Similar results were obtained for the tibialis anterior PPTs from both sides (p = 0.001 in both). However, both clinical groups exhibited lower thresholds than the healthy subjects (p < 0.001). In multifidus muscle cross-sectional area (CSA), no statistically significant differences were found between migraine patients and healthy subjects, both in relaxation and contraction (right; p > 0.05 and p > 0.05; left: p > 0.05 and p > 0.05). However, patients with TTH exhibited a smaller CSA than both migraine patients and healthy controls in multifidus relaxed and contracted state (right: p < 0.001 in both relaxed and contracted multifidus; left: p = 0.001 and p < 0.001, respectively). Similar results were obtained for the left longus colli muscle in both relaxation and contraction for patients with TTH and migraine compared with healthy subjects (p = 0.001 and p < 0.001, respectively, for muscle relaxation and p < 0.001 for muscle contraction). However, no significant differences were observed between patients with TTH and migraine (p < 0.05 in both relaxation and contraction). In the right longus colli, TTH and migraine patients had a significantly smaller CSA during contraction than healthy subjects (p < 0.001 in both comparisons). In the craniocervical flexion test, both groups of patients with TTH and migraine showed significantly lower values than healthy subjects (p < 0.001 in both comparisons). However, no significant differences were found between patients with TTH and migraineurs (p > 0.05).

Conclusion

The findings provide a significant message for clinicians since anatomical and functional impairments were shown in patients with TTH and migraine. This study corroborates a lack of strength and smaller CSA in both clinical groups compared to controls. Therefore, strengthening programs may be addressed successfully for people with these pathological entities. To be more accurate, according to PPTs and CSA lower values in patients with TTH compared to migraine and controls, manual therapy approaches to desensitize craniocervical soft tissues and exercise therapy to increase endurance of deep cervical muscles may become meaningful especially in subjects with TTH. Nevertheless, in order to distinguish precisely between patients with TTH and migraine, different diagnostic strategies may be used in the future to describe these populations in further detail, which will assist health professionals in a more accurate treatment selection.

Headache-related clinical features in teleworkers and their association with coping strategies during the COVID-19 pandemic

Objectives

The objectives were (1) to describe and compare headache-related clinical features between teleworkers with migraine and those with tension-type headache (TTH) and (2) to determine the association between coping strategies and headache frequency, and intensity in the context of the COVID-19 pandemic.

Methods

This cross-sectional online survey was conducted with 284 teleworkers (127 with migraine and 157 with TTH). Sociodemographic data, information related to work factors, headache clinical features, coping strategies used during the COVID-19 pandemic, and headache-related clinical features were compared between headache profiles. Bivariate logistic regression analyses were used to determine the association between coping strategies and headache frequency, and intensity.

Results

Results showed that teleworkers with migraine had longer and more painful headache episodes than teleworkers with TTH (ps < 0.001). Higher migraine frequency was associated with the use of the denial coping strategy (p = 0.006) while lower migraine intensity was associated with planning (p = 0.046) and the use of positive reframing (p = 0.025). Higher TTH frequency was associated with the use of venting, self-blame, and behavioral disengagement (ps < 0.007) while higher TTH intensity was associated with substance use and behavioral disengagement (ps < 0.030). All associations remained significant after adjusting for BMI as a covariate.

Discussion/conclusion

Teleworkers with migraine had more intense and longer headache episodes than teleworkers with TTH. This could be explained by the fact that a greater proportion of individuals suffering from migraine experienced headaches prior to the beginning of the pandemic compared with teleworkers suffering from TTH. Regarding coping strategies, both primary headache profiles were associated with different types of coping strategies. Most of the coping strategies associated with headache frequency or intensity were maladaptive except for planning and positive reframing that were found to be inversely associated with migraine intensity.

The Effect of OnabotulinumtoxinA on Headache Intensity and Number of Monthly Headache Days in Individuals with Chronic Migraine with Different Levels of Neck Disability

One of the treatment methods used in chronic migraine is OnabotulinumtoxinA. The effects of OnabotulinumtoxinA on headache intensity (HI) and number of monthly headache days (NMHD) in chronic migraine (CM) patients classified according to neck disability levels are unknown. Our aim was to investigate the effect of OnabotulinumtoxinA on the HI and the NMHD in individuals with CM with different levels of neck disability. One hundred sixteen patients were enrolled in the study. The OnabotulinumtoxinA protocol was administered as per Follow-the-Pain PREEMPT. The Neck Disability Index was used to evaluate neck disability. Primary outcome measures were headache intensity, assessed with the Visual Analogue Scale, and the number of monthly headache days recorded from patients' diaries. Secondary outcome measures were migraine disability, assessed with the Migraine Disability Assessment Test, and quality-of-life, assessed with the Headache Impact Test-6. All assessments were made at baseline and end of the treatment. The OnabotulinumtoxinA treatment showed a greater improvement effect in the number of monthly headache days (p = 0.000) and migraine disability (p = 0.000) parameters in the severe and complete disability groups. CM patients with complete and severe neck disability received the most benefit in reducing the NMHD at 3 months after OnabotulinumtoxinA treatment, but the HI decreased at a similar level in all neck disability groups.