Primary headache epidemiology in children and adolescents: a systematic review and meta-analysis

INTRODUCTION

Headache is the most prevalent neurological manifestation in adults and one of the leading causes of disability worldwide. In children and adolescents, headaches are arguably responsible for a remarkable impact on physical and psychological issues, yet high-quality evidence is scarce.

MATERIAL AND METHODS

We searched cross-sectional and cohort studies in Embase, Medline, Web of Science, and Cochrane databases from January 1988 to June 2022 to identify the prevalence of headaches in 8-18 years old individuals. The risk of bias was examined with the Joanna Briggs Institute (JBI) scale. A random-effects model was used to estimate the pooled prevalence of pediatric headache. Subgroup analyses based on headache subtypes were also conducted.

RESULTS

Out of 5,486 papers retrieved electronically, we identified 48 studies that fulfilled our inclusion criteria. The pooled prevalence of primary headaches was 11% for migraine overall [95%CI: 9-14%], 8% for migraine without aura (MwoA) [95%CI: 5-12%], 3% for migraine with aura (MwA) [95%CI:2-4%] and 17% for tension-type headache (TTH) [95% CI: 12-23%]. The pooled prevalence of overall primary headache in children and adolescents was 62% [95% CI: 53-70%], with prevalence in females and males of 38% [95% CI: 16-66%] and 27% [95% CI: 11-53%] respectively. After the removal of studies ranked as low-quality according to the JBI scale, prevalence rates were not substantially different. Epidemiological data on less common primary headaches, such as trigeminal autonomic cephalalgias, were lacking.

CONCLUSION

We found an overall remarkably high prevalence of primary headaches in children and adolescents, even if flawed by a high degree of heterogeneity. Further up-to-date studies are warranted to complete the picture of pediatric headache-related burden to enhance specific public interventions.

Genetics of migraine: where are we now?

Migraine is a complex brain disorder explained by the interaction of genetic and environmental factors. In monogenic migraines, including familial hemiplegic migraine and migraine with aura associated with hereditary small-vessel disorders, the identified genes code for proteins expressed in neurons, glial cells, or vessels, all of which increase susceptibility to cortical spreading depression. The study of monogenic migraines has shown that the neurovascular unit plays a prominent role in migraine. Genome-wide association studies have identified numerous susceptibility variants that each result in only a small increase in overall migraine risk. The more than 180 known variants belong to several complex networks of "pro-migraine" molecular abnormalities, which are mainly neuronal or vascular. Genetics has also highlighted the importance of shared genetic factors between migraine and its major co-morbidities, including depression and high blood pressure. Further studies are still needed to map all of the susceptibility loci for migraine and then to understand how these genomic variants lead to migraine cell phenotypes.

Hallmarks of primary headache: part 1 - migraine

BACKGROUND AND AIM

Migraine is a common disabling conditions which, globally, affects 15.2% of the population. It is the second cause of health loss in terms of years lived with disability, the first among women. Despite being so common, it is poorly recognised and too often undertreated. Specialty centres and neurologists with specific expertise on headache disorders have the knowledge to provide specific care: however, those who do not regularly treat patients with migraine will benefit from a synopsis on the most relevant and updated information about this condition. This paper presents a comprehensive view on the hallmarks of migraine, from genetics and diagnostic markers, up to treatments and societal impact, and reports the elements that identify migraine specific features.

MAIN RESULTS

The most relevant hallmark of migraine is that it has common and individual features together. Besides the known clinical manifestations, migraine presentation is heterogeneous with regard to frequency of attacks, presence of aura, response to therapy, associated comorbidities or other symptoms, which likely reflect migraine heterogeneous genetic and molecular basis. The amount of therapies for acute and for prophylactic treatment is really wide, and one of the difficulties is with finding the best treatment for the single patient. In addition to this, patients carry out different daily life activities, and might show lifestyle habits which are not entirely adequate to manage migraine day by day. Education will be more and more important as a strategy of brain health promotion, because this will enable reducing the amount of subjects needing specialty care, thus leaving it to those who require it in reason of refractory condition or presence of comorbidities.

CONCLUSIONS

Recognizing the hallmarks of migraine and the features of single patients enables prescribing specific pharmacological and non-pharmacological treatments. Medical research on headaches today particularly suffers from the syndrome of single-disease approach, but it is important to have a cross-sectional and joint vision with other close specialties, in order to treat our patients with a comprehensive approach that a heterogeneous condition like migraine requires.

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

Tension-type headache (TTH) and migraine are two common primary headaches distinguished by clinical characteristics according to the 3^rd edition of the International Classification of Headache Disorders. Migraine is identified by specific features such as being more prevalent in females, being aggravated by physical activity, certain genetic factors, having photophobia, phonophobia, nausea, vomiting, or aura, and responding to specific drugs. Nonetheless, TTH and migraine share some common characteristics, such as onset occurring in the 20 s, and being triggered by psychological factors like stress, moderate pain severity, and mild nausea in chronic TTH. Both conditions involve the trigeminovascular system in their pathophysiology. However, distinguishing between TTH and migraine in clinical practice, research, and epidemiological studies can be challenging, as there is a lack of specific diagnostic tests and biomarkers. Moreover, both conditions may coexist, further complicating the diagnostic process. This review aims to explore the similarities and differences in the pathophysiology, epidemiology, burden and disability, comorbidities, and responses to pharmacological and non-pharmacological treatments of TTH and migraine. The review also discusses future research directions to address the diagnostic challenges and improve the understanding and management of these conditions.

Health equity, care access and quality in headache - part 2

BACKGROUND

Headache disorders are a global public health concern affecting diverse populations. This review examines headache service organizations in low-, middle-, and high-income countries. It addresses global challenges in pharmacological headache treatment, with a focus on safety, tolerability, reproductive and child health, and outlines disparities in accessing innovative treatments worldwide.

MAIN BODY

Organized headache services are essential due to the wide prevalence and varying severity of headache disorders. The tiered headache service model is globally recognized, although its implementation varies based on financial and workforce considerations. Headache burden affects well-being, causing disability, economic challenges, and work limitations, irrespective of location or income. All nations still require improved diagnosis and treatment, and the majority of countries face obstacles including limited access, awareness, economic barriers, and inadequate health policies. Provided adequate internet availability, telemedicine could help improve health equity by expanding access to headache care, since it can offer patients access to services without lengthy waiting times or extensive travel and can provide healthcare unavailable in underserved areas due to staff shortages. Numerous health disparities restrict global access to many headache medications, especially impacting individuals historically excluded from randomized controlled trials, such as those with cardiovascular and cerebrovascular conditions, as well as pregnant women. Furthermore, despite advancements in researching migraine treatments for young patients, the options for treatment remain limited. Access to headache treatment relies on factors like medication availability, approval, financial coverage, and healthcare provider expertise. Inadequate public awareness leads to neglect by policymakers and undertreatment by patients and healthcare providers. Global access discrepancies are exacerbated by the introduction of novel disease-specific medications, particularly impacting Asian, African, and Latin American nations excluded from clinical trials. While North America and Europe experience broad availability of migraine treatments, the majority of countries worldwide lack access to these therapies.

CONCLUSIONS

Healthcare disparities, treatment access, and medication availability are concerning issues in headache medicine. Variations in national healthcare systems impact headache management, and costly innovative drugs are widening these gaps. Healthcare practitioners and experts should acknowledge these challenges and work towards minimizing access barriers for equitable global headache care in the future.

Future targets for migraine treatment beyond CGRP

BACKGROUND

Migraine is a disabling and chronic neurovascular headache disorder. Trigeminal vascular activation and release of calcitonin gene-related peptide (CGRP) play a pivotal role in the pathogenesis of migraine. This knowledge has led to the development of CGRP(-receptor) therapies. Yet, a substantial proportion of patients do not respond to these treatments. Therefore, alternative targets for future therapies are warranted. The current narrative review provides a comprehensive overview of the pathophysiological role of these possible non-CGRP targets in migraine.

FINDINGS

We covered targets of the metabotropic receptors (pituitary adenylate cyclase-activating polypeptide (PACAP), vasoactive intestinal peptide (VIP), amylin, and adrenomedullin), intracellular targets (nitric oxide (NO), phosphodiesterase-3 (PDE3) and -5 (PDE5)), and ion channels (potassium, calcium, transient receptor potential (TRP), and acid-sensing ion channels (ASIC)). The majority of non-CGRP targets were able to induce migraine-like attacks, except for (i) calcium channels, as it is not yet possible to directly target channels to elucidate their precise involvement in migraine; (ii) TRP channels, activation of which can induce non-migraine headache; and (iii) ASICs, as their potential in inducing migraine attacks has not been investigated thus far. Drugs that target its receptors exist for PACAP, NO, and the potassium, TRP, and ASIC channels. No selective drugs exist for the other targets, however, some existing (migraine) treatments appear to indirectly antagonize responses to amylin, adrenomedullin, and calcium channels. Drugs against PACAP, NO, potassium channels, TRP channels, and only a PAC₁ antibody have been tested for migraine treatment, albeit with ambiguous results.

CONCLUSION

While current research on these non-CGRP drug targets has not yet led to the development of efficacious therapies, human provocation studies using these targets have provided valuable insight into underlying mechanisms of migraine headaches and auras. Further studies are needed on these alternative therapies in non-responders of CGRP(-receptor) targeted therapies with the ultimate aim to pave the way towards a headache-free future for all migraine patients.

Prolactin and oxytocin: potential targets for migraine treatment

Migraine is a severe neurovascular disorder of which the pathophysiology is not yet fully understood. Besides the role of inflammatory mediators that interact with the trigeminovascular system, cyclic fluctuations in sex steroid hormones are involved in the sex dimorphism of migraine attacks. In addition, the pituitary-derived hormone prolactin and the hypothalamic neuropeptide oxytocin have been reported to play a modulating role in migraine and contribute to its sex-dependent differences. The current narrative review explores the relationship between these two hormones and the pathophysiology of migraine. We describe the physiological role of prolactin and oxytocin, its relationship to migraine and pain, and potential therapies targeting these hormones or their receptors.In summary, oxytocin and prolactin are involved in nociception in opposite ways. Both operate at peripheral and central levels, however, prolactin has a pronociceptive effect, while oxytocin appears to have an antinociceptive effect. Therefore, migraine treatment targeting prolactin should aim to block its effects using prolactin receptor antagonists or monoclonal antibodies specifically acting at migraine-pain related structures. This action should be local in order to avoid a decrease in prolactin levels throughout the body and associated adverse effects. In contrast, treatment targeting oxytocin should enhance its signalling and antinociceptive effects, for example using intranasal administration of oxytocin, or possibly other oxytocin receptor agonists. Interestingly, the prolactin receptor and oxytocin receptor are co-localized with estrogen receptors as well as calcitonin gene-related peptide and its receptor, providing a positive perspective on the possibilities for an adequate pharmacological treatment of these nociceptive pathways. Nevertheless, many questions remain to be answered. More particularly, there is insufficient data on the role of sex hormones in men and the correct dosing according to sex differences, hormonal changes and comorbidities. The above remains a major challenge for future development.

The sense of stopping migraine prophylaxis

INTRODUCTION

Migraine prophylactic therapy has changed over recent years with the development and approval of monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway. As new therapies emerged, leading headache societies have been providing guidelines on the initiation and escalation of such therapies. However, there is a lack of robust evidence looking at the duration of successful prophylaxis and the effects of therapy discontinuation. In this narrative review we explore both the biological and clinical rationale for prophylactic therapy discontinuation to provide a basis for clinical decision-making.

METHODS

Three different literature search strategies were conducted for this narrative review. These include i) stopping rules in comorbidities of migraine in which overlapping preventives are prescribed, notably depression and epilepsy; ii) stopping rules of oral treatment and botox; iii) stopping rules of antibodies targeting the CGRP (receptor). Keywords were utilized in the following databases: Embase, Medline ALL, Web of Science Core collection, Cochran Central Register of Controlled Trials, and Google Scholar.

DISCUSSION

Reasons to guide decision-making in stopping prophylactic migraine therapies include adverse events, efficacy failure, drug holiday following long-term administration, and patient-specific reasons. Certain guidelines contain both positive and negative stopping rules. Following withdrawal of migraine prophylaxis, migraine burden may return to pre-treatment level, remain unchanged, or lie somewhere in-between. The current suggestion to discontinue CGRP(-receptor) targeted mAbs after 6 to 12 months is based on expert opinion, as opposed to robust scientific evidence. Current guidelines advise the clinician to assess the success of CGRP(-receptor) targeted mAbs after three months. Based on excellent tolerability data and the absence of scientific data, we propose if no other reasons apply, to stop the use of mAbs when the number of migraine days decreases to four or fewer migraine days per month. There is a higher likelihood of developing side effects with oral migraine preventatives, and so we suggest stopping these drugs according to the national guidelines if they are well tolerated.

CONCLUSION

Translational and basic studies are warranted to investigate the long-term effects of a preventive drug after its discontinuation, starting from what is known about the biology of migraine. In addition, observational studies and, eventually, clinical trials focusing on the effect of discontinuation of migraine prophylactic therapies, are essential to substantiate evidence-based recommendations on stopping rules for both oral preventives and CGRP(-receptor) targeted therapies in migraine.

Moderate disability has negative effect on spatiotemporal parameters in patients with chronic low back pain

BACKGROUND

It is known that the patients with chronic low back pain (CLBP) has different spatiotemporal characteristics than healthy controls such as average speed, cadence, step and stride length parameters. CLBP is a heterogeneous phenomenon in terms of causing various level of disability.

RESEARCH QUESTION

Does disability levels make a difference on spatiotemporal characteristics of patients with CLBP?

METHODS

66 patients with CLBP and 32 healthy controls between the ages of 25 and 65 years participated to study. The patients who had neurological, orthopedic, cardiovascular, metastatic history excluded from study. Resting, activity and night pain and functional disability were evaluated with Visual Analog Scale (VAS), Oswestry Disability Index (ODI) respectively. The patients were divided into two groups according to their disability level: moderate and severe. Gait analyses were performed with Optogait treadmill-based photocell system (Version 1.6.4.0, Microgate, Bolzano, Italy). After two trials were done, the spatiotemporal characteristics recorded for one minute while patients walked their preferred speed on the treadmill. One-way ANOVA was used to compare these parameters among the perceived disability level (moderate, severe) and healthy controls.The level of significance was accepted as 0.05.

RESULTS

Step length, stride length, and preferred walking speed were the parameters that differentiate the gait between healthy controls and patients with CLBP (p < 0.05). According to post-hoc analyses, moderate CLBP was identified as the group most different from the healthy controls (p < 0.05).

SIGNIFICANCE

Results of this study describe how compensating mechanism were seen in CLBP subgroups. As opposed to expectations, an increase in disability would not create higher difference in spatiotemporal characteristics between healthy controls and patients with severe disability. We propose that patients with severe and moderate disability had different ways to normalize their gait.

Effects of spinal stabilization exercises delivered using telerehabilitation on outcomes in patients with chronic neck pain: a randomized controlled trial

BACKGROUND

When spinal stabilization exercises (SSE) are performed regularly, may provide benefits on outcome measures in chronic nonspecific neck pain (CNNP) patients. The pandemic has made it difficult for CNNP patients to access regular physiotherapy-exercise services. This study aims to compare telerehabilitation (TR) with face-to-face rehabilitation in CNNP.

METHODS

Neck Functional Capacity Evaluation Test (NFCET) results were the primary outcomes. Pain intensity (PI), disability, awareness, neck muscles architecture, andexercise satisfaction were the secondary outcomes. Patients were randomized into the TR group (TRG) (n = 15) and the control group (CG) (n = 16). Patients performed SSE 3 days a week, for 8 weeks. The TRG was instructed remotely while the CG was instructed in the clinic.

RESULTS

After 8 weeks in both groups, NFCET values and neck awareness increased (p < 0.05), PI and disability decreased (p < 0.05).      Muscle architecture improved in both groups (p < 0.05), except for the Right Sternocleidomastoideus in both groups and the Right Upper-Trapezius in TRG (p > 0.05). There was no difference between the groups for all variables and exercise satisfaction(p > 0.05).

CONCLUSION

SSE for CNNP, whether supervised by therapists in the clinic or by telerehabilitation, was equally effective.

THE CLINICAL TRIAL NUMBER

NCT04691024.

Influence of next-generation artificial intelligence on headache research, diagnosis and treatment: the junior editorial board members' vision - part 1

Artificial intelligence (AI) is revolutionizing the field of biomedical research and treatment, leveraging machine learning (ML) and advanced algorithms to analyze extensive health and medical data more efficiently. In headache disorders, particularly migraine, AI has shown promising potential in various applications, such as understanding disease mechanisms and predicting patient responses to therapies. Implementing next-generation AI in headache research and treatment could transform the field by providing precision treatments and augmenting clinical practice, thereby improving patient and public health outcomes and reducing clinician workload. AI-powered tools, such as large language models, could facilitate automated clinical notes and faster identification of effective drug combinations in headache patients, reducing cognitive burdens and physician burnout. AI diagnostic models also could enhance diagnostic accuracy for non-headache specialists, making headache management more accessible in general medical practice. Furthermore, virtual health assistants, digital applications, and wearable devices are pivotal in migraine management, enabling symptom tracking, trigger identification, and preventive measures. AI tools also could offer stress management and pain relief solutions to headache patients through digital applications. However, considerations such as technology literacy, compatibility, privacy, and regulatory standards must be adequately addressed. Overall, AI-driven advancements in headache management hold significant potential for enhancing patient care, clinical practice and research, which should encourage the headache community to adopt AI innovations.

Investigating the Relationship between Body Mass Index and Pain in the Spine in Children or Adolescents: A Systematic Review

Background: Neck pain (NP), back pain (BP), and low back pain (LBP) are generally defined as "pain in the spine." With the increasing prevalence of childhood obesity, secondary problems such as pain in the spine have arisen. The purpose of this review was to investigate the relationship between body mass index (BMI) and pain in the spine in children or adolescents. Methods: Publications were searched in PubMed, Web of Science, Scopus, and Google Scholar databases up to December 12, 2020. The search strategy in the database consisted of free text words and MeSH terms. Results: Twelve studies were reviewed. It was determined that different methods were used in all 12 studies to evaluate pain. In the evaluation of overweight/obesity, these studies performed BMI assessment by dividing body weight in kilograms by height squared. Five studies showed a relationship between LBP and BMI, two studies showed a relationship between BP and BMI, and two studies showed a relationship between NP and BMI. Conclusions: The review shows that there is a relationship between BMI and pain in the spine, especially LBP. There may be factors affecting this condition such as mechanical loading and hormonal metabolic activity in childhood and adolescence. Different methods are used in the studies in literature for the assessment pain in the spine and BMI, overweight, and obesity.

Emerging experimental drugs in clinical trials for migraine: observations and key talking points

INTRODUCTION

There have been significant advances in the treatment of migraine. In response to the clinical success of monoclonal antibodies targeting calcitonin gene-related peptide, there is interest in the clinical trial outcomes of alternative emerging drugs that act on novel targets associated with migraine pathophysiology. As approximately 50% of patients do not respond to CGRP therapies, there is significant value in future drug innovation. Emerging drugs in clinical trials for the treatment of migraine aim to fill this need.

AREAS COVERED

The emerging drugs that will be discussed in this review include zavegepant, lasmiditan, delta opioid receptor agonists, neuronal nitric oxide synthase inhibitors, monoclonal antibodies targeting pituitary adenylate cyclase-activating polypeptide (PACAP) and its receptor, dual orexin receptor antagonists, metabotropic glutamate receptor 5 antagonists, and inducers of ketosis.

EXPERT OPINION

When considering the preclinical and clinical research related to the emerging drug classes discussed in this review, most therapies are derived from highly supported targets of migraine pathogenesis. Although the individual drugs discussed in this review may be of dubious clinical value, the importance of the therapeutic targets on which they act cannot be understated. Future research is necessary to appropriately target the pathways elucidated by preclinical studies.

New Migraine Drugs for Older Adults

Migraine is one of the most widespread and burdensome diseases, affecting one in every seven individuals in the world, for an estimated global prevalence of 14%. Until recently, therapeutic choices for older migraineurs have been limited by safety concerns and such patients have typically been excluded from clinical trials. However, randomized controlled trials (RCTs) of new migraine drugs have begun to include participants aged over 65 years, offering clinicians relevant safety and efficacy data to be able to treat older patients with the newest drug classes, including monoclonal antibodies for CGRP (r), CGRP antagonists, and drugs targeting the serotonin 5-HT_1F receptor. RCT inclusion criteria nonetheless select the most appropriate older patients, usually excluding polymorbid participants. In a real-life setting, older patients may have several comorbidities, and this reduces the clinical applicability of the new drugs to these patients. Two main points should be addressed to solve this barrier: the inclusion of a sufficient number of migraineurs aged over 65 years in RCTs and the publication of appropriate guidelines for a tailored treatment that considers the existence of multimorbid pathologies in this population of individuals.

Does the Intensity of the Headache Differ According to the Level of Neck Disability in Chronic Migraine Patients?

Chronic migraine (CM) patients who report a high frequency and intensity of headaches also report neck pain (NP) and neck disability (ND) in neck activities that require stability. In this context, CM patients may report different headache intensities at different levels of ND. Our aim in this study is to investigate whether the intensity of headaches differs according to the level of ND in CM patients. Headache intensity and NP intensity were evaluated with the Visual Analog Scale (VAS), and ND was evaluated with the Neck Disability Index (NDI). A total of 142 patients who met the inclusion criteria were included in the study. The mean age was 53.24 ± 12.08 years. The median number of monthly headache days was 20. According to VAS, the median headache intensity was 10(4-10) cm and the median of NP intensity was 9(1-10) cm. The mean NDI was 28.45 ± 10.28. There was a difference in headache intensity between mild and severe disability levels (p = 0.007, Z = -3.289); headache intensity between mild and complete disability levels (p = 0.000, Z = -4.421); and headache intensity between moderate and complete disability levels (p = 0.004, Z = -2.212). Although the difference in headache intensity between ND levels is small, a median increase of 2 cm in headache intensity at mild ND levels may result in complete ND. A median increase of 1 cm in headache intensity at the moderate ND level may cause complete disability in the neck. According to our results, the intensity of headaches of CM patients differed according to the level of ND. We consider our results to be clinically important in this context.

OnabotulinumtoxinA Treatment in Chronic Migraine: Investigation of Its Effects on Disability, Headache and Neck Pain Intensity

Neck disability and pain are frequently encountered problems in patients with chronic migraine (CM). The long-term stimuli of neurons in the trigeminocervical junction may explain this situation. OnabotulinumtoxinA (ONA) treatment is one of the proven treatments for CM; however, there is no study data on the efficacy of ONA treatment on neck disability and pain in CM patients. Therefore, we aimed to investigate the effect of ONA treatment on disability, neck pain and headache intensity in CM patients. One hundred thirty-four patients who met the inclusion criteria were included in the study. ONA treatment was administered at a dose of 195 U to 39 sites in total as per Follow-the-Pain PREEMPT protocol. The disability was evaluated with the Neck Disability Index and the Migraine Disability Assessment; pain intensity was evaluated with the Visual Analogue Scale; the monthly number of headache days were recorded; quality of life was evaluated with the Headache Impact Test. All assessments were recorded at baseline and 3 months after treatment. After the treatment, neck−migraine disabilities decreased from severe to mild for neck and moderate for migraine (p < 0.001). Neck pain and headache intensities decreased by almost half (p < 0.001). The median number of monthly headache days decreased from 20 days to 6 days (p < 0.000). The quality-of-life level decreased significantly from severe to substantial level (p < 0.001). According to our results, ONA treatment was effective in reducing neck-related problems in CM patients. Long-term follow-up results may provide researchers with more comprehensive results in terms of the treatment of chronic migraine−neck-related problems.

Psychometric properties of the headache needs assessment (HANA) survey in tension type headache: Turkish version, reliability, and validity study

BACKGROUND

Scales and questionnaires measure various variables, such as health symptoms, functionality, and quality of life. The Headache Needs Assessment (HANA) survey evaluates the chronic impact of migraine on quality of life, focusing on frequency and bothersomeness.

OBJECTIVE

This study aimed to adapt and validate the Turkish version of the HANA, a concise and practical tool for assessing tension-type headache-related needs.

METHODS

A total of 86 individuals with tension-type headaches were included in the test phase, while 79 participants with tension-type headaches were involved in the retest phase. Exploratory and Confirmatory Factor Analyses (EFA and CFA) were used to assess structural validity. Reliability was evaluated using Intraclass Correlation Coefficients (ICC) and Cronbach's α, and convergent validity was tested by correlating HANA scores with the Henry Ford Hospital Headache Disability Inventory (HDI) and Headache Impact Test-6 (HIT-6).

RESULTS

Test-retest reliability was strong (ICC 0.789-0.840), and internal consistency was high (α = 0.882-0.913). Good correlations with HDI (r = 0.545; p = 0.000) and HIT-6 (r = 0.484; p = 0.000) supported convergent validity, while it was observed a low correlation with Visual Analog Scale (r = 0.342; p = 0.001). There were no floor or ceiling effects observed.

CONCLUSION

The Turkish version of the HANA is a valid and reliable tool in individuals with tension-type headache that is easy to administer in both clinical and research contexts.

CLINICALTRIALS

GOV NUMBER

NCT06675292.

Onabotulinumtoxin A for the Treatment of Post-Traumatic Headache: Is It Better than Anti-CGRP Antibodies?

Post-traumatic headache (PTH) is a common and debilitating consequence of traumatic brain injury (TBI), often resembling migraine and tension-type headaches. Despite its prevalence, the optimal treatment for PTH remains unclear, with current strategies largely extrapolated from other headache disorders. This review evaluates the use of onabotulinumtoxin A (ONA) and anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) in the treatment of PTH. A comprehensive literature search was conducted on PubMed, including studies published up to September 2024, focusing on the efficacy, safety, and mechanisms of onabotulinumtoxin A and anti-CGRP mAbs in PTH. Both clinical trials and observational studies were reviewed. ONA, widely recognized for its efficacy in chronic migraine, has shown limited benefits in PTH with only one trial involving abobotulinumtoxin A in a cohort of 40 subjects. A phase 2 trial with fremanezumab, an anti-CGRP monoclonal antibody, failed to demonstrate significant efficacy in PTH, raising questions about the utility of targeting CGRP in this condition. ONA may offer advantages over anti-CGRP mAbs, not only in terms of its broader mechanism of action but also in cost-effectiveness and higher patient adherence. Both ONA and anti-CGRP mAbs are potential options for the management of PTH, but the current evidence is insufficient to establish clear guidelines. The negative results from the fremanezumab trial suggest that CGRP inhibition may not be sufficient for treating PTH, whereas onabotulinumtoxin A's ability to target multiple pain pathways may make it a more promising candidate.

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.

POS0028 THE EFFECTS OF TELEREHABILITATION WITH REMOTELY SPINAL STABILIZATION EXERCISES ON CLINICAL VARIABLES, FUNCTIONAL ACTIVITIES, EXERCISE ADHERENCE AND MUSCLE ARCHITECTURE OF NECK MUSCLES IN INDIVIDUALS WITH CHRONIC NECK PAIN

Background

Doing a job with functional activity may aggravate chronic neck pain(CNP). Thickness, PCSA of the neck muscles can be improved with exercise. During the Covid-19 pandemic, people has caused an increase in home workload, the frequency of performing functional activities related to performance has increased. The distance between physiotherapists and the patient should be at least 2 meters in clinics due to the risk of transmission. As a result, the importance of telerehabilitation has increased.

Objectives

Our aim is to investigate the effect of remotely spinal stabilization exercises(SSE) with telerehabilitation on clinical variables, the functional activities, exercise adherence and muscle architecture patients with CNP.

Methods

The demographic characteristics were recorded. Pain intensity with Visual Analog Scale (VAS), disability level with Neck Disability Index (NDI), neck awareness with Fremantle Neck Awareness Questionnaire (FreNAQ), the functional capacity levels with neck function capacity evaluation test, the difficulty of functional activities with VAS were assessed. Muscle thickness of M. Sternocleideomastoideus, M. Upper Trapezius, PCSA of M. Longus Colli, M. Cervical Multifidus was evaluated in the resting with 3.5-10 MHz ultrasound. The exercise adherence with Exercise Adherence Rating Scale and exercise program satisfaction with VAS were evaluated. The telerehabilitation group (TG) used exercises videos and video conferences, control group (CG) did SSE in the clinic. To study the effects of the interventions, the outcome measures were compared time-by-group interaction effects, one the within-groups factor (time) and one the between-groups factor (group) by repeated-measures two-way ANOVA. The Mann Whitney-U test was performed to compare two groups for non-parametric data.

Results

Twenty-eight patients were randomly allocated to the TG and the CG. The VAS, NDI, FreNAQ, the functional capacity levels, muscle architecture showed similar changes over time in both groups. Results showed no significant time-by-group interaction effects of VAS, NDI, FreNAQ, the functional capacity levels, the difficulty of functional activities and muscle architecture (p>0.05); a significant effect for time in the VAS, NDI, FreNAQ, the functional capacity levels, the difficulty of functional activities and muscle architecture (p<0.001). There was no difference between the groups in terms of VAS, NDI, FreNAQ, the functional capacity levels, the difficulty of functional activities and muscle architecture. Results showed no significant effect for the group in the VAS, NDI, FreNAQ, the functional capacity levels, the difficulty of functional activities and muscle architecture (p>0.05). Both groups adapted well to the exercise program and were highly satisfied with the SSE (p<0.05).

Conclusion

The VAS, NDI, difficulty of functional activities decreased; FreNAQ, functional capacity levels, architecture of neck muscles increased in both groups after 8 weeks SSE. It was determined that telerehabilitation with remotely SSE was beneficial as face-to-face SSE.

References

[1]Kashfi P, Karimi N, Peolsson A, Rahnama L. The effects of deep neck muscle-specific training versus general exercises on deep neck muscle thickness, pain and disability in patients with chronic non-specific neck pain:protocol for a randomized clinical trial (RCT).BMC Musculoskelet Disord. 2019;20(1):540. doi:10.1186/s12891-019-2880-x.

[2]Amiri-Arimi S, Mohseni Bandpei MA, Rezasoltani A, Javanshir K, Biglarian A. Measurement of Cervical Multifidus and Longus Colli Muscle Dimensions in Patients With Cervical Radiculopathy and Healthy Controls Using Ultrasonography:A Reliability Study. PM R. 2019;11(3):236-242. doi:10.1016/j.pmrj.2018.07.014.

[3]Lee, A. 2020. “COVID-19 and the Advancement of Digital Physical Therapist Practice and Telehealth”.Physical Therapy. pzaa079, doi:10.1093/ptj/pzaa079.

Disclosure of Interests

None declared

Investigation of masticatory muscle thickness and mechanosensitivity of cervical and masticatory muscles in myofascial temporomandibular disorder patients with bruxism: A cross-sectional study

OBJECTIVE

Bruxism is a common problem associated with temporomandibular disorders (TMD). The aim of this study was to compare a patient group with Myofascial TMD and bruxism and a healthy control group in terms of masseter and temporal muscle thickness (clenching and resting), mechanosensitivity of neck and jaw muscles, craniofacial pain, and disability and emotional stress status.

METHODS

The study included 31 patients with myofascial TMD and bruxism (19 females, 12 males) with a mean age of 29.96 ± 8.12 years (range, 18-45 years), and a control group of 31 healthy subjects (19 females, 12 males) with a mean age of 27.58 ± 9.39 years years (range, 18-45 years). Masseter and temporal muscle thicknesses were evaluated with a mobile ultrasound device both at rest and when clenching the jaw. The mechanosensitivity values between the upper trapezius, obliquus capitis inferior, masseter and temporal muscles were measured with a digital algometer device. Craniofacial pain and disability level were evaluated with the Craniofacial Pain and Disability Index (CFPDI), and emotional stress levels with the Perceived Stress Scale-14 (PSS-14).

RESULTS

No difference was determined between the two groups in respect of the clenching and resting ratios of muscle thickness in any muscle (p > 0.05). The mechanosensitivity values in all muscles were lower in the myofascial TMD group than in the healthy group (p < 0.05). The CFPDI and PSS-14 scores were higher in the myofascial TMD group (p < 0.05). There was a moderate positive correlation between CFPDI, PSS-14 and Bruxism Frequency Score (p < 0.05).

CONCLUSION

The difference in mechanosensitivity and CFPDI values between the myofascial TMD patients with bruxism and the healthy control group indicates that the problem in this patient group has effects in the craniocervical and cervical regions. In addition, the correlation between CFPDI, PSS-14 and Bruxism Frequency Score in myofascial TMD patients suggests that this problem may be affected by the interaction of different parameters.

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.

Reaching the Nadir of Medication Overuse in Chronic Migraine

The introduction of new drug classes for chronic migraine, such as monoclonal antibodies for calcitonin-gene-related peptide or its receptor (CGRPr), or antagonists of the same CGRP, have opened a new scenario in a selected population of individuals with migraine, and those presenting with chronic form of migraine in association with medication overuse. Medication overuse is now considered a complication of chronic migraine and, in fact, the treatment with CGRP(r)-MAbs of chronic migraine with medication overuse results in a clinical improvement of chronic migraine itself, accompanied by a parallel and obvious reduction in the intake of specific and non-specific acute migraine drugs. Education on the correct use of these drugs will be an essential tool to reduce the disability and costs of people suffering from CM complicated by MO, considering the long-term safety of the new therapies targeting the CGRP pathways. Only in this way can medication overuse risk can be reduced at its nadir in the scenario of chronicity of migraines.

Body awareness and chronic low back pain: validity and reliability study of Turkish version of body awareness rating scale

Background/aim

Previous studies reported that patients with chronic low back pain (CLBP) had trouble describing senses or body functions. A questionnaire, the body awareness rating questionnaire (BARQ), was recently developed for assessing body awareness. The aim of the study was to develop a Turkish version of the BARQ and investigate the validity and reliability in patients with CLBP.

Materials and methods

BARQ translated to Turkish with forward-backward method. Ninety-nine patients with CLBP and 101 healthy controls (HC) completed the BARQ-T. Fifty-one of patients with CLBP and HC repeated BARQ-T 3 days later. In addition to BARQ-T, Oswestry disability index (ODI), pain severity, short form 36 (SF-36) and Toronto alexithymia scale (TAS) were administered.

Results

The current study found good-excellent Cronbach’s alpha values for patients with CLBP (α: between 0.883–0.967) and acceptable-good Cronbach’s alpha values for HC (α: between 0.649–0.825) in factors of BARQ-T. ICC values for test-retest validity were found to be good-excellent for patients with CLBP in all factors. BARQ-T was positively correlated with SF-36 and negatively correlated with ODI and TAS (P < 0.05).

Conclusion

The study confirmed that the BARQ-T has acceptable validation and reliability in terms of pain perception and pain assessment in the Turkish CLBP community.

The Efficacy of Physical Therapy and Rehabilitation Approaches in Chronic Migraine: A Systematic Review and Meta-Analysis

BACKGROUND

Pharmacological treatment is the primary approach in chronic migraine (CM), although non-drug interventions such as physical therapy are used as adjunct treatments. We aimed to review the efficacy of physical therapy and rehabilitation approaches for CM and their impact on quality of life (QoL) and disability.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and included randomized controlled trials (RCTs) in adults with CM. The primary outcomes were changes in intensity, frequency, duration of headache, disability, and QoL. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Data synthesis and quantitative analysis were conducted on relevant studies.

RESULTS

Seven RCTs were included in the narrative review, and five of them were eligible for quantitative analysis. Aerobic exercise (AE), osteopathic manipulative treatment (OMT), occipital transcutaneous electrical stimulation (OTES), acupressure, hydrotherapy, instrument-assisted soft tissue mobilization (IASTM), facial proprioceptive neuromuscular facilitation (FPNF), and connective tissue massage (CTM) were used in CM. AE combined with pharmacological therapy reduced the frequency, duration, and intensity of headache. OMT combined with medication improved QoL and reduced disability, intensity of pain, and migraine days per month. Hydrotherapy combined with medication also resulted in improvements in the intensity of headache, frequency, and overall QoL. IASTM and OTES reduced the intensity of headache, alleviated neck pain, and improved QoL, although there were conflicting findings following OTES alone on disability and intensity of headache. Both FPNF and CTM reduced the intensity of headache. Acupressure as an adjunct to medication did not show additional benefits on the intensity of headache and QoL. Quantitative analysis of the data showed that manual physical therapy combined with medication reduced the intensity of headache (p = 0.0796), and manual or AE combined with medication reduced the headache days per month (p = 0.047).

CONCLUSIONS

A limited number of RCTs investigating the efficacy of physical therapy and rehabilitation approaches show promise in improving headache symptoms, reducing disability, and enhancing QoL in CM. Meta-analysis of the data also supported favorable outcomes for both intensity and headache days per month. Further research is needed to better understand the efficacy, optimal duration, and safety of physical therapy and rehabilitation approaches for CM, and to explore alternative interventions.