Neck pain and associated head pain: persistent neck complaint with subsequent, transient, posterior headache

Background – During the Vågå headache epidemiology study, there were indications that various types of work, such as carpentry and hairdressing, frequently seemed to be linked to a combination of neckache and headache. Objectives – A post hoc study was conducted among 1838, 18‐ to 65‐year‐old Vågå citizens, looking for patients with combined neck/headache. Design – Face‐to‐face interview was conducted. Results – Combined neckache and headache were detected in 121 (6.6%) individuals. The bilateral headache originated in the neck; it was mild/moderate, symptom‐poor, and frequently provoked by awkward neck positions. No such headache occurred without a neckache. Headache in this group of patients resembles tractor drivers’ headache, except for the provoking factor itself. Conclusions – This headache is not listed in headache classification systems/textbooks on headache. This headache must be distinguished from the unilateral cervicogenic headache proper because of the different treatment perspectives.     

Whiplash: pathophysiology, diagnosis, treatment, and prognosis

We have reviewed the literature relevant to pathophysiology, diagnosis, treatment, and prognosis of whiplash-associated disorder (WAD) since 1995 and provided a brief summary of literature pertaining to forces action on the head and neck during a motor vehicle accident. The scope of the current review is confined to the Quebec guidelines for WAD grades 1-3 but excludes grade 4 (neck complaints and fracture or dislocation). After excluding papers without scientific data and single case reports or case series with fewer than 20 patients, articles were reviewed for methodological quality. The diagnosis remains clinical. No imaging, physiological, or psychological study provides specific diagnostic criteria. In the acute period up to 2 weeks, soft collars or rest and work-leave do not shorten the duration of neck pain. Sick leave is reduced by high-dose methylprednisolone given within 8 h of injury, but confirmatory studies examining the cost-benefit relationship are needed. In the first 6 months, active as opposed to passive treatment results in improved outcomes. Specific exercise strategies have not been studied. For those with symptoms lasting more than 6 months, percutaneous radio-frequency neurotomy can provide pain relief for many months in those responding to blind local anesthetic facet blocks. Intra-articular corticosteroids are ineffective. Uncontrolled trials suggest that multimodal rehabilitation programs result in improved overall function. The overall prognosis for recovery has varied considerably across studies. Such variability is likely due to differences in case identification methods and whether outcome is assessed in terms of symptoms or the receipt of financial compensation for injury. The impact on prognosis of both collision- and patient-related factors is also reviewed.     

A double-blind, randomized, placebo-controlled, single-dose study of the cyclooxygenase-2 inhibitor, GW406381, as a treatment for acute migraine

The objective of the present study was to explore the clinical efficacy and tolerability of GW406381, a cyclooxygenase-2 (COX-2) inhibitor with relatively high CNS penetration, in acute migraine. This was a double-blind, single-dose study of GW406381 compared with placebo and naproxen sodium compared with placebo (protocol number CXA20008). Three hundred and thirty-seven subjects were randomized 1:1:1 to GW406381 (70 mg), naproxen sodium (825 mg), or placebo for the treatment of one migraine headache of moderate or severe intensity in a potential 8-week period. The primary end-point was the proportion of subjects with headache relief [reduction in headache severity score from pre-dose 2 (moderate) or 3 (severe) to 0 (no pain) or 1 (mild)] at 2 h post-dose for GW406381 compared with placebo. Significantly higher proportions of subjects treated with GW406381 (50%, P  = 0.032) or naproxen sodium (56%, P  = 0.005) than with placebo (35%) reported headache relief at 2 h post-dose. Additional significant benefits were observed on many secondary outcomes, including proportions of subjects pain-free, for both GW406381 and naproxen sodium treatment compared with placebo. Both active treatments were well tolerated. Single-dose GW406381 (70 mg) and naproxen sodium (825 mg) were effective and well tolerated in the treatment of acute migraine.     

Determinants of disability in everyday activities differ in primary and cervicogenic headaches and in low back pain

The aim of this study was to test whether the association between disability and depressive symptoms in patients with cervicogenic headache is similar to that found in primary headaches or to the pattern found in low back pain. During a 2-year period, 716 consecutive patients with the clinical diagnosis of cervicogenic headache (n=182), low back pain (n=116), migraine (n=231), tension-type headache (n=176), and cluster headache (n=11) filled in the Beck Depression Inventory (BDI). Disability was scored by the migraine disability score questionnaire reflecting the number of days with lost or decreased work, household and social activities. Non-parametric tests and multiple general regression were used for statistical analysis. In multivariate testing, significant independent determinants of disability were pain frequency, pain intensity and the severity of depressive symptoms in migraine and tension-type headache; pain frequency and the BDI score in cervicogenic headache, and pain frequency alone in low back pain. Disability is related to pain frequency in all pain syndromes evaluated in the present study. The level of disability is associated with the severity of pain only in primary headaches, but not in pain syndromes of vertebral origin (cervicogenic headache and low back pain). Disability is associated with the severity of depressive symptoms in all headache types but not in low back pain. Both the location and the etiology of pain have importance in determining the interrelationship between pain characteristics, depression and disability.     

Prevalence of migraine, tension-type headache and trigeminal neuralgia in multiple sclerosis

Background:  Prevalence rates of headache in multiple sclerosis (MS) patients varied widely in recent studies. This study aimed to investigate the 1 year prevalence of headache in MS compared with the general population.
Methods:  Population-based case–control study in Germany.
Results:  We included 491 patients with definite MS (68% female, mean age 45.3 years, 63.7% relapsing remitting MS, mean Expanded Disability Status Scale (EDSS) 3.2, 106 treated with interferon-β, 53 with glatiramer acetate, 271 untreated) and 447 age and gender matched controls. Headache was diagnosed with a validated questionnaire according to the International Headache Society Criteria. Headache prevalence was 56.2% (tension type headache 37.2%, migraine 24.6%). Headache prevalence rates did not differ from controls. Headache was not associated with disability or treatment. Trigeminal neuralgia was found in 6.3% of MS cases.
Conclusion:  Results suggest that headache in MS patients reflects comorbidity in most conditions.     

Clinical trials of carbamazepine for autonomic seizures with and without generalized epileptic seizures

Carbamazepine (CBZ) was used for the treatment of 52 children of autonomic seizures with and without generalized epileptic seizures. Their ages ranged from 4 to 17 years. Their autonomic seizures were recurrent episodic headaches and/or abdominal pains. EEG abnormalities were found in all cases in this study. The abnormal EEG findings consisted of diffuse paroxysmal slow dysrhythmia, generalized spike and wave complexes, focal spike and wave complexes with diffuse slow wave bursts, spike and wave complexes with 14 and 6 Hz positive spikes of 14 and 6 Hz positive spikes. Of the 40 patients with autonomic seizures only, 36 (90%) showed disappearance of pain, and of the remaining 4, 2 showed moderate improvement and 2 showed no change as far as their clinical symptoms were concerned. Of the 12 patients with both autonomic seizures and generalized epileptic seizures, 10 (83%) became free from headache and 2 improved moderately. The efficacy of CBZ was found to be very satisfactory. The effective dosage of CBZ ranged from 3.9 to 11.4 mg/kg/day (total dose, 100 to 400 mg/day) with the mean value of 7.0 mg/kg/day.     

Long-term safety and tolerability of oxcarbazepine in painful diabetic neuropathy

BACKGROUND: Painful diabetic neuropathy is a common complication of diabetes and often resistant to treatment with standard analgesics. Treatment of diabetic neuropathy with antiepileptic drugs may provide pain relief. AIM: To evaluate the long-term safety and tolerability of oxcarbazepine in two studies investigating the treatment of diabetic neuropathy. OBJECTIVES: Patients with diabetes and a history of neuropathic pain were included. Study 1 was a multicenter, open-label study comprising a screening and 12-month treatment phase. Study 2 was a multicenter, open-label extension to a double-blind, randomized study. Oxcarbazepine was initiated at 300 mg/day and titrated over 4 weeks to tolerability or a maximum dose of 900 mg b.i.d. Safety was assessed by monitoring adverse events (AEs), serious AEs (SAEs), hematology, blood chemistry, urinalysis values, and vital signs. RESULTS: Adverse events were most frequently reported in the nervous and gastrointestinal systems; 20.5% and 21.6% of patients withdrew because of AEs in study 1 and study 2, respectively. SAEs were reported in 13.7% and 14.4% of patients in study 1 and study 2, respectively. CONCLUSIONS: Long-term treatment with oxcarbazepine is generally well tolerated in patients with painful diabetic neuropathy. Rapid titration of oxcarbazepine may be responsible for discontinuations resulting from AEs during early stages of treatment.     

Botulinum toxin type A injections for myofascial pain syndrome and tension-type headache

Myofascial pain syndrome (MPS) is characterised by acute and specific pain affecting the piriformis, iliopsoas or scalenus anterior muscles. Tension-type headache (TH) is a common pathological condition, which can be chronic or episodic. Based on its muscle-relaxant properties, botulinum toxin type A (BTX-A) has demonstrated efficacy in a variety of conditions involving dysregulated muscle contractions. Patients with MPS ( n = 40) or TH (n = 20) were recruited to two randomised, single-blind studies, respectively. Each patient received either BTX-A or methylprednisolone, injected into the affected muscles after administration of a local anaesthetic. Pain was assessed at baseline, and 30 and 60 days post-treatment using a standard visual analogue scale. At 30 days post-injection, the mean pain score in all treatment groups was reduced compared with baseline in both studies, although the difference between treatment groups was not significant at this time in either study. However, by 60 days post-injection, the mean pain score has continued to fall in the BTX-A treatment groups, compared with a waning of the steroid therapeutic activity in the controls. The net effect was a highly significant difference between the two treatments in both the MPS ( P < 0.0001) and TH ( P < 0.0005) studies. No major adverse events were reported. In conclusion, BTX-A produces a more prolonged pain relief than methylprednisolone in patients suffering from MPS or TH.     

Nummular headache and pituitary lesion: A case report and literature review

Nummular headache (NH) is a newly categorized headache disorder characterized by a consistent clinicographics in each attack. Currently, it is considered as a primary headache disorder due to epicranial neuralgia but the pathomechanism is still unknown. We report a woman, whose recurrent NH subsided after trans-sphenoidal surgery for her pituitary oncocytoma. The recovery of NH in this patient encourages the central mechanism for NH occurrence. After a review of literature concerning, NH and intracranial secondaries we propose that central NH is a referral pain from pain-sensitive structures, such as meninges, superimposing by pre-existing lower pain threshold or pain modulation.     

Sensitization of the Trigeminovascular Pathway: Perspective and Implications to Migraine Pathophysiology

Migraine headache is commonly associated with signs of exaggerated intracranial and extracranial mechanical sensitivities. Patients exhibiting signs of intracranial hypersensitivity testify that their headache throbs and that mundane physical activities that increase intracranial pressure (such as bending over or coughing) intensify the pain. Patients exhibiting signs of extracranial hypersensitivity testify that during migraine their facial skin hurts in response to otherwise innocuous activities such as combing, shaving, letting water run over their face in the shower, or wearing glasses or earrings (termed here cephalic cutaneous allodynia). Such patients often testify that during migraine their bodily skin is hypersensitive and that wearing tight cloth, bracelets, rings, necklaces and socks or using a heavy blanket can be uncomfortable and/or painful (termed her extracephalic cutaneous allodynia). This review summarizes the evidence that support the view that activation of the trigeminovascular pathway contribute to the headache phase of a migraine attack, that the development of throbbing in the initial phase of migraine is mediated by sensitization of peripheral trigeminovascular neurons that innervate the meninges, that the development of cephalic allodynia is propelled by sensitization of second-order trigeminovascular neurons in the spinal trigeminal nucleus which receive converging sensory input from the meninges as well as from the scalp and facial skin, and that the development of extracephalic allodynia is mediated by sensitization of third-order trigeminovascular neurons in the posterior thalamic nuclei which receive converging sensory input from the meninges, facial and body skin.     

Increased muscular and cutaneous pain sensitivity in cephalic region in patients with chronic tension-type headache

Increased excitability of the central nervous system generated by repetitive and sustained pericranial myofascial nociception may be responsible for transformation of episodic tension-type headache into chronic form. We aimed to compare mechanical and electrical (intramuscular and cutaneous) pain thresholds in trapezius and anterior tibial regions between 20 patients with chronic tension type headache and 20 healthy controls. Pain thresholds to three types of electrical stimulation (single pulse, 2 and 100 Hz) were significantly lower in patients than in controls in trapezius muscle (P < 0.02) and in skin overlying the trapezius muscle (P < 0.05), whilst electrical pain thresholds did not differ between groups in anterior tibial muscle and skin. Quantitative sensory testing revealed increased pain sensitivity in patients as assessed by pressure-controlled manual palpation (local tenderness score, LTS; P < 0.01) and by pressure algometry (mechanical pain thresholds; P < 0.05) in test areas over the trapezius muscle, but not the anterior tibial muscle. In summary, this study demonstrates lower pain thresholds in muscle and skin of the cephalic region but not in lower limb muscle and skin in patients with chronic tension-type headache than in healthy controls. Increased sensitivity in nociceptive pathways from cephalic region may be of importance in the pathophysiology of chronic tension type headache.     

Effects of induced stress on experimental pain sensitivity in chronic tension-type headache sufferers

Background and purpose:  It has been proposed that stress may contribute to chronic tension-type headache (CTH) through hyperalgesic effects on already sensitized pain pathways in CTH sufferers. This hypothesis could be partially tested by examining effects of stress on mechanical and thermal pain sensitivity in CTH sufferers. Such examinations have not been reported to date.
Materials and methods:  In the present study, we measured cephalic and extra-cephalic pressure [pressure-pain threshold (PPT)] and cold-pain thresholds (CPT) in CTH sufferers ( n  = 8 females, n  = 8 males) and healthy control subjects ( n  = 8 males, n  = 7 females) recruited from the general population before and after exposure to a 15-min stressful mental task.
Results:  Results indicated that PPT's at head and hand were lower in the CTH compared with control group both before and after task exposure. PPT's and CPT's decreased from pre- to post-task in both groups, with a significantly greater pre- to post-task reduction in cephalic PPT in the CTH compared with control group. Subjective stress increased from pre- to post-task in both groups and did not differ between groups. In the CTH group, stress reactivity was negatively correlated with PPT's, whilst absolute stress levels were positively correlated with pre- to post-task decrease in PPT's.
Conclusions:  The main finding is an enhanced hyperalgesic effect of stress on cephalic pressure-pain sensitivity in the CTH sufferers compared with the healthy controls. The results support the hypothesis that stress may contribute to CTH through hyperalgesic effects on already sensitized pain pathways in CTH sufferers.     

Intracutaneous sterile water injections do not relieve pain in cervicogenic headache

Intracutaneous sterile water injections have been reported to relieve acute labor pain and cervical pain in whip-lash patients. A double blind cross-over trial has presently been conducted in 10 women with cervicogenic headache in order to investigate whether sterile water injections were effective in this disorder. No benefit was observed for either treatment (isotonic saline or sterile water), neither on pain during the first 14 days nor on neck mobility. We conclude that intracutaneous sterile water injections is not effective in cervicogenic headache.     

Occipital Nerve Stimulation for the Treatment of Occipital Neuralgia—Eight Case Studies

Objective. The aim of this study was to examine the hypothesis that subcutaneous occipital stimulation influences pain due to occipital neuralgia. Materials and Methods. Between 2001 and 2004 eight patients with intractable occipital neuralgia were referred to our center. Their records were reviewed. Each patient was interviewed over the telephone. They were all offered a trial of stimulation using a percutaneous lead over 1 week. If they achieved 50% pain reduction a permanent lead was implanted. The impact of occipital stimulation was measured by pain score, analgesic requirements, and employment status. Results. Seven proceeded to a permanent stimulator. There was a reduction in the visual analog score postimplantation in five of the seven patients. The total quantity of opiates taken after implantation showed a marked reduction. Of the seven who had a permanent implant two acquired full‐time employment. Conclusion. Occipital neuralgia is a useful and reversible treatment for intractable occipital neuralgia.     

Thermal pain thresholds are decreased in the migraine preattack phase

Background and purpose: Migraine patients may have cutaneous allodynia during attacks. In order to investigate if pain physiology changes in the preattack phase we estimated heat pain and cold pain detection threshold (HPT and CPT) on three different days in 41 migraine patients and 28 controls. Methods: A thermode was applied at four sites bilaterally: forehead, face, neck, and hand. A subgroup of 11 migraine patients had been tested within 24 h before their next attack and in the interictal phase. Results: In the preattack phase, HPT was lower compared with the paired interictal recording for the hand (44.8°C vs. 45.9°C, P = 0.009), neck (46.8°C vs. 48.2°C, P = 0.02), and forehead (45.1°C vs. 46.3°C, P = 0.02). Neck and hand CPT were higher in the preattack phase than interictally (10°C vs. 7.3°C, P = 0.01 and 11.6°C vs. 9.4°C, P = 0.06, respectively). Preattack forehead changes were most apparent on the headache side of the subsequent attack. Discussion: Subclinical preattack thermal pain hypersensitivity seems to be a feature of the process that leads to a migraine attack.