Photophobia and phonophobia in tension-type and cervicogenic headache

Light and sound-induced discomfort and pain thresholds were measured in 26 patients with cervicogenic headache, in 40 patients with tension-type headache, and in 100 headache-free controls. Neither headache group was significantly different as to photophobia and phonophobia, but both were significantly more sensitive to light and sound than controls ( p <0.0001), even when patients were tested in the headache-tree period ( p <0.05). Episodic and chronic tension-type headache had similar photo- and phonophobia thresholds ( p ≥0.7). Tension-type headache patients were more photo- and phonophobic during headache than outside attack ( p <0.05), but this was not true for cervicogenic headache ( p ≥0.56). In cervicogenic headache patients, photophobia ( p <0.05) but not phonophohia ( p =0.28) was greater on the symptomatic side than on the non-symptomatic side.     

The wavelength of light causing photophobia in migraine and tension-type headache between attacks

OBJECTIVE: To ascertain the wavelength of light that patients with migraine and tension-type headache find uncomfortable between attacks. BACKGROUND: Photophobia is an abnormal perceptual sensitivity to light experienced by most patients with headache during and, also, between attacks. METHODS: We examined the discomfort threshold to light of low, medium, and high wavelengths in a group of patients with migraine (n=21), patients with tension-type headache (n=19), and healthy controls (n=21). RESULTS: The results indicate that the migraine group had significantly lower discomfort thresholds at the low (P=.001) and high (P=.031) wavelengths compared with both the tension-type headache and control groups; the latter two groups had similar average discomfort levels at these two wavelengths. With the medium wavelength, the control group had significantly higher discomfort thresholds than the migraine (P=.002) and tension-type headache (P=.031) groups; the latter two groups had similar discomfort levels at this wavelength. With unfiltered (white) light, the migraine group had the lowest discomfort threshold and the control group the highest (P=.026), whereas the tension-type headache group had an intermediate discomfort threshold. CONCLUSIONS: There were significant differences between migraineurs, patients with tension-type headache, and healthy controls in the wavelengths that are uncomfortable between attacks.     

Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A discriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.     

Cervicogenic headache, migraine, and tension-type headache. Pressure-pain threshold measurements.

Pressure-pain threshold (PPT) measurements were performed with a pressure algometer, at 22 specified points in the head in patients with cervicogenic headache (n = 32), migraine (with and without aura) (n = 26) and tension-type headache (n = 17). Comparisons were made with a group of healthy controls (n = 20). The average PPT differed significantly between the groups (ANOVA, F = 9.5, P < 0.0005), largely caused by the low threshold in cervicogenic headache patients. There were no significant differences between controls and the 2 other headache groups. In the cervicogenic headache group, the lowest PPT was found in the occipital part of the head on the side with pain predominance. The ratio between the dominant and non-dominant sides (all 11 points on each side) was 0.85 in cervicogenic headache, whereas it was 0.99 in migraine patients with side preponderance of the pain. The present results support the view that the pathogenesis of cervicogenic headache differs from that of migraine and tension-type headache. The results may further support the theory that fibres from the C2 level (innervating the occipital part of the head) may be included in the pathogenetic mechanism in cervicogenic headache.     

Neck Mobility in Different Headache Disorders

The main purpose of this study was to assess neck mobility (by Cybex equipment) in different headache disordered and, in particular, cervicogenic headache, and to compare; these findings with those in controls. A total of 51 control subjects and 90 headache patients were investigated, whereof 28 patients suffered from common migraine (migraine without aura), 34 from tension-type headache (H episodic and 25 chronic), and 28 patients from cervicogenic headache. One-way ANOVA and post hoc Bonferroni analysis showed significant differences between those with cervicogenic headache and the other groups for rotation ( P <0.001) and flexion/extension ( P <0.001), but not for lateral neck movement ( P =NS). There were no significant differences between migraine patients, tension-type headache patients, and controls. In all four groups, there was a significant positive correlation between active and passive neck movement for rotation ( P <0.001), flexion/extension ( P <0.001), and lateral neck movement ( P <0.001). Repeated measures analysis of variance (ANOVA) showed no significant day-to-day differences in 10 control subjects. In the control group (n=51), there was a significant negative correlation between age and neck movement. For rotation. Pearson's correlation coefficient was: r =-0.71 ( P <0.001), for flexion/extension r =-0.71 ( P <0.001), and for lateral neck movement r =-0.67 ( P <0.001). No significant sex difference was found as for any of the neck movements. Pain at the time of investigation did not seem to influence neck mobility. Cervicogenic headache has been recognized as a pair syndrome by the International Association for the Study of Pain (IASP). Since reduced neck mobility is one of the major criteria for this diagnosis, it emphasizes the need for systematic, objective neck mobility measurements in the individual patient to substantiate the diagnosis. The technique is simple and proved reliable.     

Possible Identification of Cervicogenic Headache Among Patients With Migraine: An Analysis of 374 Headaches

According to Sjaastad, the pain in cervicogenic headache, a form not recognized by the IHS, is long lasting and always side-locked unilateral. The frequency of side-locked unilateral pain (defined here as no change in side from onset) and other characteristics of cervicogenic headache were investigated in 300 outpatients using information collected on standard forms in structured interviews. Three hundred seventy-four headaches diagnosed according to IHS criteria were identified. Three hundred forty-eight of these headaches were long-lasting (duration of more than 4 hours); migraine (65%) followed by tension-type headache (25%) were the commonest forms. Side-locked unilaterality was present in 29% (101 of 348), and occurred most frequently in migrainous disorders not fulfilling the criteria (25 of 56, 44.6%). This group differed significantly from the other migraine conditions for longer pain duration ( P <0.02) and less frequent nausea, vomiting, photophobia, phonophobia ( P <0.0001), and aggravation by physical activity ( P <0.02). With these characteristics, this group resembled cervicogenic headache. However, in none of these patients was pain triggered by head or neck movements, and the frequency of head or neck trauma did not differ from other headaches. A more precise definition of clinical criteria for cervicogenic headache vs migraine is, therefore, required.     

Muscular Factors are of Importance in Tension-Type Headache

Recent studies have indicated that muscular disorders may be of importance for the development of increased pain sensitivity in patients with chronic tension-type headache. The objective of the present study was to investigate this hypothesis by examining the pain perception in tension-type headache with and without muscular disorders defined as increased tenderness. We examined 28 patients with episodic tension-type headache, 28 patients with chronic tension-type headache, and 30 healthy controls. Pericranial myofascial tenderness was recorded with manual palpation, and pressure pain detection and tolerances in cephalic and extracephalic locations with an electronic pressure algometer. In addition, thermal pain sensitivity and electromyographic activity were recorded. The main result was significantly lower pressure pain detection thresholds and tolerances in all the examined locations in patients with chronic tension-type headache with a muscular disorder compared to those without a muscular disorder. There were no such differences in any of the examined locations when the two subgroups of patients with episodic tension-type headache were compared. Thermal pain sensitivity did not differ between patients with and without a muscular disorder, while electromyographic activity levels were significantly higher in patients with chronic tension-type headache with than in those without a muscular disorder. Our results strongly indicate that prolonged nociceptive stimuli from the pericranial myofascial tissue sensitize the central nervous system and, thereby, lead to an increased general pain sensitivity. Muscular factors may, therefore, be of major importance for the conversion of episodic into chronic tension-type headache. The present study complements the understanding of the important interactions between peripheral and central factors in tension-type headache and may lead to a better prevention and treatment of the most prevalent type of headache.     

Side-Locked Unilaterality and Pain Localization in Long-Lasting Headaches: Migraine, Tension-Type Headache, and Cervicogenic Headache

SYNOPSIS
Side-locked unilaterality and specific localization of pain are not as well-defined clinical characteristics in long-lasting headaches (duration more than 4 hours) as they are in short-lasting forms. We examined side-locked unilaterality and pain distribution at onset and at peak headache in 74 patients with different forms of long-lasting headache: migraine and tension-type headache (IHS) and cervicogenic headache (according to Sjaastad et al). Side-locked unilaterality of pain was found in all forms, but to differing extents-20.8% in migraine, 12.5% in tension-type headache, while it was a mandatory criterion for cervicogenic headache. The pain tended to localize anteriorly, particularly at onset, in migraine; was more diffuse in tension-type headache; and always began in the occipitonuchal region in cervicogenic headache. Our results may contribute to a better clinical definition of long-lasting headaches.     

Transcranial Doppler ultrasound in migraine and tension-type headache after apomorphine administration: double-blind crossover versus placebo study

The effect of the dopaminergic agonist apomorphine on blood velocity in the middle cerebral artery has been studied in patients with migraine, tension-type headaches, and healthy subjects by means of transcranial Doppler monitoring. Following the administration of apomorphine, systolic velocity and mean velocity significantly increased and pulsatility index significantly decreased in migraineurs compared to placebo and to the other groups of subjects. These changes were dose-dependent and showed a time-curve compatible with the pharmacokinetic profile of the drug. The different effect of apomorphine in migraineurs compared with controls and tension-type headache patients implies that migraineurs have increased sensitivity to dopaminergic stimuli and suggests that transcranial Doppler monitoring after apomorphine administration could be a useful tool in the evaluation of migraineurs.     

Light-induced discomfort and pain in migraine

Quantitative thresholds for discomfort and pain with monocular and binocular light stimuli were measured in 67 controls and 67 migraine patients 37 migraine with aura and 30 migraine without aura). Patients were more photophobic during attack than outside attack ( p <0.03), and they were more sensitive to light than controls even between attacks ( p 0001). We found no differences in light sensitivity between migraine with aura and migraine without aura ( p 0.93). Unilateral pain affected light sensitivity on both sides. When asked with a questionnaire, 74% of patients answered that they were sensitive to light outside attack and 100% were sensitive during attack. Pain thresholds were generally lower among sensitive than non-sensitive patients ( p =0.004), indicating some agreement between subjective opinion and objective measurements of photophobia. Photophobia seems to be an intrinsic property of migraineurs. It is increased by migraine pain, but seems to be unrelated to migraine characteristics such as nausea, severity of attacks, pain character and pain laterality.     

Increased muscle pain sensitivity in patients with tension-type headache

Nociceptive mechanisms in tension-type headache are poorly understood. The aim was to investigate the pain sensitivity of pericranial muscles and a limb muscle in patients with tension-type headache. Experimental muscle pain was induced by standardized infusions of 0.5 ml of 1 M hypertonic saline into two craniofacial muscles (anterior temporalis (TPA) and masseter (MAS)) and a limb muscle (anterior tibial (TA)) in 24 frequent episodic tension-type headache patients (FETTH), 22 chronic tension-type headache patients (CTTH) and 26 age and gender matched healthy subjects. Headache patients were examined twice, both on days with and on days without headache. The pressure pain thresholds (PPTs) were determined before and after infusions. The subjects continuously reported intensity of saline-induced pain on an electronic visual analogue scale (VAS) and the perceived area of pain was drawn on anatomical maps. Headache patients demonstrated significantly lower PPTs, higher saline-evoked VAS pain scores and greater pain areas than healthy subjects at all the tested muscle sites (P<0.05). There was a significant gender difference for the PPTs in all three groups of participants (P<0.05) and for VAS pain scores in the CTTH patients (P<0.05). There was no difference in pain sensitivity between FETTH and CTTH or between patients with or without headache. In conclusion, the present study demonstrates the presence of generalized pain hypersensitivity both in FETTH and CTTH compared to controls which is unrelated to actual headache status and extends to include responses to longer-lasting stimuli which are clinically highly relevant. Gender differences in deep pain sensitivity seem to be a consistent finding both in healthy controls and patients with tension-type headache.     

The blink reflex in chronic tension-type headache, migraine, and cervicogenic headache

R1 and R2 blink reflex latencies were investigated blind in 10 patients with cervicogenic headache, 11 patients with chronic tension-type headache, 11 patients with migraine, and 9 headache-free controls. There were no R1 or R2 latency differences between the four groups. The latency of R1 increased significantly with headache duration in tension-type headache patients. Shorter R1 latencies were found on the symptomatic side than on the non-symptomatic side in cervicogenic headache patients. The results suggest that a state of hyperactivity may be present in the ipsilateral trigeminal nucleus in cervicogenic headache. Hypoactivity, however, may develop over time in tension-type headache.     

Pathophysiological mechanisms of tension-type headache: a review of epidemiological and experimental studies

In this present thesis I have discussed the epidemiology and possible pathophysiological mechanisms of tension-type headache. A population-based study of 1000 subjects randomly selected from a general population, two clinical studies, and a method study of EMG recordings, were conducted. Tension-type headache was the most prevalent form of headache, with a life-time prevalence of 78% in a general adult population. Thirty percent were affected more than 14 days per year and 3% were chronically affected, i.e. had headache at least every other day. Females were more frequently affected than males, and young subjects more frequently affected than older subjects. Females were more sensitive to mechanical pressure pain and revealed more tenderness from pericranial muscles and tendon insertions than males, and young subjects were more pain-sensitive than older subjects. Significantly higher tenderness in pericranial muscles was found in subjects with tension-type headache compared to migraineurs and to subjects without any experience of headache. Tenderness increased significantly with increasing frequency of tension-type headache in both males and females, whereas no such relation was found for mechanical pain thresholds. The applied EMG methodology was fairly reliable and nonpainful, but due to intersubject variability paired studies should be preferred. Subjects with chronic tension-type headache had slightly increased EMG levels during resting conditions and decreased levels during maximal voluntary contraction compared with headache-free subjects, indicating insufficient relaxation at rest and impaired recruitment at maximal activity. In a subsequent clinical, controlled study, the effect of 30 min of sustained tooth clenching was studied. Within 24 h, 69% of patients and 17% of controls developed a tension-type headache. Shortly after clenching, tenderness was increased in the group who subsequently developed headache, whereas tenderness was stable in the group of patients who remained headache-free, indicating that tenderness might be a causative factor of the headache. Likewise, psychophysical and EMG parameters were studied in 28 patients with tension-type headache, both during and outside of a spontaneous episode of tension-type headache. It was concluded that a peripheral mechanism of tension-type headache is most likely in the episodic subform, whereas a secondary, segmental central sensitization and/or an impaired supraspinal modulation of incoming stimuli seems to be involved in subjects with chronic tension-type headache. Prolonged nociceptive stimuli from myofascial tissue may be of importance for the conversion of episodic into chronic tension-type headache. The author emphasizes that tension-type headache is a multifactorial disorder with several concurrent pathophysiological mechanisms, and that extracranial myofascial nociception may constitute only one of them. The present thesis supplements the understanding of the balance between peripheral and central components in tension-type headache, and thereby, hopefully, leads us to a better prevention and treatment of the most prevalent type of headache.     

Nitric oxide: emerging implications for headache mechanics

The involvement of nitric oxide (NO) in the pathophysiology of primary headaches was suggested by several authors during the last decade. Migraine, cluster headache, tension headache, and cervicogenic headache have been extensively studied on the basis of NO donor headache pain. Different mechanisms seem to be involved in the generation of pain in these clearly different clinical head pain disorders. NO could control all the mechanisms leading to head pain. In migraine NO is correlated with endothelial activation, in cluster headache with a brainstem unravelling of the on/off regulatory clocks, in cervicogenic headache with a cytokine-dependent pain, and in tension-type headache with a sensitization of pain pathways at the spinal/trigeminal level. The next natural frontier in the study of pain in primary headaches seems to be the functional study of the relationship between NO and the immune regulatory system. Received: 30 Devember 2000 / Accepted in revised form: 9 April 2001     

Characteristics of headache in migraine without aura and episodic tension-type headache in the Turkish population according to the IHS classification

We evaluated the characteristics of headache in migraine without aura and episodic tension-type headache diagnosed according to the International Headache Society (IHS) Classification. Fifty migraine without aura and 50 tension-type headache patients were selected prospectively. Fifty-eight percent of migraineurs had pain of a pulsating quality; 88% had severe pain and 74% had unilateral pain; aggravation by routine physical activity was reported by 96%. Episodic tension-type headache was of a pressing quality in 52%, moderate in 40%, bilateral in 82% and aggravated by routine physical activity in 16%. Nausea and/or vomiting, photophobia and phonophobia were reported significantly more commonly in migraineurs than tension-type headache patients.     

Acetazolamide Testing of Cerebral Vasodilator Capacity Provokes "Vascular" But Not Tension Headaches

Cerebrovascular capacitance was tested by measuring local cerebral blood flow (LCBF) by xenon-contrasted CT scanning before and after the oral administration of 14.3 mg/kg of acetazolamide among 45 subjects including 15 age-matched controls without history of headache, 20 migraineurs with and without aura, 3 patients with cluster headache, and 7 patients with tension-type headache. Percentage increases of LCBF were measured in 10 regions located throughout both hemispheres. Laterality indices for asymmetric LCBF increases were calculated. Local cerebral blood flow in cortical gray matter increased 5.9% in controls, 9.9% in patients with tension headaches, but 18.6% in both migraine and cluster headache patients; significantly greater LCBF increases than among controls or among patients with tension headaches (P<0.05). Increases in LCBF were significantly asymmetric among migraine and cluster patients and provoked typical unilateral vascular headaches which responded to sumatriptan. Maximal asymmetric LCBF increases also corresponded to the reported side of the induced headaches confirming their vascular pathogenesis. Patients with tension headaches and controls without history of headache did not develop head pain after acetazolamide.     

Cephalic and extracephalic pressure pain thresholds in chronic tension-type headache.

Pressure pain thresholds were assessed with an algometer (Somedic Inc.), over the forehead, temple and suboccipital region as well as over the Achilles tendon. A group of 32 patients suffering from chronic tension-type headache was compared to 20 healthy controls and to 10 migraineurs without aura. Although individual values were widely scattered, pressure pain thresholds were on average significantly lower in chronic tension-type headache, not only at pericranial sites but also over the Achilles tendon. Only 50% of these patients had one or more pericranial thresholds 1.5 S.D. below the mean of controls. After muscular biofeedback therapy, all pain thresholds were on average increased. Along with results obtained previously, the present data support the hypothesis that diffuse disruption of central pain-modulating systems, possibly due to a modified limbic input to the brain-stem, is pivotal in the pathophysiology of chronic tension-type headache.     

Quality of life of patients with cervicogenic headache: a comparison with control subjects and patients with migraine or tension-type headache

OBJECTIVE: To establish the health-related quality of life of patients with cervicogenic headache and to compare it with a random Dutch sample of control subjects and with patients with migraine without aura or with episodic tension-type headache. METHODS: Thirty-seven patients with cervicogenic headache, 42 patients with episodic tension-type headache, and 39 patients with migraine without aura completed a Medical Outcomes Study 36-Item Short Form questionnaire. RESULTS: Domain scores for "physical functioning" of patients with cervicogenic headache were worse than those of patients with migraine or tension-type headache. Physical functioning scores were lower for patients with tension-type headache than for those with migraine. Migraineurs reported a diminished score for "social functioning" compared to patients with tension-type headache. All Medical Outcomes Study 36-Item Short Form domain scores were significantly lower for patients with cervicogenic headache relative to the control group. CONCLUSIONS: Patients with cervicogenic headache have a quality of life burden that is substantial. Although impairment in the quality of life of patients with cervicogenic headache is comparable to patients with migraine without aura and those with episodic tension-type headache, there are some specific differences.     

Cervicogenic Headache: Responses to Nitroglycerin, Oxygen, Ergotamine and Morphine

SYNOPSIS
The responses in cervicogenic headache to four different agents have been studied. Nitroglycerin was given sublingually to 27 patients. Eighteen patients got more than 20% increase of their headache. Of those with any headache increase at all, 12 got bilateral and 12 unilateral pain. The typical late cluster headache response to nitroglycerin was not seen in cervicogenic headache. The provocative effect of nitroglycerin seemed less marked in cervicogenic than in cluster headache. Oxygen inhalation, a frequently used treatment for cluster headache, was given to 14 patients with cervicogenic headache. In general, the effect seemed uncertain and probably clearly inferior to the effect in cluster headache. Ergotamine treatment (given to 13 patients) also seemed to be of little avail in cervicogenic headache. Morphine injections given to 11 cervicogenic headache patients resulted in "marked" improvement in 4, but complete pain freedom was only seen in 2 cases. In our opinion, the present results add further evidence to the view that different etiologic and pathogenetic factors underlie cervicogenic headache and cluster headache.     

Orbital Phlebography: A Comparison Between Cluster Headache and Other Headaches

Orbital phlebography has previously been found to be pathologic in 8 of 13 patients with episodic cluster headache. To compare the frequency and pattern of the pathologic findings in cluster headache with those in other headache categories, orbital phlebographies were carried out in patients with cluster headache, cervicogenic headache, migraine and tension-type headache (tension headache). The investigations were evaluated independently by two radiologists, one of whom had no knowledge of the diagnoses. The frequencies of pathologic findings were at maximal 2/12 in the cluster headache group, 2/11 in the cervicogenic headache group, 5/12 in the migraine group and 5/15 in the tension-type headache group. The investigators agreed completely in the evaluation of 39/50 phlebograms, with lesser disagreements in 7. In conclusion, the frequency of pathologic findings at orbital phlebography in cluster headache was not higher than in the other diagnostic categories investigated, and the pattern of the pathology was generally the same.