TENSION-TYPE HEADACHE

Tenderness is the most prominent abnormal finding in patients with tension-type headache (TTH). Recently we developed a model of myofascial tenderness using intramuscular infusion of a combination of bradykinin, serotonin, histamine and prostaglandin E2. We aimed to examine tenderness after this combination in patients with episodic TTH (ETTH). Fifteen patients and 15 healthy controls completed the study. Participants received the combination into the non-dominant trapezius muscle in a randomized, double-blinded and placebo-controlled design. Local tenderness and stimulus-response functions, mechanical pain thresholds (PPDT) in the temporal region and on the finger, and total tenderness score (TTS) were recorded. A local, prolonged, and mild to moderate tenderness was reported both in patients ( P = 0.001) and in controls ( P = 0.001) after the combination compared with the placebo. The response to the combination tended to be increased in patients. The stimulus-response function was leftward shifted after the combination, compared with baseline in both groups. No changes in PPDT or TTS were found after the infusions, whereas baseline PPDTs were decreased in ETTH compared with controls (PPDT finger: P = 0.033; PPDT temporal: P = 0.015). Intramuscular infusion of a combination of endogenous substances induced prolonged tenderness in both patients with episodic TTH and healthy subjects. The present results suggest an increased excitability of peripheral muscle afferents in TTH.     

Experimental induction of muscle tenderness and headache in tension-type headache patients

The aim of the present study was to investigate the impact of static contraction of the shoulder and neck muscles on muscle tenderness and headache in patients with tension-type headache. Twenty patients with frequent episodic tension-type headache and 20 healthy age- and sex-matched controls were examined using a placebo-controlled cross-over design. The subjects performed static contraction of the trapezius muscles (active procedure) or the anterior tibial muscles (placebo procedure) with 10% of maximal force for 30 min. Total tenderness score, local tenderness score and headache intensity were evaluated before and after the static work. Changes in headache intensity were followed for 24 h. Pericranial tenderness increased significantly more in patients than in controls after the active procedure (P = 0.04). The increase in pericranial tenderness tended to be higher after the active procedure than after the placebo procedure in patients (P = 0.08) and in controls (P = 0.07). Sixty per cent of the patients and 20% of the healthy controls developed headache after the active procedure. Fifty per cent of the patients and none of the controls developed headache after the placebo procedure. There was no significant difference in headache development between the active and the placebo procedure in patients or controls. These findings demonstrate that tension-type headache patients are more liable to develop shoulder and neck pain in response to static exercise than healthy controls.     

Botulinum toxin injections for the treatment of frontal tension headache

Abstract We performed a randomized, double-blind, placebo-controlled trial to determine the efficacy of botulinum toxin type A (BOTOX; Allergan) in treating frontal tension-type headache (TTH). A total of 40 patients attending a headache treatment center were randomized to receive 50 U botulinum toxin type A or saline, injected at 10 sites of the forehead. Frequency and severity of headaches before and after injection were compared. The intensity of headaches in the botulinum toxin type A group, but not the placebo group, fell significantly from an average score of 5.19 to 4.65 (p<0.0001). Botulinum toxin type A patients and placebo patients experienced an average reduction in the number of headaches per month, but these reductions were not significantly different between groups. Botulinum toxin type A was well tolerated, with no significant adverse events. Botulinum toxin type A injections in the management of frontal TTH has been shown by this study to be both effective and well tolerated. It should be noted that the effect of botulinum toxin on intensity of headache, although statistically significant, was relatively small.     

A randomized, double-blind, placebo-controlled study of venlafaxine XR in out-patients with tension-type headache

The aim of this study was to evaluate in a double-blind, randomized, placebo-controlled study the safety and efficacy of venlafaxine extended release (XR) in the prophylactic treatment of out-patients with tension-type headache (TTH) and no current depression or anxiety disorders. Sixty neurology and headache clinic out-patients meeting the International Headache Society diagnostic criteria for TTH were treated with venlafaxine XR (150 mg/day, n = 34) or placebo (n = 26) for 12 weeks. The primary efficacy variable was the decline in number of days with headache. At end-point, the venlafaxine XR group had a significantly greater decrease in the number of days with headache compared with placebo (P = 0.05). Differences with regard to secondary efficacy variables where not significant. The number needed to treat for responders (>or=50% reduction in days with headache) was 3.48. Six patients in the venlafaxine XR group interrupted therapy due to adverse events, while no patients in the placebo group did so for the same reason. The number needed to harm was 5.58. This study provides preliminary evidence for the efficacy and safety of venlafaxine XR 150 mg/day in reducing the number of days with TTH.     

Muscle tenderness in tension headache treated with acupuncture or physiotherapy

Sixty-two female patients with chronic tension headache were randomized into two treatment groups--acupuncture and physiotherapy. The intensity of headache, muscle tenderness and neck mobility was assessed before and after treatment. Thirty healthy women were used for comparison. Before treatment it was found that muscle tenderness was increased and neck rotation was reduced in the patient group compared with controls. There was a significant correlation between the intensity of headache and muscle tenderness. After treatment, the intensity of headache and muscle tenderness were reduced in both treatment groups. The headache was more improved in the physiotherapy group, and there was a marked reduction in the intake of analgesics. The tenderness was reduced in all muscles tested in the physiotherapy group but only in some of the muscles after acupuncture. The limitation of neck rotation was not influenced by either treatment.     

A comparison of selected osteopathic treatment and relaxation for tension-type headaches

OBJECTIVE: The objective of this study was to compare the effects of osteopathic treatment and progressive muscular relaxation (PMR) exercises on patients with tension-type headache (TTH). BACKGROUND: Relaxation is generally accepted as a treatment for TTH. Osteopathy is considered by some practitioners to be useful for headache management but there is limited scientific evidence regarding the effectiveness. This study compares relaxation and relaxation plus selected osteopathic techniques in the treatment of people with TTH. DESIGN: This was a single-blind, randomized, clinical study using an experimental design. Twenty-nine patients with TTH according to the International Headache Classification Subcommittee, 2004, were recruited for this study and randomly placed in either a control or experimental group. Both groups practiced PMR exercises at home while the experimental group also received 3 osteopathic treatments. METHOD: All participants recorded headache frequency and intensity in a headache diary (HD) for 2 weeks pretreatment, and continued recording during the treatment period until reassessment for a total of 6 to 7 weeks. All tests of significance were set at P相似文献   

Treatment of chronic cervical-associated headache with botulinum toxin A: a pilot study

OBJECTIVE: To see whether therapy with botulinum toxin A may prove to be an effective treatment for headache of musculoskeletal origin. BACKGROUND: Headache is a common finding associated with neck injury. Cervicogenic headache, which is believed to be attributable to injury of the ligaments, muscles, or joints of the cervical spine, is centered in the occipital region with pain referred to the frontotemporal region. Botulinum toxin A produces prolonged muscle relaxation, which is dose dependent and can be easily targeted to affected muscles. METHODS: This randomized, double-blind, placebo-controlled study compares outcome measures in 26 patients suffering from chronic headache subsequent to a cervical whiplash injury. One half of the patients received botulinum toxin A, 100 units, diluted in 1 mL of saline, while the other half received just saline (1 mL). Five cervical trigger points received 0.2 mL each of injectant via a 30-gauge needle. Outcome measures included subjective head pain based on visual analog scales, as well as range of neck motion. Follow-up assessments were carried out at 2 and 4 weeks after treatment. RESULTS: Fourteen subjects who received botulinum toxin A and 12 who received saline completed the study. At both 2 and 4 weeks post injection, the treatment group showed a significant improvement in pain and range of motion from preinjection levels (P<.01). The placebo group demonstrated no statistically significant changes at any posttreatment time.     

Increased prevalence of tension-type headache over a 12-year period is related to increased pain sensitivity. A population study

We recently reported an increase in prevalence and frequency of tension-type headache (TTH) over a 12-year period in the young Danish population. The aim of the present study was to analyse whether this increase was related to increased pain sensitivity. The study was a cross-sectional replicate of a large Danish population study. It compared 113 subjects aged 25-36 years in 2001, with 221 comparable subjects in 1989. Tenderness was considerably higher in 2001 than in 1989. When stratified according to presence of headache, the increase in tenderness was clinically and statistically significant only in women with frequent TTH. The pressure pain threshold was significantly lower in 2001 compared with 1989 in women with frequent TTH. The increase in tenderness in the population may predict an even higher prevalence of TTH in future. The changes support the hypothesis of central sensitization in TTH.     

Pressure pain threshold and needle acupuncture in chronic tension-type headache--a double-blind placebo-controlled study

In order to examine the role of muscular mechanisms in chronic tension-type headache a study with needle acupuncture was performed. Needle acupuncture could be of therapeutic value because it has shown some positive effects in myofascial pain syndromes. We performed a double-blind, placebo-controlled study with 39 patients (mean age 49.0 years, SD=14.8) fulfilling the International Headache Society criteria for chronic tension-type headaches. Participants were randomly assigned to verum or placebo condition. Six weeks after end of treatment no significant differences between placebo and verum could be observed with respect to visual analogue scale and frequency of headache attacks. Nevertheless, pressure pain thresholds significantly increased for the verum group. The findings of our study support the hypothesis that peripheral mechanisms - such as increased muscle tenderness - only play a minor role in the pathogenesis of chronic tension-type headache.     

Botulinum Toxin A in the Treatment of Chronic Tension-Type Headache With Cervical Myofascial Trigger Points: A Randomized, Double-Blind, Placebo-Controlled Pilot Study

Objective.— To evaluate the efficacy of botulinum toxin A (BT-A) as a prophylactic treatment for chronic tension-type headache (CTTH) with myofascial trigger points (MTPs) producing referred head pain. Background.— Although BT-A has received mixed support for the treatment of TTH, deliberate injection directly into the cervical MTPs very often found in this population has not been formally evaluated. Methods.— Patients with CTTH and specific MTPs producing referred head pain were assigned randomly to receive intramuscular injections of BT-A or isotonic saline (placebo) in a double-blind design. Daily headache diaries, pill counts, trigger point pressure algometry, range of motion assessment, and responses to standardized pain and psychological questionnaires were used as outcome measures; patients returned for follow-up assessment at 2 weeks, 1 month, 2 months, and 3 months post injection. After 3 months, all patients were offered participation in an open-label extension of the study. Effect sizes were calculated to index treatment effects among the intent-to-treat population; individual time series models were computed for average pain intensity. Results.— The 23 participants reported experiencing headache on a near-daily basis (average of 27 days/month). Compared with placebo, patients in the BT-A group reported greater reductions in headache frequency during the first part of the study (P = .013), but these effects dissipated by week 12. Reductions in headache intensity over time did not differ significantly between groups (P = .80; maximum d = 0.13), although a larger proportion of BT-A patients showed evidence of statistically significant improvements in headache intensity in the time series analyses (62.5% for BT-A vs 30% for placebo). There were no differences between the groups on any of the secondary outcome measures. Conclusions.— The evidence for BT-A in headache is mixed, and even more so in CTTH. However, the putative technique of injecting BT-A directly into the ubiquitous MTPs in CTTH is partially supported in this pilot study. Definitive trials with larger samples are needed to test this hypothesis further.     

A型肉毒毒素治疗紧张性头痛的临床研究

目的观察A型肉毒毒素治疗紧张性头痛的临床疗效和不良反应。方法选取31例紧张性头痛患者,应用A型肉毒毒素进行颅周肌肉注射治疗。问卷调查并记录每例紧张性头痛患者治疗前、后3个月紧张性头痛发作情况,比较紧张性头痛发作频率、持续时间、严重程度及使用止痛药物情况,观察不良反应。结果A型肉毒毒素治疗后第1个月,紧张性头痛发作频率、发作持续时间、发作严重程度均较治疗前明显下降(P<0.01),使用止痛药物较治疗前显著减少(P<0.01),疗效至少可维持3个月,且不良反应轻微、短暂。结论A型肉毒毒素颅周肌肉注射治疗紧张性头痛有一定疗效,不良反应轻微、短暂,值得进一步验证。     

Brainstem and cervical spinal cord Fos immunoreactivity evoked by nerve growth factor injection into neck muscles in mice

Although myofascial tenderness is thought to play a key role in the pathophysiology of tension-type headache, very few studies have addressed neck muscle nociception. The neuronal activation pattern following local nerve growth factor (NGF) administration into semispinal neck muscles in anaesthetized mice was investigated using Fos protein immunohistochemistry. In order to differentiate between the effects of NGF administration on c-fos expression and the effects of surgical preparation, needle insertion and intramuscular injection, the experiments were conducted in three groups. In the sham group (n=7) cannula needles were only inserted without any injection. In the saline (n=7) and NGF groups (n=7) 0.9% physiological saline solution or 0.8 microm NGF solution were injected in both muscles, respectively. In comparison with sham and saline conditions, NGF administration induced significantly stronger Fos immunoreactivity in the mesencephalic periaqueductal grey (PAG), the medullary lateral reticular nucleus (LRN), and superficial layers I and II of cervical spinal dorsal horns C1, C2 and C3. This activation pattern corresponds very well to central nervous system processing of deep noxious input. A knowledge of the central anatomical representation of neck muscle pain is an essential prerequisite for the investigation of neck muscle nociception in order to develop a future model of tension-type headache.     

Heat pain thresholds and cerebral event-related potentials following painful CO2 laser stimulation in chronic tension-type headache

Current opinion concerning the pathophysiology of tension-type headache (TTH) and its related pericranial muscle tenderness proposes a primary role of central sensitization at the level of dorsalhorn/trigeminal nucleus as well as the supraspinal level. Investigation of these phenomena can be conducted using laser-evoked potentials (LEPs), which are objective and quantitative neurophysiological tools for the assessment of pain perception. In the present study we examined features of LEPs, as well as cutaneous heat-pain thresholds to laser stimulation, in relation to the tenderness of pericranial muscles in chronic TTH resulting from pericranial muscle disorder, during a pain-free phase. Twelve patients with TTH and 11 healthy controls were examined using the Total Tenderness Scoring (TTS) system. The stimulus was a laser pulse generated by a CO(2) laser. The dorsum of the hand and the cutaneous zones corresponding to pericranial muscles were stimulated. Subjective perception of stimulus intensity was assessed by a visual analogue scale. Two responses, the earlier named N2a and the last named P2, were considered; the absolute latency was measured at the highest peak of each response. The N2a-P2 components' peak-to-peak amplitude was detected. The heat pain threshold was similar in TTH patients and controls at the level of both the hand and pericranial skin. The TTS scores at almost all pericranial sites were higher in TTH patients than in normal controls. The amplitude of the N2a-P2 complex elicited by stimulation of the pericranial zone was greater in TTH patients than in controls; the amplitude increase was significantly associated with the TTS score. Our findings suggest that pericranial tenderness may be a primary phenomenon that precedes headache, and is mediated by a greater pain-specific hypervigilance at the cortical level.     

Head pain referral during examination of the neck in migraine and tension-type headache

Objective.— To investigate if and to what extent typical head pain can be reproduced in tension‐type headache (TTH), migraine without aura sufferers, and controls when sustained pressure was applied to the lateral posterior arch of C1 and the articular pillar of C2, stressing the atlantooccipital and C2‐3 segments respectively. Background.— Occipital and neck symptoms often accompany primary headache, suggesting involvement of cervical afferents in central pain processing mechanisms in these disorders. Referral of head pain from upper cervical structures is made possible by convergence of cervical and trigeminal nociceptive afferent information in the trigemino‐cervical nucleus. Upper cervical segmental and C2‐3 zygapophysial joint dysfunction is recognized as a potential source of noxious afferent information and is present in primary headache sufferers. Furthermore, referral of head pain has been demonstrated from symptomatic upper cervical segments and the C2‐3 zygapophysial joints, suggesting that head pain referral may be a characteristic of cervical afferent involvement in headache. Methods.— Thirty‐four headache sufferers and 14 controls were examined interictally. Headache patients were diagnosed according the criteria of the International Headache Society and comprised 20 migraine without aura (females n = 18; males n = 2; average age 35.3 years) and 14 TTH sufferers (females n = 11; males n = 3; average age 30.7 years). Two techniques were used specifically to stress the atlantooccipital segments (Technique 1 – C1) and C2‐3 zygapophysial joints (Technique 2 – C2). Two techniques were also applied to the arm – the common extensor origin and the mid belly of the biceps brachii. Participants reported reproduction of head pain with “yes” or “no” and rated the intensity of head pain and local pressure of application on a scale of 0 ‐10, where 0 = no pain and 10 = intolerable pain. Results.— None of the subjects reported head pain during application of techniques on the arm. Head pain referral during the cervical examination was reported by 8 of 14 (57%) control participants, all TTH patients and all but 1 migraineur (P < .002). In each case, participants reported that the referred head pain was similar to the pain they usually experienced during TTH or migraine. The frequency of head pain referral was identical for Techniques 1 and 2. The intensity of referral did not differ between Technique 1 and Technique 2 or between groups. Tenderness ratings to thumb pressure were comparable between the Techniques 1 and 2 when pressure was applied to C1 and C2 respectively and across groups. Similarly, there were no significant differences for tenderness ratings to thumb pressure between Technique 1 and Technique 2 on the arm or between groups. While tenderness ratings to thumb pressure for Technique 2 were similar for both referral (n = 41) and non‐referral (n = 7) groups, tenderness ratings for Technique 1 in the referral group were significantly greater when compared with the non‐referral group (P = .01). Conclusions.— Our data support the continuum concept of headache, one in which noxious cervical afferent information may well be significantly underestimated. The high incidence of reproduction of headache supports the evaluation of musculoskeletal features in patients presenting with migrainous and TTH symptoms. This, in turn, may have important implications for understanding the pathophysiology of headache and developing alternative treatment options.     

Regional head and face pain relief following lower cervical intramuscular anesthetic injection

BACKGROUND: Although cervical trigger point intramuscular injections are commonly used to relieve localized neck pain, regional head pain relief from lower cervical paravertebral injections has not been reported previously. PURPOSE: To evaluate the safety and efficacy of such injections in a selected group of patients with intractable head or face pain. METHODS: In a series of patients with chronic head or face pain, local anesthetic was injected into the lower cervical spine paravertebral musculature approximately 1 to 2 inches lateral to the seventh cervical spinous process. RESULTS: In addition to producing rapid relief of palpable scalp or facial tenderness (mechanical hyperalgesia and allodynia pain), this lower cervical intramuscular injection technique alleviated associated symptoms of nausea, photophobia, and phonophobia in patients with migrainous headache. CONCLUSION: Our results suggest that lower cervical intramuscular anesthetic injection may be an effective treatment for head or face pain.     

Neck mobility and forward head posture are not related to headache parameters in chronic tension-type headache

The relationship between the changes in forward head posture (FHP), neck mobility and headache parameters was analysed in 25 patients with chronic tension-type headache (CTTH) undergoing a physical therapy programme. Side-view pictures were taken to measure the cranio-vertebral angle in the sitting and standing positions. A cervical goniometer was employed to measure the range of all cervical motions. A headache diary was kept to assess headache intensity, frequency and duration. All patients received six sessions of physical therapy over 3 weeks. Outcomes were assessed at baseline, after treatment and 1 month later. Neck mobility and headache parameters showed a significant improvement after the intervention, whereas posture changes did not reach statistical significance. No correlations were found between FHP, neck mobility and headache parameters at any stage. Changes in these outcomes throughout the study were not correlated either. FHP and neck mobility appear not to be related to headache intensity, duration or frequency in patients suffering from CTTH. Although patients showed a reduction in the range of motion in the neck, it is uncertain whether this is consistent with TTH.     

Pericranial tenderness in chronic tension-type headache: the Akershus population-based study of chronic headache

Background

Most knowledge on chronic tension-type headache (CTTH) is based on data from selected clinic populations, while data from the general population is sparse. Since pericranial tenderness is found to be the most prominent finding in CTTH, we wanted to explore the relationship between CTTH and pericranial muscle tenderness in a population-based sample.

Methods

An age- and gender-stratified random sample of 30,000 persons aged 30-44 years from the general population received a mailed questionnaire. Those with a self-reported chronic headache were interviewed and examined by neurological residents. The questionnaire response rate was 71% and the interview participation rate was 74%. The International Classification of Headache Disorders II was used. Pericranial muscle tenderness was assessed by a total tenderness score (TTS) involving 8 pairs of muscles and tendon insertions. Cross-sectional data from the Danish general population using the same scoring system were used for comparison.

Results

The tenderness scores were significantly higher in women than men in all muscle groups. The TTS was significantly higher in those with co-occurrence of migraine compared with those without; 19.3 vs. 16.8, p = 0.02. Those with bilateral CTTH had a significantly higher TTS than those with unilateral CTTH. The TTS decreased significantly with age. People with CTTH had a significantly higher TTS compared to the general population.

Conclusions

People with CTTH have increased pericranial tenderness. Elevated tenderness scores are associated with co-occurrence of migraine, bilateral headache and low age.Whether the increased muscle tenderness is primary or secondary to the headache should be addressed by future studies.     

Coping strategies in episodic and chronic tension-type headache

OBJECTIVE: To study the importance of coping with illness strategies in tension-type headache (TTH). BACKGROUND: The pathophysiology of TTH is complex, and coping with illness strategies might contribute to the transformation to a chronic form. METHODS: We examined 89 subjects (mean age, 45.6 +/- 14.8 years; range, 18 to 72 years) with episodic (n = 37) and chronic (n = 52) TTH. Patients were required to fill in a Freiburg Questionnaire of Coping with Illness (FQCI), a von Zerssen Depression Scale, quality-of-life questionnaires, and a headache home diary (over 4 weeks). In addition, pressure pain thresholds (temporal muscles) and total tenderness scores were obtained. RESULTS: Patients with chronic TTH exhibited poorer quality-of-life measures, slightly more depressive symptoms, and significantly stronger avoidance behavior and endurance strategies on FQCI scales F4 and F5 (P< .05). There was no difference between episodic and chronic TTH with respect to measures of muscle tenderness or pain thresholds. CONCLUSIONS: We conclude that disadvantageous coping with illness strategies might contribute to a transformation to chronic TTH.     

Oral acupuncture in the therapy of craniomandibular dysfunction syndrome – a randomized controlled trial

CONTEXT: Patients with disorders of the stomatognathic system describe pain and clicking phenomena as primary symptoms. Rapid improvement of the pain is required to ensure and maintain adequate patient compliance. OBJECTIVE: The study was intended to assess the effects of acupuncture in patients with temporomandibular disorders as compared to placebo therapy (sham laser); the primary target parameter was the subjective pain sensation. DESIGN: Randomized, placebo-controlled trial. PATIENTS AND METHODS: 23 patients were enrolled and randomly assigned to one of the two groups. One group received acupuncture treatment according to the very-point technique, the other group received sham laser treatment. The following observer-blinded findings were evaluated before and after treatment: subjective pain, mouth opening, and muscular tenderness and pain on pressure. In addition, mandibular joint movement pathways were recorded using electronic axiography. OUTCOMES: Improvements in pain scores (scale, 0-100) in the acupuncture group (19.1 +/- 11.9) were significant (p = 0.03) versus those in the placebo group (6.2 +/- 14.8). Mouth opening showed an insignificant trend towards improvement (p > 0.1) in the acupuncture (5.0 +/- 6.2 mm) versus the placebo group (1.0 +/- 4.7 mm), differences in tenderness and pain on pressure in neck and masticatory muscles were significant (p < 0,05) for most of the muscles having shown pretreatment tenderness or pain. The axiographic tracings were assessed for quality, symmetry and curve characteristics. Recordings of the opening and closing movement in the acupuncture group showed an increased frequency of improvements of curve characteristics as compared to the placebo group. The acupuncture group also showed an increased frequency of improvement in protrusion and retrusion movements, though no statistical significance could be obtained. CONCLUSION: On the basis of the results of the present study, acupuncture may be recommended as acute treatment of craniomandibular disorders, but studies with larger numbers of patients as well as about long-term treatment outcomes should be conducted.     

Physiotherapy for tension-type headache: a controlled study

The role of non-pharmacological therapies in the preventive treatment of tension-type headache (TTH) is still an object of debate. The primary aim of this study was therefore to investigate the therapeutic effect of physiotherapy in properly classified patients with TTH in a controlled trial. Fifty patients with TTH, 26 with episodic, frequent (ETTH) and 24 with chronic TTH (CTTH) fulfilling the International Headache Society classification criteria were included in the study. After a 4-week run-in period, they were randomized to either an 8-week period of standardized physiotherapy (group 1) or to an 8-week observation period followed by an identical course of physiotherapy (group 2); after the physiotherapy all patients were followed for a 12-week follow-up period. We then evaluated the number of days with headache, severity and duration of the headache attacks, and drug consumption for symptomatic treatment before and after the course of physiotherapy. Forty-eight patients completed the study. The average number of days with headache per 4-week period was reduced from 16.3 days at baseline to 12.3 days in the last 4 weeks of treatment [from 14.5 days to 10.5 days (P < 0.001) in group 1 and from 18.1 days to 14.1 days (P < 0.001) in group 2]. Severity and duration of headache as well as drug consumption were unchanged throughout the study. Analysing the response to treatment separately in the various subgroups, we found that the number of responders was significantly higher among patients with CTTH vs. patients with ETTH (P < 0.002) and in females vs. males (P < 0.02). No differences were found between patients with and without disorder of pericranial muscles. We conclude that a standardized physiotherapy programme has a good therapeutic effect, albeit on a restricted group of patients.