The Temporomandibular Joint Pain-dysfunction Syndrome: A Frequent Cause of Headache

SYNOPSIS
One hundred consecutive headache clinic patients were evaluated prospectively for features of the temporomandibular joint (TMJ) pain-dysfunction syndrome. The syndrome was identified in 14, mainly young women, who differed significantly in physical findings and headache associated symptoms from those with tension or vascular headache, but not in the frequency of anxiety-relieving chronic oral habits usually said to be causal. They resembled tension headache patients in their high incidence of associated depression, and most improved following treatment with physical therapy and tricyclic antidepressants. Radiologic joint abnormalities were uncommon. The TMJ pain-dysfunction syndrome appears to be a frequent, easily diagnosed, and easily treated, but usually unappreciated cause of headache distinct from other headache entities.     

Hemicrania continua in a headache clinic: referral source and diagnostic delay in a series of 22 patients

Hemicrania continua (HC) is a unilateral and continuous primary headache with superimposed exacerbations frequently associated with autonomic features. Diagnostic criteria of HC, according to II Edition of International Classification of Headache Disorders require complete response to indomethacin. HC is probably misdiagnosed more often than other primary headaches. We aim to analyze characteristics of a series of 22 consecutive cases of HC. We recruited patients from a headache outpatient clinic in a tertiary hospital over a 3-year period (January 2008 to January 2011). We prospectively gathered demographic and nosological characteristics and considered referral source and delay between onset of headache and diagnosis of HC. Twenty-two patients (14 females, 8 males) out of 1,150, who attended the mentioned clinic during the inclusion period (1.9 %) were diagnosed with HC. All cases responded to indomethacin. No patient received a diagnosis of HC before attending our headache office. Mean latency of diagnosis was 86.1 ± 106.5 months (range 3–360). 11 patients (50 %) were referred from primary care, with 9 (40.9 %) from other neurology clinics and 2 (9.1 %) from other specialities offices. According to our series, HC is not an infrequent diagnosis in a headache outpatient clinic. Diagnostic delay is comparable to data collected in previous studies. As HC is frequently misdiagnosed, we thing there is a need for increasing the understanding of this entity, potentially responsive to indomethacin.     

Specific Headache Phenomena: Their Frequency and Coincidence

The correlation of specific headache attack characteristics derived from a standardized questionnaire was studied in a consecutive series of 392 patients attending a headache clinic. In patients reporting headache with aura such attacks tended to be infrequent, and the percentage of their headache attacks that were preceded by aura varied widely, many cases having very low percentages. Paresthesias as auras were uncommon and rarely occurred without visual aura. Unilateral headaches were associated with nausea to widely varying degrees. Most patients reported both unilateral headache and headache with tension characteristics. Definite history of hypertension was significantly correlated specifically with migraine with aura (classic migraine).     

Outcomes of a headache-specific cross-sectional multidisciplinary treatment program

Aim.— Chronic headache is a disabling disorder that is frequently poorly managed in general clinical practice. Objectives.— To investigate primary (headache frequency in days/month) and secondary (headache‐related disability, lost work/school time, anxiety and depression, amount and intake frequency of acute medication) 12‐month outcomes of a headache‐specific cross‐sectional outpatient and inpatient multidisciplinary treatment program using a dedicated computer system for data collection and corresponding between integrated care team in a tertiary headache center and practicing headache specialists. Background.— A need for integrated headache care using comprehensive and standardized assessment for diagnosis of headache, psychiatric comorbidity, and burden of disease exists. There are little published data on long‐term efficacy of multidisciplinary treatment programs for chronic headache. Design.— A prospective, observational, 12‐month, follow‐up study. Subjects and Methods.— Prospectively recruited consecutive patients with frequent difficult‐to‐treat headaches (n = 201; 63 migraine, 11 tension‐type headache, 59 combined migraine/tension‐type headache, and 68 medication overuse headache) were enrolled. Outcome measures included prospective headache diaries, a medication survey, Migraine Disability Assessment, 12‐item short form health survey, and the Hospital Anxiety and Depression Scale. Results.— The primary outcome of a reduction of ≥50% of headache frequency (days/month) was observed in 62.7%. Mean headache frequency decreased from 14.4 ± 8.2 to 7.6 ± 8.3 days/month, P < .0001. Secondary outcomes improved significantly in the total cohort and all headache subgroups. Predictors for good outcome were younger age, few days lost at work/school, and familiarity with progressive muscle relaxation therapy at baseline. Conclusions.— The present analysis provided support for a cross‐sectional multidisciplinary integrated headache‐care program.     

College Health Center Utilization Among a Sample of Senior College Women

This secondary analysis examines the self-reported reasons for visiting campus health centers (health care utilization) among senior college women. The original cross-sectional study recruited female college seniors from 2 northeastern 4-year universities. Nearly 82% of college women reported visiting their campus health center at some point during their time in college, with the majority (53.8%) reporting sickness as the reason for the visit (eg, headache, cold, flu). Injuries and gynecology services were also reasons reported. Findings illuminate specific health care utilization among college women, which can inform college health center practice and availability of services.     

The Comparison of Patients Suffering from Temporo-mandibular Disorders and a General Headache Population

SYNOPSIS
The purpose of this study was to examine the possible association of signs and symptoms of temporomandibular disorders relative to headache. Fifty-six sequential patients referred to the Headache Institute of Minnesota for evaluation and treatment of migraine and tension headaches were examined for signs and symptoms of temporomandibular disorders. The results of the examination of headache patients were compared to patients suffering from myofascial pain dysfunction and/or TMJ internal derangements from the TMJ and Craniofacial Pain Clinic at the University of Minnesota. Finally the migraine and tension headache patients were compared to each other and an asymptomatic population.
Results indicate that patients with temporomandibular disorders exhibit significantly more jaw dysfunction and pericranial muscle tenderness than migraine and tension headache patients. ^Migraine and tension headache patients were found to have similar amounts of pericranial muscle tenderness. Migraine and tension headache patients exhibited significantly more pericranial and neck muscle tenderness than a general population.     

Migraine and Tension Headache: Is There a Physiological Difference?

SYNOPSIS
The purpose of this study was to conduct a controlled comparison of tension and migraine headache under several experimental conditions.
Ten subjects from each of the following diagnostic groups - tension headache, migraine headache, and healthy controls - were observed under conditions of unstructured relaxation, mild stress, and recovery from stress. Forearm and forehead muscle potential, peripheral temperature, electrodermal response, heart rate, and systolic and diastolic blood pressure were monitored during these sessions. In addition, ratings of pain were obtained, and booklets II and III of the Edwards Personality Inventory were completed by each subject. The hypotheses that tension headache is associated with increased frontalis muscle tension and that migraine headache is associated with increased vasomotor activity were not supported with respect to resting levels, response to physical or psychological stress, or in relationship to pain. Personality differences between the three groups were observed. Migraine subjects appeared to be more perfectionistic and success-oriented than the other groups: and tension headache subjects, more anxious and insecure. It was suggested that although personality differences indicate the existence of two distinct disorders, physiological variables that were believed to be basic to the pathophysiology of these headaches (e.g. frontalis EMG in tension headache) do not distinguish these two types of headache.     

Hypnotic relaxation vs amitriptyline for tension-type headache: let the patient choose

(Headache 2012;52:785‐791) Background.— Although both pharmacological and behavioral interventions may relieve tension‐type headache, data are lacking regarding treatment preference, long‐term patient compliance, and feasibility of behavioral intervention in a standard neurological outpatient clinic setting. Objective.— To describe patient choice, long‐term compliance, and clinical outcome in a neurological clinic setting where patients are given the choice of the approach they wish to pursue. Design.— Patients presenting to the headache clinic with a diagnosis of tension‐type headache that justified prophylactic therapy (frequent episodic tension‐type headache or chronic tension‐type headache) were given the choice of amitriptyline (AMT) treatment or hypnotic relaxation (HR), and were treated accordingly. Patients were given the option to cross‐over to the other treatment group at each visit. HR was performed during standard length neurology clinic appointments by a neurologist trained to perform hypnosis (Y.E.). Follow‐up interviews were performed between 6 and 12 months following treatment initiation to evaluate patient compliance, changes in headache frequency or severity, and quality‐of‐life parameters. Results.— Ninety‐eight patients were enrolled, 92 agreed to receive prophylactic therapy of some kind. Fifty‐three (57.6%) patients chose HR of which 36 (67.9%) actually initiated this treatment, while 39 (42.4%) chose pharmacological therapy with AMT of which 25 (64.1%) patients actually initiated therapy. Patients with greater analgesic use were more likely to opt for AMT (P = .0002). Eleven of the patients initially choosing AMT and 2 of the patients initially choosing HR crossed over to the other group. Seventy‐four percent of the patients in the HR group and 58% of patients in the AMT group had a 50% reduction in the frequency of headaches (P = .16). Long‐term adherence to treatment with HR exceeded that of AMT. At the end of the study period, 26 of 47 patients who tried HR compared with 10 of 27 who tried AMT continued receiving their initial treatment. Conclusions.— HR treatment was a more popular choice among patients. Patients choosing HR reported greater symptom relief than those choosing AMT and were found to have greater treatment compliance. Patients receiving HR were less likely to change treatments. HR practiced by a neurologist is feasible in a standard neurological outpatient clinic setting; HR training should be considered for neurologists involved in headache treatment.     

Comorbidity of depressive and anxiety disorders in chronic daily headache and its subtypes

OBJECTIVE: To investigate the frequency of depressive and anxiety disorders in patients with chronic daily headache. BACKGROUND: There is a lack of data in the literature on the extent of psychiatric comorbidity in patients with different subtypes of chronic daily headache. METHODS: We recruited consecutive patients with chronic daily headache seen in a headache clinic from November 1998 to December 1999. The subtypes of chronic daily headache were classified according to the criteria proposed by Silberstein et al. A psychiatrist evaluated the patients according to the structured Mini-International Neuropsychiatric Interview to assess the comorbidity of depressive and anxiety disorders. RESULTS: Two hundred sixty-one patients with chronic daily headache were recruited. The mean age was 46 years, and 80% were women. Transformed migraine was diagnosed in 152 patients (58%) and chronic tension-type headache in 92 patients (35%). Seventy-eight percent of patients with transformed migraine had psychiatric comorbidity, including major depression (57%), dysthymia (11%), panic disorder (30%), and generalized anxiety disorder (8%). Sixty-four percent of patients with chronic tension-type headache had psychiatric diagnoses, including major depression (51%), dysthymia (8%), panic disorder (22%), and generalized anxiety disorder (1%). The frequency of anxiety disorders was significantly higher in patients with transformed migraine after controlling for age and sex (P =.02). Both depressive and anxiety disorders were significantly more frequent in women. CONCLUSION: Psychiatric comorbidity, especially major depression and panic disorders, was highly prevalent in patients with chronic daily headache seen in a headache clinic. These results demonstrate that women and patients with transformed migraine are at higher risk of psychiatric comorbidity.     

Expectations of patients attending a combined headache clinic

Abstract We audited the expectations of patients referred to a combined headache clinic from a specialist headache clinic and a pain relief unit due to the intractable nature of their headache. Our aim was to assess the expectations of definitive diagnosis for the cause of headache, as well as the acceptance of its symptomatic management. We reviewed the notes of all patients referred to the combined clinic over a 2-year period from January 1998 to January 2000. It has been standard practice in the clinic to document patients expectations of definitive diagnosis for the cause of their headache and for its symptomatic treatment. Fifty-two patients (29 women, 23 men; mean age, 40.5 years; range, 15–76 years) were referred to the combined clinic over the two years. These patients had been selected from a total of 460 new patients seen in the specialist headache clinic over this period. All patients had been reviewed by at least one consultant neurologist. Nearly all suffered chronic daily headache of mean duration 8.25 years (range, 1–40 years). Only three patients suffered from migraine as well. Forty patients (77%) were still concerned about the cause of their headaches; 13 (33%) of these wanted further investigations. Fourteen (27%) of the original 52 patients were discharged from the clinic, 9 (17%) were satisfied and accepted symptomatic management of their headache, 5 patients (10%) were unsatisfied and were still looking for a cause for their pain. Five more patients (10%) who demanded further investigations failed to keep follow-up appointments. The remaining 33 patients (64%) accepted symptomatic management within the clinic. One in five patients (20%) attending a tertiary referral clinic for symptomatic treatment of chronic headache did not want symptomatic treatment. They wanted to know the cause of the headache and be provided with a cure. This observation is important when one is assessing outcome measures, because 20% of these patients did not want symptomatic management, the only treatment on offer.     

Demographics of Headache in Elderly Patients

This study seeks to define the types of headache and the sex and age distribution, of headache patients aged 65 and older. A computer search was performed of outpatients with a diagnosis of headache or temporal arteritis seen during 1988 at the Cleveland Clinic Foundation. Of over 120,000 outpatients treated at the clinic 9,950 had a diagnosis of headache; of these, 359 were 65 or older. We found that, compared with younger patients, older headache patients had more tension headache and less migraine headache. In our population, temporal arteritis occurred with the same frequency as migraine, and in patients with a similar demographic profile.     

Headache and temporomandibular disorders: evidence for diagnostic and behavioural overlap

To assess the diagnostic and behavioural overlap of headache patients with temporomandibular disorders (TMD), individuals recruited from the general population with self-described headaches were compared with non-headache controls. The examination and diagnostic procedures in the Research Diagnostic Criteria (RDC) for TMD were applied to both sets of subjects by a blinded examiner. Following their examination, subjects used experience sampling methods to obtain data on pain, tooth contact, masticatory muscle tension, emotional states and stress. Results showed that a significantly higher proportion of the headache patients received an RDC/TMD diagnosis of myofascial pain than non-headache controls. Headache patients also reported significantly more frequent and intense tooth contact, more masticatory muscle tension, more stress and more pain in the face/head and other parts of the body than non-headache controls. These results are similar to those reported for TMD patients and they suggest that headache patients and TMD patients overlap considerably in diagnosis and oral parafunctional behaviours.     

Does medication overuse headache represent a behavior of dependence?

Medication overuse is relatively common in patients with frequent headache. To explore the prevalence of patients who meet the criteria for substance dependence in Diagnostic and Statistical Manual of Mental Disorders, Edition IV (DSM-IV), and to identify variables of substance dependence among patients with chronic daily headache, we recruited consecutive patients with chronic daily headache at a headache clinic from November 1999 to June 2004. Each patient completed a headache intake form, a dependence questionnaire modified from DSM-IV, and the Hospital Anxiety and Depression Scale (HADS). The presence of probable medication overuse headache (pMOH) was defined on the basis of the International Classification of Headache Disorders, 2nd edition, 2004. A total of 1,861 patients with chronic daily headache (1,369 women, 492 men; mean age, 49.6+/-15.4 years) were recruited. Almost half (895/1,861, 48%) met criteria of pMOH, and 606 of these patients (606/895, 68%) met three of five DSM-IV substance dependence criteria. In contrast, only 191 of 968 patients without pMOH (20%) met the DSM-IV criteria (OR=8.6, [7.0-10.6], chi-square test, P<0.001). Patients who fulfilled DSM-IV criteria of dependence had higher numbers of physician appointments in the past year. Multivariate logistic regression analyses revealed that migraine headache, frequent physician consultation, intensity of headache, and presence of a higher anxiety score were significant independent variables for substance dependence. Among patients with chronic daily headache, pMOH was associated with behaviors of substance dependence.     

Chronic tension-type headache in children and adolescents

In this study, the causes, predisposing factors and clinical features of chronic daily headache in children and adolescents were studied within the population of patients attending a specialist headache. The International Headache Society's (IHS) criteria for the diagnosis of chronic tension type headache (CTTH) were assessed for their applicability in the paediatric age group. Over a period of three years, demographic and clinical data were collected prospectively on all children who attended the clinic and suffered from daily attacks of headache. One hundred and fifteen children and adolescents (32% of all clinic population) had chronic daily headache, of whom 93 patients (81%) fulfilled the IHS criteria for the diagnosis of CTTH. They were between 3-15 years of age (mean: 11.1, SD: 2.3) and their female to male ratio was 1.2 : 1. Around one third of the patients also suffered from migraine (mainly migraine without aura). The headache was described as mild in 60.9%, moderate 36.5% and severe 2.6%. Headache was located at the forehead in 53% or over the whole of the head in 29.6%. Pain was described as 'just sore' or dull by 73.9%. During attacks of headache, at least half the patients reported light intolerance, noise intolerance, anorexia or nausea. Thirty-two percent of patients had at least one underlying chronic disease that may have contributed to the pathogenesis of the CTTH. Eleven percent had serious stressful events related to family illnesses and in four patients headaches were triggered by family bereavement. Fourteen percent were investigated with neuroimaging and 22% were referred for clinical psychology assessment and management. In conclusion, CTTH is a common cause of headache in children attending a specialist headache clinic. The clinical features closely match those of adult population and the IHS criteria for the diagnosis of CTTH can be adapted for use in children. Predisposing stressful risk factors, physical or emotional, are present in a large proportion.     

Personality and Headache Type: a Controlled Study

SYNOPSIS
This study tested several clinical hypotheses about personality traits of migraine and tension headache patients in a controlled design. Achievement motivation was found to be elevated in both headache groups. The tension headache patients also exhibited greater rigidity in comparison to the migraine group and the controls. In migraine patients, both traits were positively correlated with duration of headache attacks. When the two patient groups were combined , the headache patients had, in addition to raised achievement motivation and rigidity, more fear of failure and less impulsiveness than the controls. No evidence was found for higher prevalence of neuroticism and obsessive-compulsive behavior in the headache groups. Neither migraine nor tension headache patients revealed an abnormal pattern of defense mechanisms. Generally, those traits related to aspects of performance were found to be more prevalent in headache patients than in controls.     

A high incidence of migraine with aura among morbidly obese women

INTRODUCTION: Nearly two-thirds of adults in the United States and an increasing percentage of the population worldwide are overweight or obese. The relationship of obesity to headache has received inadequate attention. We evaluated the incidence of headache in a sample of morbidly obese women. METHODS: Morbidly obese women, attending the surgical preoperative clinic of Soroka University Medical Center for preoperative assessment for laparoscopic gastric banding were evaluated using a structured interview and their medical charts were reviewed. RESULTS: During a 2-month period, 27 morbidly obese women were interviewed, with a mean BMI of 41.07. Ten patients suffered from migraine with aura, three from migraine without aura, and four from tension headache. CONCLUSION: The unusually high incidence of migraine with aura can be attributed to extraovarian production of estrogen and estradiol in the adipose tissue. Further study is indicated to explore the therapeutic role of weight loss in headache care.     

Pediatric Headaches: A One Year Retrospective Analysis

SYNOPSIS
Epidemiologically, headaches are common in children. In order to ascertain the type of headache problems that result in a referral by pediatricians to a pediatric neurology clinic, the charts were reviewed of all patients evaluated in 1978 with the diagnosis of headache.A chief complaint of headache was given in 116 (22%) of all new patients evaluated. Final diagnostic groups were migraine headaches or variants (47%), tension headaches (28%), seizure equivalent (15%) and miscellaneous (10%). Almost two thirds of the patients were female. The mean ages of the seizure equivalent group and the tension headache group were similar, 9.3 and 9.5 years respectively. The migraine group was older with a mean age of 9.8 years. Of the 54 patients with migraine headaches, 78% were characterized as common migraine. This evaluation of the migraine patients differed from that of patients considered to have seizure equivalents on the basis of family history (63% vs 12%), abnormalities noted on neurological examination (7% vs 24%) and EEG abnormalities (20% vs 84%). Abnormalities in the tension headache group were less than 10% in all three categories evaluated.Although some overlaps exist, these data suggest a bimodel curve with migraine headaches and recurrent seizures at the extreme ends of the spectrum rather than a single entity with varying manifestations. Historically, the family history is the most distinguishing characteristic, but abnormalities on neurological evaluation, especially the EEG, were considered more significant factors in arriving at a diagnosis.     

Analysis of the patients attending a specialist UK headache clinic over a 3-year period

OBJECTIVE: This study analyzed the profile of patients who attended a specialist UK headache clinic over a 3-year period. METHODS: An audit was conducted of the clinical records of patients attending the specialist headache clinic at King's College, London, between January 1997 and January 2000. Data were collected for diagnoses given, current medications taken, medications prescribed and recommended, and investigations conducted. Results were calculated as numbers and proportions of patients for the 3-year period and for the 3 separate 12-month periods. RESULTS: A total of 458 patients were included in the audit. Most patients were diagnosed as having chronic daily headache (CDH, 60%) or migraine (33%). Prior to the clinic visit, most patients with CDH and migraine treated their headaches with analgesics, and there was little use of prophylactic medication. In the clinic, 74% of patients with CDH and 85% of migraineurs were prescribed prophylactic medication, and 81% of migraineurs were given triptans for acute treatment. Diagnostic testing was performed in 12% of the patients, and all results were normal or negative. CONCLUSIONS: CDH and migraine were the most common headache types encountered in this UK secondary-care clinic. Review of treatment patterns used prior to the initial clinic evaluation suggests that management of CDH and migraine in UK primary care is suboptimal, and educational initiatives are needed to improve headache management.     

Some Benefits of High Frontalis Tension in Tension Headache Sufferers

SYNOPSIS
Although the relationship between EMG levels and tension headache remains unclear, elevated frontalis EMG levels in tension headache sufferers are usually assumed to be part of the debilitating experience of headache. Elevated tension levels are seldom considered in an activation-type framework. Consequently, headache patients are encouraged to relax in almost all situations. Two experiments were performed to examine whether tension headache sufferers showed any benefits from elevated tension levels during periods demanding a sustained level of cognitive efficiency. Headache subjects were compared with non-headache subjects during discrimination and reaction time task performance across three levels of frontalis tension. Both groups' performance improved under increasing tension conditions relative to the low tension condition. In both experiments improvement was noted as a reduction in the most extreme scores, reflecting possible "mental blocks". In Experiment 2 median reactions times were also affected. In Experiment I the variation in reaction time scores across the tension levels was greater in the headache group than the non-headache group. Even when the optimal level of tension varied across task difficulty levels, low frontalis tension was never the optimal condition. It was concluded that tension headache prone individuals being treated by relaxation or biofeedback techniques need to be informed about the increased tendency towards slower responding under conditions of frontalis relaxation.