Referred pain from the trochlear region in tension-type headache: a myofascial trigger point from the superior oblique muscle

BACKGROUND: Tension-type headache (TTH) is a prototypical headache in which myofascial trigger points (MTrPs) can play an important role. To our knowledge, MTrPs in the muscle tissues of the trochlear region, ie, the superior oblique muscle (SOM), have not been previously mentioned, and a referred pain pattern from this region has never been reported. OBJECTIVE: To describe the referred pain from the trochlear area based on the examination of MTrPs in the SOM in patients with episodic and chronic TTH (CTTH). DESIGN: A blinded, controlled study. METHODS: The trochlear region was examined in 15 patients with CTTH, 15 patients with episodic TTH (ETTH), and 15 control subjects. Referred pain elicited by different maneuvers performed during manual palpation, ie, maintained pressure, active muscle contraction, and stretching of the muscle, was assessed with a visual analogue scale. Patients with ETTH were examined on days when they were headache-free, whereas CTTH patients were examined on days in which headache intensity was less than 4 points on a 10-cm horizontal visual analogue scale. RESULTS: Eighty-six percent of patients with CTTH and 60% with ETTH had referred pain that originated from MTrPs in the SOM, while only 27% of the controls reported referred pain. This pain was perceived as a deep ache located at the retro-orbital region, sometimes extending to the supra-orbital region or the homo-lateral forehead. Pain intensity was greater in CTTH patients than in ETTH patients or control subjects (P < .001). CONCLUSIONS: MTrPs in the SOM may evoke a typical referred pain pattern in patients with TTH. The presence of a myofascial disorder in the trochlear region might contribute to the pathogenesis of TTH.     

Sertraline versus amitriptyline in the prophylactic therapy of non-depressed chronic tension-type headache patients

Abstract Patients with chronic tension- type headache (CTTH) are the most difficult to treat. Tricyclic antidepressants are the first-line therapeutic agents, but their anticholinergic side effects limit their usage. Selective serotonin reuptake inhibitors (SSRI) with fewer side effects than tricyclic antidepressants have also been used in treatment of CTTH, but the results are conflicting. In this study, prophylactic action of sertraline in treatment of nondepressed patients with CTTH was investigated and compared with amitriptyline in a prospective, randomized, open label, parallel-group study. A 4-week baseline period was followed by a 12-week treatment period with either 50 mg sertraline (n=41 patients) or 25 mg amitriptyline (n=44 patients). Efficacies of treatments were determined by using a headache diary, in which patients recorded the occurrence, number, intensity and duration of headaches in days, analgesic drug consumption and any adverse events. Both drugs reduced headache symptoms and analgesic drug consumption at the first, second and third months of treatment compared to baseline values. There was significant superiority of amitriptyline in the headache symptoms and drug consumption reductions versus sertraline at the second and third months of treatment. Side effects were more favorable in the sertraline-treated patients, but dropouts were similar in both groups. These results suggest that both drugs were effective in the treatment of non-depressed patients with CTTH, but in comparison between groups, amitriptyline was more effective than sertraline.     

Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study

Forward head posture (FHP) and neck mobility were objectively assessed in 25 patients with chronic tension-type headache (CTTH) and 25 healthy controls. Side-view pictures were taken in a sitting position to measure the cranio-vertebral angle. A cervical goniometer was employed to measure the range of all cervical motions. Patients with CTTH showed a smaller cranio-vertebral angle (45.3 degrees +/- 7.6 degrees) than controls (54.1 degrees +/- 6.3 degrees), thus presenting a greater FHP (P < 0.001). Patients also had lesser neck mobility for all cervical movements, except for right lateral flexion (P < 0.01). There was a positive correlation between the cranio-vertebral angle and neck mobility. Within the CTTH group, a negative correlation was found between the cranio-vertebral angle and headache frequency, but neck mobility did not correlate with headache parameters. Further research is needed to define a potential role of FHP and restricted neck mobility in the origin or maintenance of TTH.     

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 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   

Osmophobia in migraine and tension-type headache and its clinical features in patients with migraine

Intolerance to smell is often reported by migraine patients. This study evaluates osmophobia in connection with the diagnosis of migraine and episodic tension-type headache (ETTH). The characteristics of this symptom are also investigated. We recruited from our Headache Centre 1005 patients (772 female, 233 male; age 37 +/- 11 years), of whom 677 were migraine without aura (MoA), 130 migraine with aura (MA) and 198 TTH. Patients with two or more forms of primary headache were excluded. Among migraine patients, 43.9% with MoA and 38.5% with MA reported osmophobia during the attacks; none of the 198 TTH patients suffered this symptom. Most frequently offending odours were scents (63.9%), food (55.2%) and cigarette smoke (54.8%). Osmophobia appears structurally integrated into the migraine history of the patient. It seems to be a peculiar symptom favouring the diagnosis of migraine (MoA and MA) in the differential diagnosis with ETTH.     

Advances in the pathophysiology of tension-type headache: From stress to central sensitization

Tension-type headache (TTH) is the most common and most socioeconomically costly headache. Yet our knowledge regarding TTH pathophysiological mechanisms is still in its early stages. Psychological stress and weak coping mechanisms may initiate and propagate physiological pain via activation of second messengers in downstream substrates involved in pain. It seems that peripheral mechanisms are predominant in the episodic type (ETTH), whereas central mechanisms are involved in the chronic type (CTTH) of tension headache. The conversion from ETTH to CTTH is most relevant to the clinician and the patient, as CTTH is the most debilitating. This paper focuses and summarizes our current understanding of central sensitization, the process by which this conversion occurs in TTH, and proposes an integrated model to explain how ETTH progresses into CTTH in genetically susceptible individuals.     

Psychiatric comorbidity in medication overuse headache patients with pre-existing headache type of episodic tension-type headache.

BACKGROUND: Medication overuse headache (MOH) mostly evolves from migraine and episodic tension-type headache (ETTH). Chronic tension-type headache (CTTH) is another headache type that evolves over time from ETTH. It is well known that psychiatric comorbidity is high in MOH patients. AIM: To investigate the frequency of psychiatric comorbidity, and the intensity of depression and anxiety in MOH patients evolving from ETTH and to compare results with CTTH patients and MOH patients evolving from migraine. METHODS: Twenty-eight CTTH (Group C) and 89 MOH patients were included into the study. MOH patients were divided into two groups according to their pre-existing headache types: MOH patients with pre-existing ETTH (Group E, n = 31), and with pre-existing migraine (Group M, n = 58). All patients were interviewed with a psychiatrist and SCID-CV and SCID-II were applied. Beck Anxiety Inventory and Beck Depression Inventory scales were also performed. RESULTS: Eleven patients (39.3%) in Group C, 21 patients (67.7%) in Group E, and 31 patients (53.7%) in Group M were diagnosed to have comorbid psychiatric disorders. The psychiatric comorbidity was found significantly higher in Group E than Group C. In Group E, mood disorders were found significantly higher, but the difference between the two groups with regard to anxiety disorders was insignificant. Mean depression scores were significantly higher in Group E than Group C. The mostly diagnosed type was obsessive-compulsive personality disorder in all the three groups, and was statistically significant in Group M than Group C. CONCLUSION: Psychiatric comorbidity in MOH patients with pre-existing ETTH is common as in those with pre-existing migraine headache and MOH with regard to developing psychiatric disorders should be interpreted as a risk factor in chronic daily headache patients.     

Chronic tension-type headache treated with acupuncture, physical training and relaxation training. Between-group differences

The aim of this study was to compare acupuncture, relaxation training and physical training in the treatment of chronic tension-type headache (CTTH). The study comprised 90 consecutive patients with CTTH who were randomly allocated to acupuncture, relaxation training or physical training. Headache intensity, headache-free days and headache-free periods were registered using a visual analogue scale and a headache diary. The measurements were made 4 weeks before, immediately after, and 3 and 6 months after the treatment period. Immediately after the last treatment, the number of headache-free periods and of headache-free days was higher in the relaxation group compared with the acupuncture group. There were no other significant differences between the groups at any time point. The clinical implications of our findings are that relaxation training induced the most pronounced effects directly after the treatment period, compared with acupuncture and physical training.     

Acupuncture for tension-type headache: a multicentre,sham-controlled,patient-and observer-blinded,randomised trial

Acupuncture treatment is frequently sought for tension-type headache (TTH), but there is conflicting evidence as to its effectiveness. This randomised, controlled, multicentre, patient-and observer-blinded trial was carried out in 122 outpatient practices in Germany on 409 patients with TTH, defined as > or =10 headache days per month of which < or =1 included migraine symptoms. Interventions were verum acupuncture according to the practice of traditional Chinese medicine or sham acupuncture consisting of superficial needling at nonacupuncture points. Acupuncture was administered by physicians with specialist acupuncture training. Ten 30-min sessions were given over a six-week period, with additional sessions available for partial response. Response was defined as >50% reduction in headache days/month at six months and no use of excluded concomitant medication or other therapies. In the intent-to-treat analysis (all 409 patients), 33% of verum patients and 27% of sham controls (p=0.18) were classed as responders. Verum was superior to sham for most secondary endpoints, including headache days (1.8 fewer; 95% CI 0.6, 3.0; p=0.004) and the International Headache Society response criterion (66% vs. 55% response, risk difference 12%, 95% CI: 2%-21%; p=0.024).). The relative risk on the primary and secondary response criterion was very similar ( approximately 0.8); the difference in statistical significance may be due to differences in event rate. TTH improves after acupuncture treatment. However, the degree to which treatment benefits depend on psychological compared to physiological effects and the degree to which any physiological effects depend on needle placement and insertion depth are unclear.     

Myofascial trigger points, neck mobility, and forward head posture in episodic tension-type headache

OBJECTIVE: To assess the differences in the presence of trigger points (TrPs) in head and neck muscles, forward head posture (FHP) and neck mobility between episodic tension-type headache (ETTH) subjects and healthy controls. In addition, we assess the relationship between these muscle TrPs, FHP, neck mobility, and several clinical variables concerning the intensity and the temporal profile of headache. BACKGROUND: TTH is a headache in which musculoskeletal disorders of the craniocervical region might play an important role in its pathogenesis. Design.-A blinded, controlled pilot study. METHODS: Fifteen ETTH subjects and 15 matched controls without headache were studied. TrPs in both upper trapezius, both sternocleidomastoids, and both temporalis muscles were identified according to Simons and Gerwin diagnostic criteria (tenderness in a hypersensible spot within a palpable taut band, local twitch response elicited by snapping palpation, and elicited referred pain with palpation). Side-view pictures of each subject were taken in both sitting and standing positions, in order to assess FHP by measuring the craniovertebral angle. A cervical goniometer was employed to measure neck mobility. All measures were taken by a blinded assessor. A headache diary was kept for 4 weeks in order to assess headache intensity, frequency, and duration. RESULTS: The mean number of TrPs for each ETTH subject was 3.7 (SD: 1.3), of which 1.9 (SD: 0.9) were active, and 1.8 (SD: 0.9) were latent. Control subjects only had latent TrPs (mean: 1.5; SD: 1). TrP occurrence between the 2 groups was significantly different for active TrPs (P < .001), but not for latent TrPs (P > .05). Differences in the distribution of TrPs were significant for the right upper trapezius muscles (P= .04), the left sternocleidomastoid (P= .03), and both temporalis muscles (P < .001). Within the ETTH group, headache intensity, frequency, and duration outcomes did not differ depending on TrP activity, whether the TrP was active or latent. The craniovertebral angle was smaller, ie, there was a greater FHP, in ETTH patients than in healthy controls for both sitting and standing positions (P < .05). ETTH subjects with active TrPs in the analyzed muscles had a greater FHP than those with latent TrPs in both sitting and standing positions, though differences were only significant for certain muscles. Finally, ETTH patients also showed lesser neck mobility than healthy controls in the total range of motion as well as in half-cycles (except for cervical extension), although neck mobility did not seem to influence headache parameters. CONCLUSIONS: Active TrPs in the upper trapezius, sternocleidomastoid, and temporalis muscles were more common in ETTH subjects than in healthy controls, although TrP activity was not related to any clinical variable concerning the intensity and the temporal profile of headache. ETTH patients showed greater FHP and lesser neck mobility than healthy controls, although both disorders were not correlated with headache parameters.     

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.     

Chronic migraine and chronic tension-type headache are associated with concomitant low back pain: Results of the German Headache Consortium study

The objective of this study was to evaluate the association between low and frequent low back pain and chronic migraine (CM) and chronic tension-type headache (CTTH) in a large, German population-based sample. Headaches were diagnosed according to International Classification of Headache Disorders-2 criteria and categorized according to frequency (episodic 1–14 days/month or chronic ?15 days/month) and headache type (migraine or TTH). We defined frequent low back pain as self-reported low back pain on ?15 days/month. We calculated odds ratios and 95% confidence intervals (CI) using logistic regression analyses, adjusting for sociodemographic covariates. There were 5605 respondents who reported headache in the previous year, of whom 255 (4.5%) had Chronic Headache. Migraine was diagnosed in 2933 respondents, of whom 182 (6.2%) had CM. TTH was diagnosed in 1253 respondents, of whom 50 (4.0%) had CTTH. Among 9944 respondents, 6030 reported low back pain, of whom 1267 (21.0%) reported frequent low back pain. In adjusted models, the odds of having frequent low back pain were between 2.1 (95% CI 1.7-2.6) and 2.7 (95% CI 2.3-3.2) times higher in all episodic headache subtypes when compared to No Headache. The odds of having frequent low back pain were between 13.7 (95% CI 7.4-25.3) and 18.3 (95% CI 11.9-28.0) times higher in all chronic headache subtypes when compared to No Headache. Low and frequent low back pain was associated with CM and CTTH. Multiple explanations may contribute to the association of headache and back pain, including the notion that the neurobiology of chronic headache, independent of primary headache type, not only involves the trigeminal pain pathway, but is also a part of abnormal general pain processing.     

The prevalence of headache with emphasis on tension-type headache in rural Tanzania: a community-based study

The aim of the study was to assess the prevalence of headache with special attention to tension-type headache (TTH) in a rural area in northern Tanzania. A door-to-door study was performed using a standardized and validated questionnaire. A total of 7412 participants were screened. The total headache prevalence during the past year was 12.1%; the overall 1-year prevalence of TTH was 7%; 5% reported episodic TTH and 0.4% chronic TTH. Borderline cases (International Headache Society code 2.3) were described in 1.6%. The prevalence of headache was highest in the 41–50-year-old group in women and in the 61+ age group in men. This is the first account of the prevalence of TTH in a rural Tanzanian population, and shows that headache in general and, more specifically, TTH are prevalent disorders that deserve attention. However, the prevalence of primary headache seems to be lower than in Western countries.     

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.     

Lumiracoxib is effective in the treatment of episodic tension-type headache

OBJECTIVE: To evaluate the efficacy of single doses of lumiracoxib, the most selective cyclo-oxygenase (COX)-2 inhibitor, in the treatment of episodic tension-type headache (ETTH), with particular emphasis on time to onset of analgesia. BACKGROUND: ETTH is the most frequently occurring type of headache with an annual prevalence rate of up to 40%. Some patients with ETTH do not respond to currently available therapies, thus an effective analgesic is needed that provides a rapid onset of analgesia alongside significant pain relief. Lumiracoxib is the most selective COX-2 inhibitor developed for the treatment of acute and chronic pain. METHODS: In this single-center, randomized, double-blind, double-dummy, placebo-controlled, parallel-group study, patients with ETTH were randomly assigned to receive single-dose lumiracoxib (200 or 400 mg, n = 60 in each group) or placebo (n = 30) within 1 hour of an ETTH. Efficacy was assessed over a 3-hour period, the primary efficacy variable being the time to onset of analgesia. Other efficacy variables included summed pain intensity difference from 0 to 3 hours after dosing, time-specific pain intensity difference, time-specific pain relief, time-specific pain relief intensity difference, total pain relief over 0 to 3 hours, patient's global evaluation of treatment effect, the proportion of patients who achieved onset of analgesia by 1 hour and time to rescue medication intake. Safety was assessed by monitoring and recording of all adverse events (AEs). RESULTS: The median time to onset of analgesia was significantly faster for lumiracoxib 200 mg (47 minutes; 95% confidence interval [CI]: 41, 52) and lumiracoxib 400 mg (41 minutes; 95% CI: 36, 48) than for placebo (>3 hours; both P < .001). Both doses of lumiracoxib were significantly superior to placebo for all secondary efficacy variables. There were no AEs recorded in any treatment group. CONCLUSIONS: Single 200 or 400 mg doses of lumiracoxib provided rapid and effective relief from the acute pain associated with ETTH.     

Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial

We conducted a multicentre, randomized controlled trial with blinded outcome assessment. The treatment period was 6 weeks with follow-up assessment immediately thereafter and after 6 months. The objective was to determine the effectiveness of a craniocervical training programme combined with physiotherapy for tension-type headache. Eighty-one participants meeting the diagnostic criteria for tension-type headache were randomly assigned to an exercise group (physiotherapy and an additional craniocervical training programme) and a control group (physiotherapy alone). The primary outcome measure was headache frequency. Secondary outcomes included headache intensity and duration, Quality of Life (SF-36) and the Multidimensional Headache Locus of Control scale (MHLC). At 6 months' follow-up, the craniocervical training group showed significantly reduced headache frequency, intensity and duration (P < 0.001 for all). Effect sizes were large and clinically relevant. Loss to follow-up amounted to 3.7%. Physiotherapy including craniocervical training reduces symptoms of tension-type headache significantly over a prolonged time frame.     

Pericranial tenderness is not related to nummular headache

The aim of the present study was to investigate whether nummular headache (NH) patients show increased pericranial tenderness in relation to healthy subjects, and to compare pericranial tenderness between both NH and chronic tension-type headache (CTTH) patients. Three tenderness (total, cephalic and neck) scores were objectively and blinded assessed in 10 NH patients, 10 CTTH subjects and 10 healthy matched controls. No significant differences were found in any tenderness score between the symptomatic and non-symptomatic sides in NH, or between right and left sides in either CTTH or control groups. All tenderness scores were significantly greater in CTTH patients compared with both NH patients and controls (P < 0.001), but not significantly different between NH patients and controls. Therefore, NH patients had lower tenderness than patients with CTTH and did not show increased tenderness when compared with healthy subjects. In addition, tenderness in NH patients was quite symmetrical between both the symptomatic and the non-symptomatic sides. The absence of increased pericranial tenderness could be clinically useful in distinguishing NH from CTTH. Current findings expand the evidence supporting the notion that NH is a non-generalized and rather limited disorder, marking the presence of a well-delimited painful zone.     

Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache

OBJECTIVE: To assess the presence of trigger points (TrPs) in several head and neck muscles in subjects with chronic tension-type headache (CTTH) and in healthy subjects; and to evaluate the relationship of these TrPs with forward head posture (FHP), headache intensity, duration, and frequency. BACKGROUND: Tension-type headache (TTH) is a headache in which myofascial TrPs in head and neck muscles might play an important etiologic role. DESIGN: A blinded, controlled, pilot study. METHODS: Twenty-five CTTH subjects and 25 matched controls without headache were studied. TrPs in bilateral upper trapezius, sternocleidomastoids, and temporalis muscles were identified according to Simons et al's diagnostic criteria: tenderness in a hyperirritable spot within a palpable taut band, local twitch response elicited by snapping palpation, and elicited referred pain with palpation. A TrP was considered active if the subject recognized the evoked referred pain as familiar headache. If the evoked referred pain was not recognized as familiar headache, the TrP was considered as latent. Side-view pictures of each subject were taken in both sitting and standing positions in order to assess FHP by measuring the cranio-vertebral angle. Both measurements were made by a blinded assessor. A headache diary was kept for 4 weeks in order to assess headache intensity, frequency, and duration. RESULTS: The mean number of TrPs on each CTTH subject was 3.9 (SD: 1.2), of which 1.9 (SD: 1.2) were active TrPs and 1.9 (SD: 0.8) were latent TrPs. Control subjects only exhibited latent TrPs (mean: 1.4; SD: 0.8). There was a significant difference between the CTTH group and the controls for active TrPs (P < .001), but not for latent TrPs (P > .05). Differences in the distribution of active and latent TrPs within each muscle were also significant for all the analyzed muscles (P < .01). CTTH subjects with active TrPs in the right upper trapezius muscle or left sternocleidomastoid muscle showed a greater headache intensity and duration, but not headache frequency, compared to those with latent TrPs (P < .05). Active TrPs in the right temporalis muscle were associated with longer headache duration (P < .01), whereas active TrPs in the left temporalis muscle were associated with greater headache intensity (P < .05). CTTH subjects with active TrPs in the analyzed muscles had a greater FHP than those with latent TrPs in both sitting and standing positions. Differences were only significant for TrPs in the left sternocleidomastoid and FHP in the sitting position (P < .01). CONCLUSIONS: Active TrPs in upper trapezius, sternocleidomastoid, and temporalis muscles were associated with CTTH. CTTH subjects with active TrPs usually reported a greater headache intensity and longer headache duration than those with latent TrPs. CTTH subjects with active TrPs tended to have a greater FHP than CTTH subjects with latent TrPs.     

Predictor variables for identifying patients with chronic tension-type headache who are likely to achieve short-term success with muscle trigger point therapy

To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with tension-type headache pain who are likely to benefit from muscle trigger point (TrP) therapy. The purpose of this study was to develop a preliminary clinical prediction rule (CPR) to identify chronic tension-type headache (CTTH) patients who are likely to experience a successful response from TrP therapy. Consecutive patients with CTTH underwent a standardized examination and then received six sessions of TrP therapy over 3 weeks (two sessions per week). They were classified as having experienced a successful outcome at short-term (1 week after discharge) and 1-month follow-up based on a 50% reduction on at least one headache parameter (intensity, frequency or duration) and self-report perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for identifying treatment success. Data from 35 patients were included, of which 19 (55%) experienced a successful outcome. A CPR with four variables for short-term (headache duration < 8.5 h/day, headache frequency < 5.5 days/week, bodily pain < 47 and vitality < 47.5) and a CPR with two variables for 1-month (headache frequency < 5.5 days/week and bodily pain < 47) follow-up were identified. At short-term follow-up, if three of four variables [positive likelihood ratio (LR) 3.4] were present, the chance of experiencing a successful outcome improved from 54% to 80%, and if all the variables (positive LR 5.9) were present, the probability of success was 87.4%. At 1-month follow-up, if one of two variables (positive LR 2.2) was present, the probability of success increased from 54% to 72%, and if both variables (positive LR 4.6) were present, the probability of success was 84.4%. The present CPR provides the potential to identify CTTH patients who are likely to experience short-term and 1-month follow-up success with a muscle TrP therapy approach. Future studies are necessary to validate the CPR.