Changes in Psychological Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

Investigations into complementary and alternative medicine (CAM) approaches to address stress, depression, and anxiety of those experiencing chronic pain are rare. The objective of this pilot study was to assess the value of a structured massage therapy program, with a focus on myofascial trigger points, on psychological measures associated with tension-type headache. Participants were enrolled in an open-label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week periods) and a follow-up phase. Eighteen subjects with episodic or chronic tension-type headache were enrolled and evaluated at 3-week intervals using the State-Trait Anxiety Inventory, Beck Depression Inventory, and the Perceived Stress Scale. The Daily Stress Inventory was administered over 7-day periods during baseline and the final week of massage. Twice weekly, 45-minute massage therapy sessions commenced following the baseline phase and continued for 6 weeks. A significant improvement in all psychological measures was detected over the timeframe of the study. Post hoc evaluation indicated improvement over baseline for depression and trait anxiety following 6 weeks of massage, but not 3 weeks. A reduction in the number of events deemed stressful as well as their respective impact was detected. This pilot study provides evidence for reduction of affective distress in a chronic pain population, suggesting the need for more rigorously controlled studies using massage therapy to address psychological measures associated with TTH.KEYWORDS: Beck Depression Inventory, Complementary and Alternative Medicine, Daily Stress Inventory, Myofascial Pain, State-Trait Anxiety InventoryTension-type headache (TTH) is a 15 days per month and the chronic form dull aching headache that affects a 15 or more days per month¹. The epilarge percentage of the population sodic form of TTH affects between 20to varying degrees; it frequently resolves 42% of the population while the chronic with time or over-the-counter analgesics. form affects 2.5-3%^2,3. The authors of a however, for some individuals, the regu-recent review article concluded that larity of headache persists to a clinical worldwide disability attributable to condition that is recognized as either epi-headache is greater for TTH than other sodic or chronic, the difference based classifications including migraine head-primarily on the frequency of attack with ache⁴. The personal burden associated the episodic form occurring fewer than with these clinical forms of TTH can be substantial as it encompasses physical suffering alongside the personal economic effect from lost work days, which in turn perpetuate psychological symptoms such as stress, anxiety, and depression. Yet while TTH is the most prevalent form of headache and has a considerable impact on quality of life, treatment avenues have been under-investigated⁵. Moreover, due to the pervasive nature of TTH, pain measures alone that are typically used in the current literature provide incomplete information about the impact of headache on these associated psychological aspects.On average, perceived stress is higher in individuals who report chronic daily headache than in a healthy population⁶. Although recurrent TTH sufferers have similar physiological responses to laboratory stressors, they report a greater number of everyday stresses or daily “hassles” than do matched non-headache control subjects^7,8. Furthermore, stressful events are appraised as more stressful for recurrent TTH sufferers than for headache-free subjects⁷. Stress is also the most frequent headache trigger with 88% of patients from the general population in urban and rural areas reporting this variable as a cause for ensuing headache⁹. Finally, stress has been noted to exacerbate headache symptoms; and minor everyday stressors, rather than major life events, have been tagged as a contributor to maintaining or prolonging existing headache¹⁰. Thus, stress, particularly as a result of minor everyday frustrations, is an important area of investigation in relation to headache.In addition to stress, elevated anxiety and depression are commonly reported among those with headache¹¹. Again, the prevalence of anxiety and depression is greater in those with TTH than in a non-headache population¹¹, with chronicity of headache associated with increased affective distress¹². In adult patients with chronic TTH, major depression has been reported in 59%, with 25% experiencing an anxiety disorder¹³. The effect is not limited to adults; a study involving children and young adults with TTH reported that 50% suffer from one or more psychiatric disorders, with anxiety and depression the two most commonly cited¹⁴. In a study examining stress, depression, and anxiety in primary headache patients, depression and anxiety were found to frequently co-exist in the same subject¹⁵. Affective distress, in addition to pain, has been described as an important component to address in the treatment of TTH patients⁹.Complementary and alternative therapies have been used as corrective treatments for ailments including chronic pain and psychopathological conditions¹⁶. Of patients visiting a headache clinic, 40% use one or more complementary and alternative medicine modalities to reduce pain associated with chronic TTH¹⁷, with 26.7% using massage as a coping strategy for the pain¹⁸. Additional reference to the use of massage has been noted in several studies involving TTH patients. Scalp massage is cited as a primary self-treatment used by TTH sufferers¹⁹, and self-massage of cranial musculature is regularly employed by 25% of TTH patients as a quick means to reduce pain although the immediate benefit was found to wane within 5 minutes of stopping the maneuver²⁰. Although only a few pilot studies have directly investigated the effect of massage therapy on TTH, the findings have been positive for reducing headache frequency and intensity^21,22.In addition to its use for reducing headache pain, massage therapy has also been suggested as a means for reducing psychological distress. Reductions in measures of stress, anxiety, and depression have been noted in healthy populations^23–25 as well as those experiencing chronic pain^26,27. healthcare professionals also rank massage therapy as effective for stress and anxiety reduction²⁸. The effect of massage therapy on psychological affect in a TTH population has not been specifically studied. Subsequently, the objective of this study was to evaluate a replicable massage therapy treatment directed at cervical and cranial musculature on psychological measures including stress, anxiety, and depression in subjects with TTH.     

Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

Abstract

Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its efficacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45-minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereafter. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7±0.7 episodes per week during baseline to 3.7±0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2±1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0±1.3 to 2.8±0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.     

Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its efficacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45-minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereafter. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7±0.7 episodes per week during baseline to 3.7±0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2±1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0±1.3 to 2.8±0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.     

Factors associated with burden of primary headache in a specialty clinic

OBJECTIVE: To examine factors associated with social, occupational, and psychological burden of common primary headache (migraine and tension-type headache). BACKGROUND: The personal and social burden of primary headache is high. Health, occupational, social, and psychological factors contributing to burden in people with disabling headache have not been fully unravelled. METHODS: One hundred eighty consecutive patients with either migraine or tension-type headache attending a specialty headache outpatient clinic for the first time were evaluated over a 9-month period. Headache subtype was operationally defined according to International Headache Society criteria. Headache frequency, duration, and severity were recorded. Occupational and social disability were quantified using the Migraine Disability Assessment questionnaire. Psychological burden was quantified using the 28-item General Health Questionnaire, the Beck Depression Inventory, and the State-Trait Anxiety Inventory. Premorbid vulnerability to life stress was quantified using the neuroticism subscale of the Eysenck Personality Inventory. RESULTS: Patients with frequent (chronic) headache scored higher on the Migraine Disability Assessment questionnaire and had higher Beck Depression Inventory and General Health Questionnaire depression scores than those with less frequent (episodic) headache. Frequency of headache, but not pain severity, duration, or diagnosis, predicted both Migraine Disability Assessment total disability and General Health Questionnaire/Beck Depression Inventory depression. Neuroticism was predictive of depression but not disability. Patients with chronic migraine had the highest depression and disability scores. CONCLUSION: The number of days per month with headache is a key determinant of headache-related burden in those attending specialty clinics. Frequent (chronic) headache is associated with significantly higher psychopathology scores and general social impairment, but the direction of this relationship is not clear. Those with migraine and chronicity are the most impaired.     

Examination of anxiety, hostility and psychiatric disorders in patients with migraine and tension-type headache

The role of psychological factors related to headache has long been a focus of investigation. The aim of this study was to evaluate anxiety, depression, hostility and psychological symptoms in patients with migraine and tension-type headache (TTH) and to compare the results with healthy controls. Seventy-five subjects with migraine and 55 subjects with TTH (according to the criteria of the International Headache Society classification) and a control group including 73 healthy subjects were studied. The Buss-Durkee Hostility Inventory, Brief Symptom Inventory, State-trait Anxiety Inventory, Trait form were administered to the subjects. Compared with healthy controls, the patients with headache had significantly higher scores on measures of anxiety, depression and hostility and lower scores on psychological symptoms. The present results indicate the need to distinguish the unique dimensions of anxiety, depression and hostility that should be assessed in the population with headaches.     

Chronic Tension-Type Headache, Mood Depression and Serotonin: Therapeutic Effects of Fluvoxamine and Mianserine

SYNOPSIS
Forty out-patients affected by chronic tension-type headache were selected according to the diagnostic criteria of International Headache Society (IHS) Headache Classification Committee. In a controlled trial patients received placebo for a four-week baseline period, then they were randomized in double-blind fashion to therapy with mianserine (30-60 mg/day) or fluvoxamine (50-100 mg/day) for another eight-week period. Frequency of headache, pain severity and analgesic consumption were evaluated using a self-monitoring system. Mood depression was evaluated at 0, 4 and 8 weeks by using Zung'ss Self-Rating Depression Scale and Hamilton Rating Scale for Depression. Both drugs were beneficial in the treatment of chronic tension-type headache. Non-depressed subjects with more severe headache responded best to fluvoxamine, whereas mianserine was more effective in the treatment of depressed patients with moderate headache. These results suggest that central serotoninergic neurotransmission can play a role in the pathophysiology of chronic tension-type headache also in non-depressed patients.     

Coping styles of headache sufferers

Psychological factors are important in the chronification and aggravation of headaches. We studied 90 patients suffering from migraine, chronic daily headache (CDH) evolved from migraine, and episodic or chronic tension-type headache (TTH). Emotional, cognitive, and behavioral pain coping were assessed using the Kiel Pain Inventory (KPI), Beck's Depression Inventory, the State-Trait-Anxiety Inventory, and Quality of Life Questionnaire. In addition, the clinical course of headache was analyzed using a validated headache diary. The results were as follows. Firstly, the KPI is reliable internally for the assessment of pain-coping strategy employment among headache patients. Secondly, migraine sufferers were characterized by pronounced psychological abnormalities during the headache phase, demonstrating a less adaptive coping behavior. This was in contrast to the TTH patients, who showed more general distress manifesting in elevated anxiety and lower quality of life. The only factor which appeared to be essential for differentiating between migraine and TTH was the intensity of headache. Thirdly, chronic TTH and CDH evolved from migraine demonstrated more pronounced psychological disabilities and more severe clinical courses of headaches than episodic TTH or nontransformed migraine. The predictor variable for transformation of migraine was impairment of well-being/quality of life, and for transformation of TTH, the frequency of headaches and depression. Finally, analgesic misuse seems to be less important for chronification and transformation of headaches than the degree of psychological disability. This study draws attention to the role of psychological factors in the chronification of TTH and transformation of migraine and provides some recommendations for the behavioral treatment of chronic headaches.     

Nefazodone for chronic daily headache prophylaxis: an open-label study

OBJECTIVE: To assess effectiveness, tolerability, and safety of nefazodone as a prophylactic agent for chronic daily headache. BACKGROUND: Nefazodone is a potent, selective 5-HT2 antagonist with a distinct and atypical mechanism of action. The evolution of intermittent migraine to chronic daily headache has been linked to up-regulation of 5-HT2 receptors as well as other factors. Other effective migraine prophylactic medications are also 5-HT2 antagonists. Although research has shown nefazodone to be an effective antidepressant with a good tolerability and safety profile, its potential role in headache prophylaxis has not been tested. DESIGN: This was a two-center, open-label study with a 4-week baseline, followed by 12 weeks of treatment with nefazodone at a median dose of 300 mg (mean, 303.66 +/- 65.57 mg; range, 100 to 450 mg depending on tolerability). Potential patients were required to report more than 15 days of headache per month for at least 3 months prior to screening. Only patients with at least 15 days of recorded headache during baseline were included in the final sample (N=52). Most patients (n=48) had a history of migraine based on International Headache Society criteria; 4 had primarily chronic tension-type headache, but with more migrainous features than permitted by International Headache Society criteria for a primary chronic tension-type headache diagnosis. RESULTS: Significant improvement was demonstrated for all headache diary measures, with significance levels ranging from P<.00001 for average intensity, duration, headache index (intensity x duration), peak intensity, headache days per week, and peak impairment, to P<.0033 for severe headache days per week, and P<.0051 for rescue medication days. During the last month of treatment, 71% of the patients completing the study showed at least a 50% reduction in headache index compared to baseline, and 59% had at least a 75% improvement. Visual analog scales completed at 4-week intervals showed significant improvement in patient ratings of overall headache status, quality of life, sleep, mood (P<.00001), and sexual function (P<.00053). Significant improvements were also observed in the Pain Disability Index (P<.00007), Beck Depression Inventory-II (P<.00001), Hamilton Rating Scale for Depression (P<.0008), and Hamilton Psychiatric Rating Scale for Anxiety (P<.00007). Headache indices for patients in the top quartile on the depression and anxiety scales (clinical depression/anxiety) did not differ from the other patients during baseline. However, patients who were depressed or anxious showed significantly more improvement over the course of 12 weeks of treatment (P<.0006 or less for the depression scales, P<.026 for anxiety). Common mild to moderate adverse events reported by 10% or more of the patients included fatigue, nausea, dry mouth, dizziness, sleep disturbance, blurred vision, irritability/nervousness, and sedation. Only 5 of the 52 patients discontinued the study due to adverse events: headache (2 patients), and nausea, sleep disturbance, and a drugged feeling (1 patient each). CONCLUSIONS: These results provide preliminary support for the efficacy of nefazodone in the prophylaxis of chronic daily headache. In this sample, nefazodone was safe and generally well tolerated. Patient ratings of sexual function improved over the course of treatment, in contrast to what is generally observed with most antidepressants. Nefazodone may be particularly beneficial for patients with chronic daily headache and comorbid depression. Further research is indicated.     

The importance of anxiety and depression as factors in chronicization of primary headaches

A multicenter study was carried out in 10 Italian headache centers to investigate the prevalence of anxiety and depression in patients with chronic daily headache(CDH). The study investigated 219 patients (171 F; 48 M) including 53 cases of chronic tension-type headache (CTTH), 99 cases of CTTH+ migraine and 67 cases of transformed migraine (TM). The type of headache diagnosed at the beginning was episodic tension-type headache (ETTH, n=32), ETTH + migraine (n=2), CDH ab initio (n=22), migraine with/without aura (n=151), not classifiable migraine (n=7) and not classifiable headache (n=3). The assessment of anxiety and depression was carried out using a Zung self-rating scale for anxiety (Zung A) and for depression (Zung D). The results show that anxiety and depression levels, in each group, were related to sex (F>M). Anxiety, but not depression, was related to the length of chronicization process. Anxiety and depression did not correlate with type of headache at onset, with ongoing headache or, surprisingly, with the abuse of anti-inflammatory drugs. These data suggest the chronicization is a biological and psychological trait.     

Depression, automatic thoughts, alexithymia, and assertiveness in patients with tension-type headache

OBJECTIVE: The role of psychological factors related to headache has long been a focus of investigation. The aim of this study was to evaluate depression, automatic thoughts, alexithymia, and assertiveness in persons with tension-type headache and to compare the results with those from healthy controls. METHODS: One hundred five subjects with tension-type headache (according to the criteria of the International Headache Society classification) and 70 controls were studied. The Beck Depression Inventory, Automatic Thoughts Scale, Toronto Alexithymia Scale, and Rathus Assertiveness Schedule were administered to both groups. Sociodemographic variables and headache features were evaluated via a semistructured scale. RESULTS: Compared with healthy controls, the subjects with headache had significantly higher scores on measures of depression, automatic thoughts, and alexithymia and lower scores on assertiveness. Subjects with chronic tension-type headache had higher depression and automatic thoughts scores than those with episodic tension-type headache. CONCLUSIONS: These findings suggested that persons with tension-type headache have high depression scores and also may have difficulty with expression of their emotions. Headache frequency appears to influence the likelihood of coexisting depression.     

The role of anger and depression in recurrent headache

Individuals with tension-type headache report significant anger, depression, anxiety, and stressors. However, it is not clear to what extent these variables are interrelated. The objective of the present study was to explore the role of anger in headaches, and to examine its relationship to anxiety, depression, and daily life stressors. Participants were 65 young adult women who suffered from recurrent headaches. The sample was obtained in a large-scale screening of young adult women using the Headache Symptoms List to identify those with recurrent headache. Those individuals reporting headaches completed a battery of assessment measures that included the State-Trait Anger Expression Inventory, the Mood and Anxiety Symptoms Questionnaire, and the Hassles Scale. Results revealed a significant relationship between anger suppression and depression (r = 0.40, P<.01), as well as anger expression and anxiety (r = 0.41, P<.01) for those with headache. The use of the Mood and Anxiety Symptoms Questionnaire allowed for the separate analysis of general distress symptoms and symptoms more specific to anxiety and depression. Results indicated that those with headache experience more general, nonspecific distress rather than symptoms indicative of anxiety and depression (P<.01). In addition, the mixed headache group scored high on both general (mean, 28.96) and specific measures of depression (mean, 65.76) and on anger suppression (mean, 20.12), suggesting that they might experience more psychological distress than those with tension-type headache. The present results indicate the need to distinguish the unique dimensions of anxiety and depression that should be assessed in the population with recurrent headache.     

Multiple clinical and paraclinical analyses of chronic tension-type headache associated or unassociated with disorder of pericranial muscles

Thirty-two female patients fulfilling the diagnostic criteria of chronic tension-type headache underwent multiple clinical (severity index before and after biofeedback therapy; anxiety score) and paraclinical (pericranial EMG levels and pressure-pain thresholds, temporalis exteroceptive silent period) assessments. Twenty-three patients (72%) had at least one increased EMG level and/or at least one decreased pain threshold and qualified for the subgroup" associated with disorder of pericranial muscles" (code 2.2.1). Nine patients (28%) were within the normal range for both investigations and would have been classified in the subgroup "unassociated with such disorder" (code 2.2.2). No significant differences were found between these two groups of patients for headache severity, anxiety, response to biofeedback therapy or duration of temporalis second exteroceptive silent period. The various clinical and paraclinical parameters were not significantly correlated to each other. It is therefore suggested that the subdivision of chronic tension-type headache in two subgroups based on pericranial EMG levels and/or pain sensitivity might be artificial. Since both of the latter and temporalis silent periods vary independently, they appear complementary in the study of tension-type headache patients and probably represent peripheral abnormalities, which are induced to varying intensities by a common central nervous system dysfunction.     

An experimental study on the effectiveness of massage with aromatic ginger and orange essential oil for moderate-to-severe knee pain among the elderly in Hong Kong

OBJECTIVES: To assess the efficacy of an aromatic essential oil (1% Zingiber officinale and 0.5% Citrus sinesis) massage among the elderly with moderate-to-severe knee pain. METHOD: Fifty-nine older persons were enrolled in a double-blind, placebo-controlled experimental study group from the Community Centre for Senior Citizens, Hong Kong. The intervention was six massage sessions with ginger and orange oil over a 3-week period. The placebo control group received the same massage intervention with olive oil only and the control group received no massage. Assessment was done at baseline, post 1-week and post 4 weeks after treatment. Changes from baseline to the end of treatment were assessed on knee pain intensity, stiffness level and physical functioning (by Western Ontario and McMaster Universities Osteoarthritis index) and quality of life (by SF-36). RESULTS: There were significant mean changes between the three time-points within the intervention group on three of the outcome measures: knee pain intensity (p=0.02); stiffness level (p=0.03); and enhancing physical function (p=0.04) but these were not apparent with the between-groups comparison (p=0.48, 0.14 and 0.45 respectively) 4 weeks after the massage. The improvement of physical function and pain were superior in the intervention group compared with both the placebo and the control group at post 1-week time (both p=0.03) but not sustained at post 4 weeks (p=0.45 and 0.29). The changes in quality of life were not statistically significant for all three groups. CONCLUSION: The aroma-massage therapy seems to have potential as an alternative method for short-term knee pain relief.     

Baseline Sleep Disturbances Modify Outcome Trajectories in Adolescents With Chronic Pain Receiving Internet-Delivered Psychological Treatment

Over 50% of adolescents with chronic pain report comorbid sleep disturbances (eg, difficulties with falling asleep), which is associated with increased pain-related disability and poorer quality of life. However, limited longitudinal data are available to understand how sleep disturbance may impact response to psychological treatment. Our primary hypothesis was that baseline sleep disturbances would significantly modify how adolescents responded to an internet-delivered psychological intervention for chronic pain in terms of outcome trajectories. The sample included 85 adolescents, 12 to 17 years, with chronic pain recruited from a multidisciplinary pain clinic and headache clinic who received access to an internet-delivered psychological intervention for chronic pain. Baseline sleep assessment included actigraphy monitoring for 7 days and survey measures. Outcomes were assessed at baseline, 8 weeks, and 3 months including core pain-related outcomes, executive functioning, fatigue, positive and negative affect. Results demonstrated that greater baseline insomnia and poorer sleep quality was associated with worse outcome trajectories for pain-related disability, depression, anxiety, fatigue, negative affect, and executive functioning. Findings extend the limited studies that examine how sleep disturbance may modify effectiveness of psychological treatments for adolescent chronic pain and emphasize the importance of treating comorbid sleep disturbance. This trial was registered at clinicaltrials.gov (NCT04043962).PerspectiveOur study suggests that sleep deficiency, in particular insomnia and poor sleep quality, may modify the effectiveness of psychological treatments for chronic pain, highlighting the urgent need to screen youth for sleep problems prior to initiating treatment, and to consider implementation of sleep-specific treatments such as cognitive-behavioral therapy for insomnia.     

Disability is the major determinant of the severity of depressive symptoms in primary headaches but not in low back pain

Pain syndromes are often associated with depression. In a prospective study we analysed if determinants of depression differ among patients with different primary headaches and between headaches and non-headache pain. During a 2-year period between 1 February 2002 and 31 January 2004, 635 subjects (migraine n = 231; tension-type headache n = 176; cluster headache n = 11; patients with low back pain n = 103; and healthy subjects n = 114) seen by two neurologists filled in a questionnaire on pain characteristics, the MIDAS questionnaire and the Beck Depression Inventory. A multivariate general regression model was used to identify independent predictors of the severity of depressive symptoms. Pain was most frequent in chronic tension-type headache and most intense in the cluster subgroup (P < 0.001, Kruskal-Wallis ANOVA). In univariate tests gender, age, pain frequency, pain intensity and disability were all significantly associated with the severity of depressive symptoms. In the multivariate model disability was the most important independent determinant of the severity of depressive symptoms in the pooled headache group as well as in the migraine and tension-type headache subgroups. In contrast to patients with headache, pain frequency and pain intensity were the significant independent predictors of the severity of depressive symptoms in patients with low back pain. In a multivariate model, after controlling for other factors, determinants of the severity of depressive symptoms were different in headache and non-headache pain subjects, suggesting a different mechanism for developing depression in primary headaches and in other pain syndromes.     

Increased pain sensitivity is not a risk factor but a consequence of frequent headache: a population-based follow-up study

Altered pain sensitivity is believed to play an important role for chronification of headache. It has however mainly been evaluated in highly selected patients from headache clinics and never in longitudinal studies. The present study is a 12-year follow-up of a population-based study of primary headache disorders and pain perception, combining a diagnostic headache interview with examination of muscle tenderness and measurement of pressure pain thresholds in 1000 subjects drawn randomly from the general population in Denmark. The aim of the study was to explore the cause–effect relationship between the increased pain sensitivity and the development of headache. The pressure pain thresholds were normal at baseline but had decreased at follow-up in subjects who developed chronic tension-type headache over the 12-year period (p = 0.025). In subjects who developed frequent episodic tension-type headache the tenderness was normal at baseline but had increased at follow-up (p < 0.01) while the pain thresholds were normal both at baseline and at follow-up. The findings demonstrate that increased pain sensitivity is a consequence of frequent tension-type headache, not a risk factor, and support that central sensitization plays an important role for the chronification of tension-type headache.     

Identification of patients with headache at risk of psychological distress

OBJECTIVE: To test the hypothesis that anxiety and depression are associated with headache frequency, severity, and disability. BACKGROUND: There is significant comorbidity between chronic headache and psychological distress. Headache associated with anxiety or depression tends to be more severe and often requires supplementary psychological treatment in addition to headache therapy. Therefore, the identification of patients with headache who are at risk of psychological distress is important. METHODS: One hundred twenty-seven consecutive patients with headache attending a university headache clinic were evaluated. Questionnaires about headache symptoms and psychological distress were completed. Comparisons were made between psychological distress and headache frequency, severity, and disability. RESULTS: Depression and anxiety were significantly greater in the subjects of this study who had frequent headache (>4 days per week) and frequent headache-associated disability (activities reduced or prohibited because of headache >3 days per week). Subjects who reported their headache severity as typically severe were no more likely to report depression or anxiety than those with mild or moderate headache severity. Quality-of-life measures of physical and social functioning, emotional distress, and general health and vitality were reduced in subjects with frequent episodes of headache-associated disability. All areas, with the exception of general health perception, were reduced in subjects with frequent headache. Severe headache was associated with reductions in role and social functioning. CONCLUSIONS: Frequent headache and frequent disability are associated with depression, anxiety, and impaired quality of life. Reports of typical headache severity are less likely to correlate with psychological distress. Therefore, patients with headache who report frequent headache or frequent periods of headache-related disability should be further evaluated for the presence of psychological disturbance.     

Effect of botulinum toxin A injections in the treatment of chronic tension-type headache: a double-blind, placebo-controlled trial

In addition to vascular and supraspinal influences, contraction of craniofacial muscles or central sensitization processes following continuous nociceptive input of craniofacial muscles may play an important role in the pathogenesis of tension-type headache. Chemodenervation induced by botulinum toxin injection is successfully used to decrease muscle tension. If muscle tension is important in this type of headache, then botulinum toxin could be helpful in its treatment. We conducted a randomized, placebo-controlled study to examine the effect of 20 U botulinum toxin injected into frontal and temporal muscles in patients with chronic tension-type headache. During a baseline of 4 weeks and a posttreatment period of 8 weeks, the effect was evaluated with daily records and the West Haven-Yale Multidimensional Pain Inventory. Some improvement in affective variables were demonstrated in the botulinum group, but important outcome variables, such as pain intensity, the number of pain-free days, and consumption of analgesics, were not statistically different between the groups. Reasons for these moderate effects may include the injection sites, dose of botulinum toxin, and duration of treatment.     

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

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