Paroxysmal stabbing headache in the multiple dermatomes of the head and neck: a variant of primary stabbing headache or occipital neuralgia?

A paroxysmal stabbing or icepick-like headache in the multiple nerve dermatomes, especially involving both trigeminal and cervical nerves, has not been fully explained or classified by the International Classification of Headache Disorder, 2(nd) Edition (ICHD-II). Of patients with acute-onset paroxysmal stabbing headache who had visited the Hallym University Medical Center during the last four years, 28 subjects with a repeated stabbing headache involving multiple dermatomes at the initial presentation or during the course were prospectively enrolled. All patients were neurologically and otologically symptom free. A coincidental involvement of both trigeminal and cervical nerve dermatomes included seven cases. Six cases involved initially the trigeminal and then cervical nerve dermatomes. Five cases showed an involvement of the cervical and then trigeminal nerve dermatomes. The remaining patients involved multiple cervical nerve branches (the lesser occipital, greater occipital and greater auricular). Pain lasted very shortly and a previous history of headache with the same nature was reported in 13 cases. Preceding symptom of an infection and physical and/or mental stress were manifested in seven and six subjects, respectively. All patients showed a self-limited benign course and completely recovered within a few hours to 30 days. Interestingly, a seasonal gradient in occurrence of a stabbing headache was found in this study. A paroxysmal stabbing headache manifested on multiple dermatomes can be explained by the characteristics of pain referral, and may be considered to be a variant of primary stabbing headache or occipital neuralgia.     

Increased prevalence of depression and anxiety among subjects with metabolic syndrome and known type 2 diabetes mellitus – a population-based study

Objectives: The metabolic syndrome (MetS) is a cluster of cardiovascular risk factors associated with high cardiovascular morbidity and mortality. The MetS and its elements have been linked to anxiety and depressive disorders. The aim of the current cross-sectional study was to assess the prevalence of depression and anxiety, measured by the Zung Self-Rating Scale in subjects with and without the metabolic syndrome and diabetes.

Methods: A total of 2111 adults were included, 1155 female, age 47.6 (13.7) and 956 male, age 45.2 (13.5). All participants filled questionnaires covering current and past disorders and medication, smoking and family history. Zung self-rating depression and anxiety scales were completed. Body weight, height and waist circumference were measured, BMI was calculated, serum glucose and lipids were measured.

Results: Depression (SDSi) and anxiety scores (SASi) were higher in the females and increased with age (p < 0.001). SDSi was higher in the females and males with metabolic syndrome (MetS) (50.9 ± 9.8 vs. 45.9 ± 8.9, p < 0.001 and 42.7 ± 9.2 vs. 40.5 ± 7.9 p < 0.001, respectively). SASi was higher in the MetS subjects (females 50.59 ± 11.35 vs. 45.97 ± 10.58, p < 0.001; males 40.48 ± 10.1 vs. 38.04 ± 8.42, p < 0.001). Both SDSi and SASi were higher in the subjects with known diabetes than in those with normal glucose tolerance (Mann-Whitney both p < 0,001). Positive depressive scores were more prevalent in subjects with MetS than those without (females 54% vs. 31.6%, p < 0.001; males 22.7% vs. 12.3%, p < 0.001). Depression and anxiety were more prevalent in the subjects with known diabetes than in those with normal glucose tolerance but not in the newly-diagnosed diabetes. The OR for depressiveness was 2.0 (1.3; 2.6) in subjects with MetS and 4.2 (2.3; 7.8) in those with known diabetes.

Conclusions: In conclusion, depressiveness and anxiety were associated positively with age and female gender and were more prevalent among subjects with MetS and known diabetes mellitus.     

Non–hypothalamic cluster headache: the role of the greater occipital nerve in cluster headache pathogenesis

Cluster headache is marked by its circadian rhythmicity and the hypothalamus appears to have a significant influence over cluster pathogenesis. However, as not all cluster patients present in the same manner and not all respond to the same combination of medications, there is likely a nonhypothalamic form of cluster headache. A patient is presented who began to develop cluster headaches after receiving bilateral greater occipital nerve (GON) blockade. His headaches fit the IHS criteria for cluster headache but had some irregularities including frequent side shifting of pain, irregular duration and time of onset and the ability of the patient to sit completely still during a headache without any sense of agitation. This article will suggest that some forms of cluster headache are not primarily hypothalamic influenced and that the GON may play a significant role in cluster pathogenesis in some individuals.     

Cervico-cephalalgiaphobia: a subtype of phobia in patients with cervicogenic headache and neck pain? A pilot study

Objectives: The term ‘cephalalgiaphobia’ was introduced in the mid-1980s and defined as fear of migraine (attacks). We hypothesized that a specific subtype of cephalalgiaphobia affects patients with cervicogenic headache (CEH). This study aimed to: (1) define the term ‘cervico-cephalalgiaphobia’; (2) develop a set of indicators for phobia relevant to patients with CEH; and (3) apply this set to a practice test in order to estimate the frequency of cervico-cephalalgiaphobia in the Dutch primary care practice of manual physical therapy.

Methods: A systematic approach was used to develop a definition and potential indicators for cervico-cephalalgiaphobia. An expert group appraised the definition and the set of indicators (score per indicator: never; sometimes; often/always). An invitation to participate in the practice test was sent to Dutch manual physical therapy practices (n?=?56) representing 134 manual physical therapists (MPTs). The cut-off point for percentages of scores for coverage of the indicators was set at ≥?60%.

Results: The expert group agreed with the proposed definition of cervico-cephalalgiaphobia. A set of eight indicators for cervico-cephalalgiaphobia was selected from 10 initial indicators. Thirty-six MPTs provided data from 46 patients diagnosed with CEH. The coverage of ‘often/always’ was substantial for the indicators, ‘Short-term positive results in previous manual physical therapeutic treatment’, ‘Shorter interval between treatment sessions’, ‘Fear of “locked facet joints” of the neck’, ‘More frequent manipulation’, and ‘Fear of increase in headaches’. Coverage was also substantial for ‘never’ regarding ‘Long-term positive results in previous manual physical therapeutic treatment’. ‘Confirmation of “locked facet joints” of the cervical spine by MPT as a cause for increase of CEH’ scored ‘often/always’ in all patients. Coverage for ‘Increased use of medication with insufficient effect’ was substantial, scoring as ‘sometimes’ in 39 (84.8%) patients.

Discussion: Cervico-cephalalgiaphobia was defined and a set of eight indicators formulated based on the literature and clinical expertise. The practice test provides valuable information on the frequency of indicators for cervico-cephalalgiaphobia in the Dutch manual physical therapy practice, suggesting that cervico-cephalalgiaphobia is common in patients with CEH.     

Normalization of the trapezius sEMG signal – a reliability study on women with and without neck-shoulder pain

Objective

To evaluate within- and between-days reliability of two normalization methods of surface electromyography (sEMG) recordings of the trapezius muscle.

Respiratory dysfunction in patients with chronic neck pain – Influence of thoracic spine and chest mobility

Patients with chronic neck pain exhibit various musculoskeletal deficits and respiratory dysfunction. As there is a link between thoracic and cervical spine motion, the aim of this study was to investigate the relationship between thoracic spine and chest mobility with respiratory function and neck disability. Nineteen patients with chronic neck pain (7 male, 46.6 ± 10.5 years) and 19 healthy subjects (7 male, 46.5 ± 9.9 years) participated. Spirometry was conducted to determine maximal voluntary ventilation (MVV), maximal inspiratory (Pi_max) and maximal expiratory pressure (Pe_max). Thoracic spine mobility was measured using the Spinal Mouse^®. Chest expansion was assessed by subtracting chest circumference during maximal inspiration and expiration. Neck function was investigated by examining range of motion, forward head posture, neck flexor muscle synergy endurance and self-assessment (Neck disability index (NDI)). Correlation analyses and multiple linear regression analyses were conducted using MVV, Pi_max and Pe_max as independent variables. Thoracic spine mobility during flexion and chest expansion correlated significantly to MVV (r = 0.45 and 0.42), all neck motions (r between 0.39 and 0.59) and neck muscle endurance (r_S = 0.36). Pe_max and Pi_max were related to NDI (r = −0.58 and −0.46). In the regression models, chest expansion was the only significant predictor for MVV, and Pe_max was determined by neck muscle endurance. These results suggest that chronic neck pain patients should improve the endurance of the neck flexor muscles and thoracic spine and chest mobility. Additionally, these patients might benefit from respiratory muscle endurance training, possibly by increasing chest mobility and Pe_max.     

Referred pain from myofascial trigger points in head and neck–shoulder muscles reproduces head pain features in children with chronic tension type headache

Our aim was to describe the referred pain pattern and areas from trigger points (TrPs) in head, neck, and shoulder muscles in children with chronic tension type headache (CTTH). Fifty children (14 boys, 36 girls, mean age: 8 ± 2) with CTTH and 50 age- and sex- matched children participated. Bilateral temporalis, masseter, superior oblique, upper trapezius, sternocleidomastoid, suboccipital, and levator scapula muscles were examined for TrPs by an assessor blinded to the children’s condition. TrPs were identified with palpation and considered active when local and referred pains reproduce headache pain attacks. The referred pain areas were drawn on anatomical maps, digitalized, and also measured. The total number of TrPs was significantly greater in children with CTTH as compared to healthy children (P < 0.001). Active TrPs were only present in children with CTTH (P < 0.001). Within children with CTTH, a significant positive association between the number of active TrPs and headache duration (r _s = 0.315; P = 0.026) was observed: the greater the number of active TrPs, the longer the duration of headache attack. Significant differences in referred pain areas between groups (P < 0.001) and muscles (P < 0.001) were found: the referred pain areas were larger in CTTH children (P < 0.001), and the referred pain area elicited by suboccipital TrPs was larger than the referred pain from the remaining TrPs (P < 0.001). Significant positive correlations between some headache clinical parameters and the size of the referred pain area were found. Our results showed that the local and referred pains elicited from active TrPs in head, neck and shoulder shared similar pain pattern as spontaneous CTTH in children, supporting a relevant role of active TrPs in CTTH in children.     

Synovial folds - a pain in the neck?

The synovial folds of the cervical spine are regarded as a potential source of neck pain and headache, especially following whiplash injury. Damage to the synovial folds following motor vehicle trauma has been well documented in post-mortem studies. However, methods of identifying injury to the synovial folds in the survivors of motor vehicle trauma have proven elusive to date. Recently, it has been made possible to image the synovial folds in vivo using magnetic resonance imaging. This now makes it feasible to investigate the potential involvement of synovial folds in the generation of neck pain and headache and its relief using spinal manipulation. This paper reviews critically the morphology of the synovial folds of the cervical spine that underpins the hypotheses proposed to explain their functional and clinical significance and a new system of naming and classifying the synovial folds is presented. Although there is some evidence to support the contribution of the synovial folds to neck pain, several theories have little or no support and require investigation and further evaluation. These findings have implications for understanding the anatomical basis of neck pain and headache and the rationale for the use of spinal manipulation in their management.     

The ProFitMap-neck – reliability and validity of a questionnaire for measuring symptoms and functional limitations in neck pain

Purpose: To assess overall reliability and validity of a neck-specific questionnaire, the Profile Fitness Mapping neck questionnaire (ProFitMap-neck), on three chronic neck pain groups. Method: Participating groups were as follows: whiplash associated disorders, inpatient care (IP-WAD, n?=?127); nonspecific neck pain, inpatient care (IP-NS, n?=?83) and nonspecific neck pain subjects (non-IP-NS, n?=?104). All groups answered the ProFitMap-neck and the SF-36, whereas non-IP-NS also answered the Neck Disability Index (NDI) and the Functional Self-Efficacy Scale (SES). Internal consistency, test–retest reliability and components of convergent construct, face and content validity were determined for the ProFitMap-neck. Results: The ProFitMap-neck showed good internal consistency in all three groups, and ICC test–retest reliability (0.80–0.91). Good correlation (0.66–0.78) and highest agreement was reached with NDI. According to the International Classification of Functioning, Disability and Health, the symptom scale of the ProFitMap-neck was mainly classified to the domain of impairments–body functions, and the functional limitation scale to the activity limitation domain. Conclusion: The results indicate that the ProFitMap-neck is valid for measuring symptoms and functional limitations in people with chronic neck pain. The combination of a composite total score of symptoms and function as well as separate scores of each domain makes ProFitMap-neck suitable for research as well as in clinical practice.

Implications for Rehabilitation

• The ProFitMap-neck can be used as a valid self-assessment tool for measuring symptoms and functional limitations in people belonging to the most prevalent categories of neck pain.

• The combination of the symptom and functional limitation questionnaire scores in a total score can be used for an overall clinical judgment.

     

Does the region of pain influence the presence of sensorimotor disturbances in neck pain disorders?

Impairments in sensorimotor control have been demonstrated in neck pain disorders. However, there are more anatomical and neurophysiological connections between the sensorimotor control system and the upper cervical region and thus potential for greater disturbances in those with upper region pain. This study investigated whether sensorimotor impairment was greater in those suffering pain from the upper rather than lower cervical spine region, taking the onset of pain into account.Sixty-four subjects with persistent neck pain were divided into 4 groups -upper and lower region non-traumatic and upper and lower region traumatic. Cervical Joint Position Error (JPE), smooth pursuit neck torsion (SPNT) and standing balance tests were compared between groups.The lower non-traumatic group demonstrated significantly less (p < 0.03) deficit in SPNT compared to all other groups as well as less total energy of sway on the eyes open balance tests (p < 0.05) compared to both traumatic neck pain groups. The upper traumatic group demonstrated significantly greater JPE following rotation to the right (p < 0.04) when compared to both lower groups.Less sensorimotor dysfunction appears to occur in those with lower compared to upper cervical region pain, although this depends on whether trauma is involved in the onset of pain.     

Chronic pain affects the whole person – a phenomenological study

Abstract

Purpose: The aim of this qualitative study was to explore participants’ perspectives on the effects of chronic pain on the psychophysical unity. Methods: Thirty-four chronic pain outpatients were interviewed, and the transcribed interviews were analysed with Giorgi’s four-phase phenomenological method. The mean age of the participants was 48 years, and 19 of them were women. For 21 of the participants, the pain duration was more than 5 years, and most had degenerative spinal pain. Results: The results of this whole research project indicated that the phenomenon chronic pain consisted of four essential themes: Pain affects the whole person, invisibility, negativity, and dominance of pain. This study concentrates only on one theme “Chronic pain affects the whole person”, in which were found eight subthemes in the interviews. The strongest argument made by the participants was not the physical pain itself but the psychosocial consequences, such as distress, loneliness, lost identity, and low quality of life which were their main problems. Conclusions: In multidisciplinary holistic rehabilitation, it is essential to take care of the patient’s psychological distress. A potential source of psychosocial symptoms may be the subjective responses to experience of chronic pain due to the subjective meanings of pain.

• Implications for Rehabilitation

• About chronic pain

• Pain is an experience, not only an aversive sensation. Intensity of pain describes only the sensation, not the experience of pain.

• In chronic pain, the main complaint may be not the physical pain, but the distress. In rehabilitation, the patient needs to be taken as a whole person.

• Multidisciplinary rehabilitation, including patient counselling should be the fundamental part of treatment.

• In rehabilitation, the individual meaning of chronic pain needs to be disclosed.

     

The role of associative learning and fear in the development of chronic pain – a comparison of chronic pain and post-traumatic stress disorder

Background:

Associative learning is the theory that two stimuli can be paired to produce similar behavioral responses. In this model, a previously innocuous stimulus can become paired with a noxious stimulus to a point that this previously innocuous stimulus can result in the perception of pain.

Objectives:

This review discusses concepts related to neural activation and structural alterations in the presence of both chronic pain and post-traumatic stress disorder (PTSD). The role of associative learning and protective memory-based behavioral responses in the perception of pain is explored to provide a framework to inform clinical management of individuals with chronic pain and will be linked to the presence of actual or perceived threat or fear.

Major Findings:

Current research demonstrates that in individuals with chronic pain, cortical and subcortical processing of information shifts from normal nocioceptive processing areas to the medial prefrontal, anterior cingulate, and insular cortices, as well as the hippocampus (Hip) regions, all of which also show dysregulation, signs of gray matter atrophy, and changes in epigenetic coding. Because these regions are involved in memory, emotional processing, learning, and conditioning, it is reasonable to suggest that associative learning may be involved in the processing of both pain and PTSD.

Conclusions:

Clinically, rehabilitation paradigms that incorporate early intervention, positive expectation, therapeutic neuroscience education, visual imagery, movement retraining, and manual therapy all have the potential to change not only pain behavior but also the neural circuitry, epigenetic coding, and cortical morphology underlying chronic pain.     

ECG markers associated with ischemic stroke at young age – a case-control study

Introduction: Certain electrocardiographic (ECG) abnormalities are associated with ischemic stroke (IS), especially cardioembolic subtype. Besides atrial fibrillation, markers of left ventricular hypertrophy (LVH) or atrial pathology also reflect elevated risk. We studied the association of ECG markers with IS in young adults.

Methods: We performed a case-control study including 567 consecutive IS patients aged 15–49 years (inclusion period: 1994–2007) and one or two age- and sex-matched control subjects enrolled during 1978–1980 (n?=?1033), and investigated also the stroke aetiologic subgroups. We studied ECGs of all participants for markers of atrial abnormality, i.e. P-terminal force (PTF) on lead V1, interatrial blocks (IAB; P-wave duration?≥110?ms), and LVH. Conditional logistic regression analyses were used.

Results: IAB (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.16–2.13) and PTF combined with LVH (HR: 6.83, 95% CI: 1.65–28.31), were independently associated with IS. LVH, abnormal P-wave (HR: 6.87, 95% CI: 1.97–135.29), PTF, IAB, and combinations of these P-wave abnormalities with LVH – were associated with cardioembolic subtype. Abnormal P-wave and IAB were associated with cryptogenic stroke subtype. In unadjusted analysis, LVH was associated with small-vessel disease subtype.

Conclusion: P-wave abnormalities on ECG were associated with cardioembolic but also with a cryptogenic subtype of IS.

• Key messages

• ECG patterns associated with atrial pathology are markers of increased risk of ischemic stroke in young adults.

• The ECG markers reflecting atrial pathology were seen in patients with cardioembolic and cryptogenic subtypes of ischemic stroke.

     

Efficacy and safety of flavocoxid compared with naproxen in subjects with osteoarthritis of the knee— a subset analysis

Objective

Twice-daily flavocoxid, a cyclooxygenase and 5-lipoxygenase inhibitor with potent antioxidant activity of botanical origin, was evaluated for 12 weeks in a randomized, double-blind, active-comparator study against naproxen in 220 subjects with moderate-severe osteoarthritis (OA) of the knee. As previously reported, both groups noted a significant reduction in the signs and symptoms of OA with no detectable differences in efficacy between the groups when the entire intent-to-treat population was considered. This post-hoc analysis compares the efficacy of flavocoxid to naproxen in different subsets of patients, specifically those related to age, gender, and disease severity as reported at baseline for individual response parameters.

Methods

In the original randomized, double-blind study, 220 subjects were assigned to receive either flavocoxid (500 mg twice daily) or naproxen (500 mg twice daily) for 12 weeks. In this subgroup analysis, primary outcome measures including the Western Ontario and McMaster Universities OA index and subscales, timed walk, and secondary efficacy variables, including investigator global assessment for disease and global response to treatment, subject visual analog scale for discomfort, overall disease activity, global response to treatment, index joint tenderness and mobility, were evaluated for differing trends between the study groups.

Results

Subset analyses revealed some statistically significant differences and some notable trends in favor of the flavocoxid group. These trends became stronger the longer the subjects continued on therapy. These observations were specifically noted in older subjects (>60 years), males and in subjects with milder disease, particularly those with lower subject global assessment of disease activity and investigator global assessment for disease and faster walking times at baseline.

Conclusions

Initial analysis of the entire intent-to-treat population revealed that flavocoxid was as effective as naproxen in managing the signs and symptoms of OA of the knee. Detailed analyses of subject subsets demonstrated distinct trends in favor of flavocoxid for specific groups of subjects.     

Is chemoimmunotherapy a game changer in the treatment of locally advanced head and neck squamous cell carcinoma?

Pembrolizumab and chemotherapy (chemoimmunotherapy) were administered to 2 head and neck squamous cell carcinoma (HNSCC) patients with extremely advanced local tumors and distant metastases with palliative intent. However, they demonstrated strikingly good responses and achieved remission. Expanded application of induction chemoimmunotherapy may be useful for locally advanced HNSCC.     

Prediction of success in the first-year exam in the study of medicine – a prospective survey

OBJECTIVE: To identify predictors of students' success in the first-year exam in a new curriculum in the study of medicine in Vienna. DESIGN: We tested 11 topics (including socio-demographic variables, family background, school performance, economic situation, living conditions, social integration and health, learning capacity, study motivation and ability to cope with stress) for their relevance in terms of study success in a prospective study of an unselected student sample. Data were collected from questionnaires filled in by 674 first-year students (50.8% of the total number of 1327 new students) who enrolled in the academic year 2002/03. MAIN OUTCOME: Comparison of students who passed the first-year exam with students who failed identified four predictors: male sex, German mother tongue, performance in secondary school and learning capacity. CONCLUSIONS: The new curriculum exerted subliminal selectivity; the predictive powers of school marks and subjective learning capacity were confirmed; the influence of a student's sex should be investigated further; the influence of mother tongue requires modification of pre-study courses for foreign students.