Site Specificity of Pain and Tension in Tension-Type Headaches

Previous studies have not found a significant correlation between location of pain and electromyogram levels in chronic headache patients. However, these studies only examined a limited number of muscle groups and did not assess subjective tension levels. The present study evaluated a group of tension-type (n = 43) and migraine and tension-type (n = 30) headache patients. Measures were obtained at five muscle sites (frontalis, temporalis, masseter, splenius capitis, and trapezius) for patient ratings of headache pain, patient ratings of muscle tension, and electromyogram recordings cross-sectionally. Neither subjective pain nor tension ratings were found to be significantly related to electromyogram levels. The site-specificity relationship between chronic headache pain, subjective report of muscular tension, and electromyogram levels remains unclear.     

Serum levels of N-acetyl-aspartate in migraine and tension-type headache

Serum levels of N-acetyl-aspartate (NAA) may be considered a useful marker of neuronal functioning. We aimed to measure serum NAA in cohorts of migraine and tension-type headache patients versus controls, performing correlations with main clinical features. A total of 147 migraine patients (including migraine without aura, with aura and chronic migraine), 65 tension-type headache (including chronic and frequent episodic tension-type headache) and 34 sex- and age-matched controls were selected. Serum was stored at −80 °C. Quantification of NAA was achieved by the standard addition approach and analysis was performed with liquid-chromatography–mass-spectrometry (LC/MS) technique. The NAA levels were significantly decreased in migraine group (0.065 ± 0.019 mol/L), compared with both tension-type headache patients (0.078 ± 0.016 mol/L) and controls (0.085 ± 0.013 mol/L). Control subjects were significantly different from migraine with and without aura and chronic migraine, who differed significantly from episodic and chronic tension-type headache. Migraine with aura patients showed lower NAA levels when compared to all the other headache subtypes, including migraine without aura and chronic migraine. In the migraine group, no significant correlation was found between NAA serum levels, and headache frequency, allodynia and interval from the last and the next attack. The low NAA in the serum may be a sign of neuronal dysfunction predisposing to migraine, probably based on reduced mitochondria function.     

Acute and interictal allodynia in patients with different headache forms: an Italian pilot study

OBJECTIVE: To investigate allodynia in patients with different primary headaches. BACKGROUND: Many migraineurs have allodynia during headache attacks; some may have allodynia outside attacks; allodynia may also be associated with other primary headaches. METHODS: A total of 260 consecutive primary headache patients presenting for the first time at a headache center, and 23 nonheadache controls answered written questions (subsequently repeated verbally) to determine the presence of acute and interictal allodynia. RESULTS: We divided the patients into: episodic migraine (N = 177), subdivided into only migraine without aura (N = 114) and those sometimes or always reporting migraine with aura (N = 63); episodic tension-type headache (N = 28); chronic headaches (headache > or = 15 days/month, N = 52), including chronic migraine, chronic tension-type headache, and medication-overuse headache; and other headache forms (N = 3). Acute allodynia was present in 132 (50.7%), significantly more often in patients sometimes or always suffering migraine with aura, and those with chronic headache forms, compared to patients with migraine without aura and episodic tension-type headache. Interictal allodynia was present in 63 (24.2%) patients, with significantly higher frequency in those having migraine with aura attacks than controls and common migraine patients. CONCLUSIONS: Allodynia is not specific to migraine but is frequent in all headache patients: acute allodynia was reported in half those interviewed and in over a third of patients in each headache category; interictal allodynia was reported by nearly 25%.     

Determinants of tension-type headache in children

The objective of this study was to study the prevalence, characteristics and predisposing factors of tension-type headache in children. An unselected population-based questionnaire study was carried out in 1409 Finnish schoolchildren aged 12 years. Of them, 1135 (81%) returned an acceptably completed questionnaire. The prevalence of episodic tension-type headache in children was 12% (138 of 1135). Children with episodic tension-type headache also often reported characteristics of pain typical for migraine. Children with frequent and persistent episodic tension-type headache reported stabbing and severe occipital pain, phonophobia and abdominal pain significantly more often than children with infrequent episodic tension-type headache. Neck-shoulder symptoms, symptoms of depression and oromandibular dysfunction were each independently associated with episodic tension-type headache. The father's occupation of a lower-level white-collar worker put the child at a four-fold risk for episodic tension-type headache. We conclude that episodic tension-type headache is as common as migraine in children. It can be associated with depression, oromandibular dysfunction and muscular stress. Especially children with frequent and persistent episodic tension-type headache report characteristics of pain typical for migraine.     

The auditory event related potentials in episodic and chronic pain sufferers.

To examine the cognitive processing differences in chronic and episodic pain sufferers, auditory event-related potentials (P300 or P3) were recorded in two consecutive trials from 23 chronic lower back pain patients, 22 episodic tension-type headache sufferers, and from 23 age- and sex-matched healthy persons. P3 latency and amplitude showed no difference between groups at first trial. Considering P3 latency habituation, healthy controls and episodic tension-type headache sufferers showed a significant change of P3 latency whereas lower back pain sufferers failed. Comparing the amount of habituation lower back pain sufferers stood clearly apart from healthy controls. Although there was a remarkable increase of P3 latency in episodic tension-type headache sufferers, the amount of habituation was not statistically different than it was in lower back pain sufferers. Significant P3 amplitude habituation was observed only in healthy controls. Actually, episodic tension-type headache sufferers also showed some degree of habituation, which was not statistically remarkable. The amount of amplitude habituation was not different between groups. No correlation was observed between P3 habituation and age, disease duration and symptom severity. These results may point to a disturbed attentional processing in chronic pain sufferers. Our findings suggest that in spite of a similar cortical information processing, the neurocognitive networks related with decision making and memory processing seem to work differently in chronic pain sufferers from those in episodic pain sufferers in repeating tasks. Taking into consideration the reported P3 habituation abnormalities in chronic migraine patients we can say that not the location of pain but rather its temporal pattern may have a role in disturbed attentional processing.     

Pathophysiological mechanisms of tension-type headache: a review of epidemiological and experimental studies

In this present thesis I have discussed the epidemiology and possible pathophysiological mechanisms of tension-type headache. A population-based study of 1000 subjects randomly selected from a general population, two clinical studies, and a method study of EMG recordings, were conducted. Tension-type headache was the most prevalent form of headache, with a life-time prevalence of 78% in a general adult population. Thirty percent were affected more than 14 days per year and 3% were chronically affected, i.e. had headache at least every other day. Females were more frequently affected than males, and young subjects more frequently affected than older subjects. Females were more sensitive to mechanical pressure pain and revealed more tenderness from pericranial muscles and tendon insertions than males, and young subjects were more pain-sensitive than older subjects. Significantly higher tenderness in pericranial muscles was found in subjects with tension-type headache compared to migraineurs and to subjects without any experience of headache. Tenderness increased significantly with increasing frequency of tension-type headache in both males and females, whereas no such relation was found for mechanical pain thresholds. The applied EMG methodology was fairly reliable and nonpainful, but due to intersubject variability paired studies should be preferred. Subjects with chronic tension-type headache had slightly increased EMG levels during resting conditions and decreased levels during maximal voluntary contraction compared with headache-free subjects, indicating insufficient relaxation at rest and impaired recruitment at maximal activity. In a subsequent clinical, controlled study, the effect of 30 min of sustained tooth clenching was studied. Within 24 h, 69% of patients and 17% of controls developed a tension-type headache. Shortly after clenching, tenderness was increased in the group who subsequently developed headache, whereas tenderness was stable in the group of patients who remained headache-free, indicating that tenderness might be a causative factor of the headache. Likewise, psychophysical and EMG parameters were studied in 28 patients with tension-type headache, both during and outside of a spontaneous episode of tension-type headache. It was concluded that a peripheral mechanism of tension-type headache is most likely in the episodic subform, whereas a secondary, segmental central sensitization and/or an impaired supraspinal modulation of incoming stimuli seems to be involved in subjects with chronic tension-type headache. Prolonged nociceptive stimuli from myofascial tissue may be of importance for the conversion of episodic into chronic tension-type headache. The author emphasizes that tension-type headache is a multifactorial disorder with several concurrent pathophysiological mechanisms, and that extracranial myofascial nociception may constitute only one of them. The present thesis supplements the understanding of the balance between peripheral and central components in tension-type headache, and thereby, hopefully, leads us to a better prevention and treatment of the most prevalent type of headache.     

Increased muscle pain sensitivity in patients with tension-type headache

Nociceptive mechanisms in tension-type headache are poorly understood. The aim was to investigate the pain sensitivity of pericranial muscles and a limb muscle in patients with tension-type headache. Experimental muscle pain was induced by standardized infusions of 0.5 ml of 1 M hypertonic saline into two craniofacial muscles (anterior temporalis (TPA) and masseter (MAS)) and a limb muscle (anterior tibial (TA)) in 24 frequent episodic tension-type headache patients (FETTH), 22 chronic tension-type headache patients (CTTH) and 26 age and gender matched healthy subjects. Headache patients were examined twice, both on days with and on days without headache. The pressure pain thresholds (PPTs) were determined before and after infusions. The subjects continuously reported intensity of saline-induced pain on an electronic visual analogue scale (VAS) and the perceived area of pain was drawn on anatomical maps. Headache patients demonstrated significantly lower PPTs, higher saline-evoked VAS pain scores and greater pain areas than healthy subjects at all the tested muscle sites (P<0.05). There was a significant gender difference for the PPTs in all three groups of participants (P<0.05) and for VAS pain scores in the CTTH patients (P<0.05). There was no difference in pain sensitivity between FETTH and CTTH or between patients with or without headache. In conclusion, the present study demonstrates the presence of generalized pain hypersensitivity both in FETTH and CTTH compared to controls which is unrelated to actual headache status and extends to include responses to longer-lasting stimuli which are clinically highly relevant. Gender differences in deep pain sensitivity seem to be a consistent finding both in healthy controls and patients with tension-type headache.     

Prevalence and clinical characteristics of an experimental model of 'ice-cream headache' in migraine and episodic tension-type headache patients

This study was designed to compare the prevalence and clinical characteristics of 'cold-induced headache' between migraine and episodic tension-type headache patients. Seventy-six migraine and 38 episodic tension-type headache patients were included in the study. An experimental model of an 'ice-cream headache' was developed for the study. The pain occurrence period, its location and quality were recorded for each patient who felt pain in their head during the test procedure. Pain in the head occurred in 74% of migraine and 32% of 'tension-type headache' patients. Although the most frequent pain location was the temple in both groups of patients, this rate was greater than twofold in migraine patients when compared with episodic tension-type headache patients. While headache quality was throbbing in 71% of migraine patients, it was so in only 8% of the episodic tension-type headache patients. Considering all the results, it seems that 'cold-stimulus headache' is not only more frequent in migraine patients, but also its location and quality differ from 'tension-type headache'.     

Amitriptyline Is Effective in Chronic But Not in Episodic Tension-Type Headache: Pathogenetic Implications

The tricyclic antidepressant amitriptyline, is an effective drug for the treatment of chronic tension-type headache and for other chronic pain syndromes, but it is also effective in the prophylaxis of an episodic type of headache such as migraine. However, its efficacy in episodic tension-type headache has not yet been clarified. We compared the efficacy of amitriptyline (25 mg/day) in 82 nondepressed patients with either chronic or episodic tension-type headache in an open-label study. Amitriptyline significantly reduced ( P <0.05) frequency and duration of headache as well as analgesic consumption in chronic, but not in episodic, tension-type headache. Further placebo-controlled trials, possibly with higher doses of amitriptyline, might confirm if the different pattern of response to amitriptyline can be explained in terms of different involvement of central nociception and of peripheral myofascial factors in the chronic and in the episodic forms of tension-type headache.     

Frequency of headache is related to sensitization: a population study

Central sensitization is thought to play an important role in the chronification of tension-type headache and in the maintenance and exacerbation of the migraine attack. It has, however, almost exclusively been studied in highly selected patients from headache clinics. The aim of the present study was to evaluate pain perception in primary headaches in the general population. Stimulus-response functions for pressure versus pain, tenderness and pressure pain thresholds were studied in a random sample of 523 adults from the general population. All results were controlled for the effects of age and gender. The area under the stimulus-response function was increased in chronic- and frequent episodic tension-type headache compared with subjects without headache (p<0.001, p<0.001) and in chronic tension-type headache compared with migraine (p=0.01). Increasing slope (p<0.0001) and displacement towards lower pressures was found in the following order: no headache, migraine, frequent episodic tension-type headache, chronic tension-type headache. The displacement of the stimulus-response function was closely associated with frequency of headache. Finally, the stimulus-response function tended to be qualitatively altered in patients with frequent headache. The findings demonstrate, for the first time in a population-based study, a close relation between altered pain perception and chronification of headache, which most likely can be explained by central sensitization.     

Muscular Factors are of Importance in Tension-Type Headache

Recent studies have indicated that muscular disorders may be of importance for the development of increased pain sensitivity in patients with chronic tension-type headache. The objective of the present study was to investigate this hypothesis by examining the pain perception in tension-type headache with and without muscular disorders defined as increased tenderness. We examined 28 patients with episodic tension-type headache, 28 patients with chronic tension-type headache, and 30 healthy controls. Pericranial myofascial tenderness was recorded with manual palpation, and pressure pain detection and tolerances in cephalic and extracephalic locations with an electronic pressure algometer. In addition, thermal pain sensitivity and electromyographic activity were recorded. The main result was significantly lower pressure pain detection thresholds and tolerances in all the examined locations in patients with chronic tension-type headache with a muscular disorder compared to those without a muscular disorder. There were no such differences in any of the examined locations when the two subgroups of patients with episodic tension-type headache were compared. Thermal pain sensitivity did not differ between patients with and without a muscular disorder, while electromyographic activity levels were significantly higher in patients with chronic tension-type headache with than in those without a muscular disorder. Our results strongly indicate that prolonged nociceptive stimuli from the pericranial myofascial tissue sensitize the central nervous system and, thereby, lead to an increased general pain sensitivity. Muscular factors may, therefore, be of major importance for the conversion of episodic into chronic tension-type headache. The present study complements the understanding of the important interactions between peripheral and central factors in tension-type headache and may lead to a better prevention and treatment of the most prevalent type of headache.     

Weekend headache: a retrospective study in migraine without aura and episodic tension-type headache

Our retrospective study was aimed at determining the existence of weekend headache and, if so, whether it has the same clinical features as migraine without aura and episodic tension-type headache, or whether it occurs as a separate form of headache which could find its own place in the International Headache Society classification.
For this study, we reviewed the clinical records of 120 patients with migraine without aura and 120 patients with episodic tension-type headache randomly selected among all those referred to the Headache Center of the University of Parma Institute of Neurology between 1985 and 1996.
A review of these records suggests that weekend headache exists for both types of headache considered. Clinically, it is interesting to note that the male-to-female ratio for the weekend form of tension-type headache was 1:1, as opposed to 1:3 for general episodic tension-type headache. As regards classification, no evidence so far seems to suggest that weekend headache should be considered as an independent entity. Apart from certain features that appear to be peculiar to this form of headache—such as increased pain intensity—it thoroughly fulfills the diagnostic criteria of the primary headaches from which it evolves. Finally, a few clinical features suggest that the weekend may simply be a triggering factor in migraine without aura attacks, while playing a major role in episodic tension-type headache. However, weekend headache is a clinical entity that clearly needs further study.     

Tension-type headache

Tension-type headache is the most common type of primary headache. Life time prevalence of tension-type headache in general population ranges from 30 to 78%. It is the least studied of the primary headache disorders, despite the fact that it has the highest socio-economic impact. In the new 'The International Classification of Headache Disorders', tension-type headache is divided into episodic and chronic subtypes. The exact mechanisms of tension -type headache are not known. Peripheral pain mechanisms are most likely to play a role in episodic headache, whereas central pain mechanisms play a more important role in chronic tension-type headache. Treatments of tension-type headache include not only medication but also the physical therapy. In many uncertain cases there is overuse of medication. Two months after medication overuse has ceased, chronic tension-type should be diagnosed.     

A community-based study of headache diagnosis and prevalence in Singapore

We present the results of a community survey based on the diagnostic criteria of the International Headache Society (IHS) describing headache prevalence and symptomatology in the Singapore population. A questionnaire administered by trained personnel was completed by 2096 individuals from a randomized sample of 1400 households. The overall lifetime prevalence of headache was 82.7%. The migraine prevalence was 2.4% in males and 3.6% in females; for episodic tension-type headache and chronic tension-type headache the corresponding figures were 11.1%/11.8% and 0.9%/1.8%, respectively. Inclusion of borderline cases (IHS codes 1.7 and 2.3) resulted in prevalences of 9.3% for migraine, 39.9% for episodic tension headache and 2.4% for chronic tension headache. Headaches described by 31.2% of the respondents were unclassifiable. The different premonitory symptoms, precipitants and aggravating factors in migraine and tension-type headache in our study population suggest that they represent two distinct syndromes rather than opposite ends of a clinical spectrum.     

Psychosocial Functioning in Schoolchildren With Recurrent Headaches

The psychosocial functioning of 113 schoolchildren (8 to 15 years old) reporting headaches at least once a month was compared to a group of headache-free control subjects matched for sex and age. Thirteen percent of the headache sufferers had migraine headaches, 28% had episodic tension-type headaches, 30% had chronic tension-type headaches, and 29% had migraine coexisting with tension-type headaches.
Overall, the headache sufferers experienced more somatic complaints, stress, and psychological symptoms, in addition to being absent from school (due to illness), more often and reported fewer caring persons as compared to headache-free controls. Although few differences between the four headache groups emerged in the children's psychosocial functioning levels, children with migraine coexisting with tension-type headaches had significantly more frequent somatic complaints than those having episodic tension-type headaches. In addition, children with migraine or migraine coexisting with tension-type headaches were more often absent from school than those having tension-type headaches only. A significant but weak relationship between children's headache severity and their somatic complaints was noted.     

Specificity and Sensitivity of Temporalis ES2 Measurements in the Diagnosis of Chronic Primary Headaches

We have evaluated the specificity and sensitivity of temporalis ES2 measurements for the diagnosis of primary headaches. Ninety-four outpatients diagnosed according to IHS criteria were prospectively included: 25 had chronic tension-type headache (code 2.2.), 15 episodic tension-type headache (code 2.1.), 20 migraine without aura (code 1.1.) and 34 chronic daily headaches with daily analgesics/ergotamine abuse (code 8.2.). In chronic tension-type, the sensitivity of the ES2 test was 84% at the 0.1 and the 0.5 Hz, but only 56% at the 2Hz stimulation rates. Its specificity was 100% at 0.1Hz, 90% at 0.5Hz and 95% at 2Hz compared to migraine; positive predictive values were at similar levels. Sensitivity of ES2 at 0.1 Hz was 67% in episodic tension-type headache, but its positive predictive value versus migraine was excellent. Comparing chronic tension-type headache and analgesic abusers, the specificity and positive predictive value of the ES2 test for diagnosing chronic tension-type headache were less satisfactory (60%) while the negative predictive values, however, remained good (83% at 0.1Hz).
The results confirm that the temporalis ES2 test has a higher diagnostic sensitivity in chronic and episodic tension-type headache, but that it has a high negative predictive value for both types of tension-type headache compared to other primary headaches. For diagnostic purposes, the 0.1Hz stimulation rate seems optimal. The 2Hz stimulation rate is the least sensitive, although it may induce total disappearance of ES2 in up to 40% of patients. ES2 is of limited usefulness for separating chronic tension-type headache and chronic drug-abuse headache, possibly because the latter group comprises both tension-type headache and migraine patients.     

Characteristics of headache in migraine without aura and episodic tension-type headache in the Turkish population according to the IHS classification

We evaluated the characteristics of headache in migraine without aura and episodic tension-type headache diagnosed according to the International Headache Society (IHS) Classification. Fifty migraine without aura and 50 tension-type headache patients were selected prospectively. Fifty-eight percent of migraineurs had pain of a pulsating quality; 88% had severe pain and 74% had unilateral pain; aggravation by routine physical activity was reported by 96%. Episodic tension-type headache was of a pressing quality in 52%, moderate in 40%, bilateral in 82% and aggravated by routine physical activity in 16%. Nausea and/or vomiting, photophobia and phonophobia were reported significantly more commonly in migraineurs than tension-type headache patients.     

Subtle grey matter changes between migraine patients and healthy controls

Local morphological alterations of the brain have recently been detected in cluster headache and chronic tension-type headache, but not in migraine. We investigated 35 patients suffering from migraine and compared them with 31 healthy controls with no headache history. Using magnetic resonance imaging and voxel based morphometry, we found a significant decrease of grey matter in areas ascribable to the transmission of pain (cingulate cortex), but not in areas specific for migraine, such as the brainstem. Our data are in line with recent findings in chronic pain states, such as chronic phantom pain and chronic back pain. We suggest that the grey matter change in migraine patients is the consequence of frequent nociceptive input and should thus be reversible when migraine attacks cease.     

Tension-type headache in children and adolescents

Although tension-type headache is at least as prevalent as migraine in children and adolescents, in contrast to migraine, childhood tension-type headache has received limited research attention. Follow-up studies have shown that migraine may reverse in tension-type headache and vice versa. In addition, children with frequent episodic tension-type headache may be at increased risk of chronic tension-type headache. It is very important to recognize these children and to intervene. Further studies are needed to clarify the pathophysiology of pediatric tension-type headache.