Strength and mobility of the neck-shoulder region in adolescent headache

The significance of the musculoskeletal function of the neck-shoulder region in different headache types in children and adolescents is not clear. The purpose of this study was to investigate the association between different types of headache and the strength and mobility of the neck-shoulder region in 13-year-old schoolchildren. A structured questionnaire on headache was sent to all 1,409 children in the sixth grade in the city of Turku. Of the 1,135 (81%) children who completed the questionnaire, a sample from different headache groups was randomly selected for clinical examination. The study consisted of 59 children with migraine, 65 with episodic tension-type headache (TTHA), and 59 headache-free controls. Dynamic muscle strength of the upper extremities (UE endurance), mobility of both shoulders (UE mobility), and the cervical range of motion (CROM) were measured. Girls with episodic TTHA had lower UE endurance of both dominant and nondominant sides than girls in the other study groups. Girls with migraine had lower UE endurance of nondominant side than girls in the control group. In boys, no significant differences were observed. An interesting association between the function of the neck-shoulder region and headache complaints in adolescents was ascertained.     

Force production and EMG activity of neck muscles in adolescent headache

Purpose. This study compared the maximal force, EMG/force ratio and co-activation characteristics of the neck-shoulder muscles between 30 adolescents with migraine-type headache, 29 with tension-type headache, and 30 headache-free controls.

Method. Force was measured with surface electromyography (EMG) from the cervical erector spinae (CES), the sternocleidomastoid (SCM) and trapezius muscles during the maximal isometric neck flexion, neck extension and shoulder flexion.

Results. Girls with migraine-type headache had higher EMG/force ratios between the EMG of the left agonist SCM muscle and the corresponding maximal neck flexion (p = 0.030) and neck rotation force to the right side (p = 0.024) than the girls with tension-type headache. Migrainous girls had more co-activation of right antagonist CES muscle during maximal neck flexion force than the girls without headache (p = 0.015). Neck force production showed no significant differences between girls. Girls with tension-type headache displayed lower left shoulder flexion force than girls with migraine-type headache (p = 0.005) or with no headache (p = 0.005). In boys, no significant differences were observed.

Conclusions. Girls with tension-type headache and migraine-type headache have differences in neuromuscular function in the neck-shoulder muscles. The data amplify our knowledge of the neck-shoulder muscle dysfunction in adolescent headache, and may encourage the use of specific rehabilitation methods in the management of different types of headache.     

Muscle tenderness in pericranial and neck-shoulder region in children with headache. A controlled study

Increased pericranial muscle tenderness is connected with tension-type headache in adults. In children, the importance of muscle tenderness in the pericranial or neck-shoulder region in the pathogenesis of different types of headache is unknown. The present study evaluated muscle tenderness in the pericranial and neck-shoulder region in children with migraine, those with tension-type headache and those without headache. An unselected population-based questionnaire study concerning headache was carried out in 1135 Finnish schoolchildren aged 12 years. Of them, 183 children were randomly selected for a face-to-face interview and a clinical examination. Muscle tenderness was recorded by manual palpation and dolorimeter. Children with migraine had increased overall tenderness, recorded by manual palpation, compared with those without headache. They also self-reported tenderness in the neck-shoulder region during daily activities more often than the children of the other groups. Muscle tenderness was not associated with paediatric tension-type headache. The mean pressure pain thresholds did not differ among the three groups. However, a negative correlation between the total tenderness score and the dolorimeter score was found in each group. In conclusion, children with migraine had increased muscle tenderness at palpation of the pericranial and neck-shoulder muscles and they also reported pain symptoms in the neck-shoulder region most frequently. Instead, increased pericranial and neck-shoulder muscle tenderness was not associated with tension-type headache in children.     

Clinical features of primary headache in children: a multicentre hospital-based study in France

The aim of this study was to evaluate the concordance between clinical diagnosis and the International Classification of Headache Disorders, 2nd edn (ICHD-II) in children and adolescents with primary headaches. This 6-month prospective multicentre study of 486 patients (mean 9.8 +/- 3.1 years; 52.6% girls) assessed the headache features through a structured questionnaire. In 398 patients with a single type of headache, headaches were bilateral (78.1%), frontal (62.4%), pulsatile (56.1%), with associated symptoms in 84.4%. The most frequently assigned diagnoses were migraine without aura (50.8%), probable migraine (14.1%), migraine with aura (11.1%) and frequent episodic tension-type headache (7.5%). For most of the diagnostic categories, the consistency of the investigator's diagnosis with the ICHD-II criteria was good (kappa > 0.6 and < or = 0.8) or excellent (kappa > 0.8). We conclude that migraine was predominant with regard to headache diagnoses repartition and that the ICHD-II seems usable in practice for evaluation of primary headache in French children and adolescents.     

Extracephalic tenderness and pressure pain threshold in children with headache

Background Sensitisation of the pain detection system has been suggested to be involved in the pathogenesis of recurrent headache. In adults, increased sensitivity to pain has been found in patients with chronic tension type headache. Children with migraine or with unspecific headache report non‐headache pains and interictal pericranial muscular tenderness more often than headache‐free children. Objective To study if children with different types of headache report non‐headache pain more often than children with no headache and if extracephalic muscular tenderness is different in children with headache in comparison to headache‐free children. To find out if interval to the headache episode has influence on the extracranial muscular tenderness. Design A population‐based sample of 13‐year‐old children with migraine (n = 48), episodic tension type headache (61) or no headache (59) were interviewed for the occurrence and characteristics of headache and fulfilled a questionnaire on non‐headache pain. A structured manual palpation test on muscular tenderness and a pain threshold measurement were done on seven cephalic and three extracephalic points. Results Children with migraine reported other pains, especially stomach pain and limb pain more often than children with episodic tension type or no headache. There were no significant differences in the extracephalic muscular tenderness or in the pressure pain thresholds between the three groups. Conclusions Children with migraine experience more non‐headache pains than children with episodic tension type headache and with no headache. However, neither children with migraine nor children with episodic tension type headache show increased interictal extracephalic muscular sensitivity for palpation.     

Headache and dysfunction of the masticatory system in adolescents

An epidemiologic group of 285 17-year-old adolescents was studied with the aid of a questionnaire for frequency and intensity of headache and for symptoms of dysfunction of the masticatory system. They were also subjected to a functional examination of the masticatory system. Recurrent headaches occurred significantly more often among the girls (18%) than the boys (6%). Girls also reported significantly more intense headaches than boys. Fatigue in the jaws and difficulties in chewing were commoner in those with frequent and more intensive headaches. Tenderness to palpation of the masticatory muscles and impaired mandibular mobility were significantly commoner findings among those with recurrent headaches and those with more intense headaches. Tooth-grinding and clenching were related to frequency but not to intensity of headache. The investigation showed a significant relationship between frequency and intensity of headaches and signs and symptoms of dysfunction of the masticatory system.     

Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance

In this study, 60 female subjects, aged between 25 and 40 years, were divided into two equal groups on the basis of absence or presence of headache. A passive accessory intervertebral mobility (PAIVM) examination was performed to confirm an upper cervical articular cause of the subjects' headache and a questionnaire was used to establish a profile of the headache population. Measurements of cranio-cervical posture and isometric strength and endurance of the upper cervical flexor muscles were compared between the two groups of subjects. The headache group was found to be significantly different from the non-headache group in respect to forward head posture (FHP) ( t = -5.98, p < 0.00005), less isometric strength ( t = 3.43, p < 0.001) and less endurance ( t = 8.71, p < 0.0005) of the upper cervical flexors. A statistically significant relationship was also established between natural head posture and isometric endurance of the upper cervical flexor musculature which demonstrated that FHP corresponded with a low endurance capacity (c²= 13.2; p < 0.01). The outcome of this study highlights the need to screen for cervical etiology in patients who are suspected of suffering from common migraine.     

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.     

Neck flexor muscle fatigue in adolescents with headache: an electromyographic study.

BACKGROUND: Muscular disorders of the neck region may be of importance for the etiology of tension-type headache. However, in adolescents, there are no data on the association between neck muscle fatigue and headache. AIM: To study differences in fatigue characteristics of the neck flexor muscles in adolescents with and without headache. METHODS: A population-based sample of 17-year-old adolescents with migraine-type headache (N=30), tension-type headache (N=29) and healthy controls without headache (N=30) was examined. Surface EMG data were recorded from the sternocleidomastoid (SCM) muscles bilaterally during an isometric neck flexor endurance test. The spectral median frequency (MF) change during the total endurance time (TMF) and the initial time of 30s (IMF) was calculated. The intensity of discomfort in the neck area was assessed with the visual analogue scale (VAS). RESULTS: The rate of decline in TMF of both SCM muscles was significantly increased in the tension-type headache group compared with controls (right SCM, P=0.030, OR 2.0, 95% 1.2-3.7; left SCM, P=0.009, OR 2.5, 95% 1.4-4.9), while no significant differences were found between controls and subjects with migraine. The rate of decline in IMF, the total endurance time (P=0.050), and VAS did not differ significantly among the study groups. CONCLUSIONS: This preliminary finding shows that increased neck flexor muscle fatigue in adolescents seems to be associated with tension-type headache.     

Primary Headache Disorders- Part 2: Tension-type headache and medication overuse headache

In Part 2 of Primary Headache disorders, we discuss the fourth Primary Headache Disorder, Tension-Type Headache (TTHA). We are again using the ICHD-III (Beta) definitions of such headaches, taking into consideration episodic and chronic TTHA, as well as the presence or absence of pericranial muscle tenderness. We discuss the pathophysiology and pharmacotherapeutic treatment of TTHA, and the aspects of the Myofascial Pain Syndrome that enhance and help the development of TTHA. We then discuss Medication Overuse Headache (MOH), itself a Secondary headache disorder, but one that is extremely important as it assists with the chronification of both migraine and TTHA. Finally we discuss how to manage and treat those patients with MOH. Chronic migraine, which is TTHA, Migraine as well as, in many patients, MOH, is discussed along with the treatment of this multifaceted disorder.     

Headache prevalence among adolescents--the German DMKG headache study

This population-based cross-sectional study examined the 3-month prevalence of headache, migraine and tension-type headache (TTH) among adolescents aged 12-15 years in Germany. Students (n = 3324) from 20 schools completed a questionnaire on general and headache-specific pain which included a sociodemographic module. The headache-specific questionnaire complied with the respective revised criteria of the International Headache Society (IHS). 'Modified criteria' changed the item 'duration' in migraine (>30 min instead of > 4 h). The overall 3-month prevalence of headache was 69.4% (boys 59.5%, girls 78.9%), with 4.4% of the adolescents suffering from frequent (>or=14 days/3 months) and severe (grade 8-10 on a 10-point visual analogue scale) headache and 1.4% (boys 0.9%, girls 1.9%) from headache >or= 15 days/month. The 3-month prevalence of migraine was 2.6% (boys 1.6%, girls 3.5%) applying strict IHS criteria and 6.9% (boys 4.4%, girls 9.3%) with modified criteria; 12.6% (boys 8.3%, girls 16.7%) suffered from probable migraine, 0.07% fulfilled the criteria for chronic migraine, 4.5% (boys 4.6%, girls 4.3%) suffered from TTH, 0.2% from chronic TTH and 15.7% (boys 14.5%, girls 16.9%) from probable TTH. Headache and migraine were more common in girls than in boys and in teenagers, especially in girls, aiming at higher education. Recurrent headache and primary headache disorders are common complaints among German adolescents, especially among girls.     

Headache prevalence in adolescents aged 12 to 17: a student-based epidemiological study in Bursa

BACKGROUND AND OBJECTIVES: The objective of this study was to investigate the prevalence and sociodemographic characteristics of headaches among Turkish adolescents aged 12 to 17 years old in Bursa province of Turkey. METHODS: A multistep, stratified, cluster sampling method was used for subject selection. The estimated sample size for 12- to 14-year-old students was 1,270 and for 15- to 17-year-old students was 1,117. Our study sample included 6.5% of the secondary schools and 1.8% of the students aged 12 to 17 years old. The study was conducted in two phases; the questionnaire phase and the face-to-face interview phase. RESULTS: The prevalence of recurrent headache in the study population was 52.2%. Girls (59.8%) had significantly more recurrent headache than boys (45.1%) The prevalence of recurrent headache increased from 42.2% up to 60.7% by age. In multivariate logistic regression analysis age and gender differed significantly between adolescents with and without recurrent headache groups. Frequent episodic tension-type headache was the most common (25.9%) headache among Turkish adolescents, followed by migraine (14.5%). CONCLUSIONS: Age and gender appeared to be demographic factors increasing adolescent headache prevalence. Frequent episodic-tension type headache was the most common headache followed by migraine. Our migraine prevalence was slightly higher than most of the previously reported prevalence rates. This might be due to the new classification criteria of headache released by International Headache Society.     

Serotonin Effects on Sleep and Emotional Disorders in Adolescent Migraine

Objective.— To determine frequency of emotional disorders and sleep disturbances in adolescent migraineurs with episodic and chronic headaches. To determine the relationship of whole blood serotonin, caffeine consumption, and frequency of sleep and mood disorders.
Background.— The neurotransmitter serotonin has been implicated to play a role in the initiation and maintenance of sleep and in modulating mood. A putative role in migraine pathophysiology is also known.
Methods.— Adolescents from 13 to 17 years of age were identified from our headache clinic with episodic or chronic migraine (according to International Classification of Headache Disorders-Second Edition criteria) and healthy controls enrolled. Psychological rating scales were completed, including Adolescent Symptom Inventory (4th Edition) and Child Depression Inventory. Sleep questionnaires (Pediatric Sleep Questionnaire and Child Sleep Habit Questionnaire) were completed by the teenager's parents/guardian. Whole blood serotonin levels were drawn and analyzed and caffeine consumption obtained by history.
Results.— A total of 18 controls (8 girls) and 15 patients each with episodic migraines (9 girls) and chronic migraine (10 girls) were studied.
Patients with headache had significantly more sleep problems than controls. Patients with chronic migraines had increased daytime sleepiness and dysthymia compared with teenagers with episodic migraines. Serotonin levels were not significantly different, and no association was noted between serotonin levels and sleep abnormalities or emotional rating scales. Increased caffeine intake was related to sleep and depressive complaints.
Conclusions.— Sleep and emotional disorders were common in adolescents with migraine. Sleep disorders and dysthymia were more prevalent with increased headache frequency. No correlation was noted with whole blood serotonin levels.     

Outcome of early school-age migraine

We studied the outcome of migraine from early school-age to prepuberty in a group of 84 children. The children belonged to a population-based, unselected follow-up sample of a 1-year age cohort. At the age of 8 to 9 years, 95 (2.7%) children of this age cohort had migraine according to a postal questionnaire. At age 11 to 12 years, 84 of them were traced and interviewed face-to-face. Only four (4.8%) of these children no longer had headache. Fifty-three (63.1%) children had migraine. Seventeen (20.2%) had migraine-type headache which did not completely fulfil the International Headache Society criteria for migraine, seven (8.3%) children had episodic tension-type headache and three (3.6%) had other headache. Among the children who had migraine at age 11 to 12, boys had significantly more frequent migraine attacks than girls (mean 2.7/month versus 1.8/month; p =0.016). They also used more drugs and were more frequently absent from school because of headache than girls, but these differences were not significant. Problems in the relationships between parents seemed to be another factor associated with frequent migraine.     

Prevalence and predictors of headaches in US adolescents

OBJECTIVES: To examine the prevalence of headaches among US adolescents; to explore the differences in prevalence by sex, race, and age; and to test the nature of the association between headaches and depression, self-esteem, and insomnia. METHODS: This longitudinal study used a nationally representative sample of adolescents (n = 6072) who were interviewed in 1995 (wave 1) and then interviewed a year later in 1996 (wave 2). Path analyses were used to test for the relationships among headaches, insomnia, depression, and self-esteem. RESULTS: More than 90% of subjects had experienced one or more headaches during the past 12 months. Of that 90%, about 30% reported recurrent headaches occurring weekly or more frequently. Girls tended to report more recurrent headaches (37.6%) than boys (21.3%). American Indians experienced the highest rate (35. 6%) of recurrent headaches followed by white adolescents (32.1%). Depression and low self-esteem in wave 1 were found to precede the headaches in wave 2 in girls, but not in boys. No causal relationship was found between insomnia and headaches. CONCLUSIONS: Headaches are prevalent among US adolescents, especially in girls and American Indians. This study suggests the existence of different paths involving different factors in headache-presenting behavior for boys and girls. Further studies are needed to illustrate the different mechanisms of headache in the two sexes.     

Rehabilitation of neck-shoulder pain in women industrial workers: a randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training

OBJECTIVES: To study whether isometric shoulder endurance was more advantageous than isometric shoulder strength training in reducing pain and perceived exertion and to increase shoulder function through improved muscle endurance and strength. DESIGN: Randomized trial. SETTING: Three occupational health care centers. PARTICIPANTS: Women industrial workers with nonspecific neck-shoulder pain. The International Classification of Diseases, 10th Revision (ICD-10) diagnosis was "cervicobrachial syndrome" (M53.1). Thirty-eight patients completed the isometric shoulder endurance training and 31 patients completed the isometric shoulder strength training. INTERVENTION: Twelve weeks of training. MAIN OUTCOME MEASURES: Self-reported pain and rating of perceived exertion (RPE), arm motion performance test, shoulder muscle strength, shoulder muscle endurance, and shoulder functional tests, as well as follow-up after supervised training had ended. RESULTS: The isometric shoulder strength training resulted in an almost one-scale step decrease in RPE at work and a 5% to 15% improvement of arm motion performance compared with the endurance training. The isometric shoulder strength training more effectively improved left side shoulder abduction strength (p < .026), but no major differences were found for the other strength measurements. The isometric shoulder endurance training was not more successful than the strength training in the endurance test (p .51 to .81). CONCLUSIONS: Physical training programs for neck-shoulder pain may include isometric shoulder muscular strength exercise in addition to isometric shoulder endurance training, rather than endurance training only.     

Physical impairments in cervicogenic headache: traumatic vs. nontraumatic onset

In order to quantify the physical impairments associated with different types of headache, 77 subjects belonging to four different groups (postmotor vehicle accident cervicogenic headache subjects, cervicogenic headache subjects nontraumatic, migraine patients and control subjects) were evaluated using the following variables: posture, cervical range of motion, strength of the neck flexors and extensors, endurance of the short neck flexors, manual segmental mobility, proprioception of the neck, and pain (McGill Pain Questionnaire and the skin roll test). The results of this study showed that postmotor vehicle accident cervicogenic patients have significantly limited active cervical range of motion (in flexion/extension and rotations), present decreased strength and endurance of neck flexors and decreased strength of the extensor muscles. Our results suggest that there are enough differences between the postmotor vehicle accident and nontraumatic cervicogenic headache subjects to warrant caution when analysing the data of these two subgroups together, as several studies have done in the past. The onset of headache is therefore an important variable that should be controlled for when attempting to characterize the physical impairments associated with cervicogenic headache.     

Chronic daily headache in children and adolescents presenting to tertiary headache clinics

BACKGROUND: Adults with chronic daily headache often describe a transformation from episodic migraine and partial retention of migrainous features. Although chronic daily headache has not been investigated as carefully in the pediatric population, one study showed a predominance of coexisting daily headache and episodic migraine, without a clear history of transformation. OBJECTIVE: To identify the clinical features of chronic daily headache in children and adolescents, to evaluate the efficacy of current headache classification criteria, and to compare the features of coexistent daily and episodic headaches so as to determine whether they represent separate syndromes or different stages in the "transformation" process. DESIGN: We surveyed 189 consecutive patients, 18 years of age or younger, who presented for initial evaluation of daily or near daily headache at one of 9 tertiary headache clinics. Data were collected in semistructured interviews employing a standard questionnaire and analyzed using Statistical Analysis Systems and Stata statistical software computer programs. RESULTS: Of the patients enrolled, 70% were female and 87% were white. Mean age was 13.0 +/- 3.1 years. Male gender was associated with a higher degree of reported disability. A family history of headache (typically migraine) was described in 79%. Use of nonsteroidal anti-inflammatory drugs 5 days per week or more was reported by 44% of patients. The International Headache Society (IHS) criteria failed to classify 64% of patients and criteria proposed by Silberstein et al failed to classify 31% of patients. Participating physicians misclassified patients according to criteria of the IHS and Silberstein et al in one third of cases. Nearly one quarter of patients reported two separate headache types with distinguishing characteristics. "Baseline" headache was present 27.3 +/- 4.1 days per month with a mean pain intensity of 5.9 +/- 2.1 on a 10-point scale. Superimposed episodic headache occurred 4.7 +/- 3.8 days per month with a mean pain intensity of 8.4 +/- 1.4, and was more often accompanied by other migrainous symptoms. After logistic regression to control for pain intensity, the only statistically significant difference between the two headache types was a lower prevalence of tension-type head pain with the superimposed headache. CONCLUSIONS: Our data suggest that rather than having two coexistent headache types, children and adolescents with chronic daily headache have a single syndrome that, in many cases, will paroxysmally worsen and gather migrainous features.     

Menstrual Migraine in Adolescents

Objective.— To characterize menstrually associated headaches and migraine in adolescent girls and identify any developmental and pubertal changes. Background.— Headache and migraine is a common problem in adolescents with a transition to adult patterns. One pattern of adult migraine is the menstrual association in a significant number of women. Methods.— A retrospective analysis was performed of characteristics of adolescent's headaches including association with menstrual pattern. A detailed analysis of the patient‐ and parent‐reported headache characteristics and patterns of longitudinal change with development and puberty was reviewed, including timing of headache with age and menstrual period and progression of these events over the adolescence. Results.— Of the 896 girls between 9 and 18 years old reviewed at initial evaluation, 331 (50.3% of menarchal girls and 36.9% of all girls) report experiencing headaches with their menstrual period. Of those reporting a menstrual pattern, 63.6% reported migraines starting between day ?2 and +3 of their menstrual period start. Girls with menstrual migraine reported increased associated symptoms compared with girls without menstrual migraine. There was no difference in disability between girls with a menstrual pattern and those without a menstrual pattern (t = 1.64; P = .10). Additionally, 160 girls reported a monthly pattern to their headaches prior to beginning menstruation, suggestive of a menstrually related migraine pattern prior to menstruation. Conclusions.— The pattern of menstrual association begins to become apparent during adolescence. Once the menstrual pattern has developed, this association is stable. Early identification of this pattern has potential long‐term benefit for improved lifelong outcome.     

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.