Prevalence of headache in Swedish schoolchildren, with a focus on tension-type headache

To estimate the prevalence of tension-type headache, migraine and other headaches, 1850 schoolchildren, age 7-15 years, from the city of Uppsala, were invited to complete a questionnaire. The response rate was 74.1%. To validate the information from the questionnaires, 131 children and their parents were interviewed. Using the criteria of the International Headache Society, the 1-year prevalence of tension-type headache and migraine was 9.8 and 11.0%, respectively. However, these prevalence rates increased considerably, to 23.0 and 17.0%, respectively, when excluding the criteria defining the number of earlier episodes and duration of headache. The prevalence of headache increased with age, similarly in girls and boys up to 11 years, and thereafter only in girls. The preponderance in teenage girls was even more pronounced for tension-type headache than for migraine. Our results indicate an increase over time in headache prevalence when compared with findings in a study conducted in the same city in 1955.     

Migraine and tension-type headache in Croatia: a population-based survey of precipitating factors

The careful monitoring of the trigger factors of headache could be an important step in treatment, because their avoidance may lessen the frequency and severity of attacks. Furthermore, they may provide a clue to the aetiology of headache. The aim of the present study was to estimate the prevalence of tension-type headache (TTH) and to establish the frequency of precipitating factors in subjects with migraine and TTH in the adult population of Bakar, County of the Coast and Gorski Kotar, Croatia. Another important purpose of the study was to examine the relationship of the precipitating factors with migraine and TTH, and with migraine subtypes: migraine with aura (MA) and migraine without aura (MO). We performed a population-based survey using a 'face-to-face door-to-door' interview method. The surveyed population consisted of 5173 residents aged between 15 and 65 years. The 3794 participants (73.3%) were screened for headache history according to the International Headache Society (IHS) criteria. Headache screen-positive responders, 2475 (65.2%), were interviewed by trained medical students with a structured detailed interview focused on the precipitating factors. The following precipitating factors in lifetime migraineurs and tension-type headachers have been assessed: stress, sleep disturbances, eating habits, menstrual cycle, oral contraceptives, food items, afferent stimulation, changes in weather conditions and temperature, frequent travelling and physical activity. A total of 720 lifetime migraineurs and 1319 tension-type headachers have been identified. The most common precipitants for both migraine and TTH were stress and frequent travelling. Stress (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.17, 1.69) was associated with migraine, whereas physical activity (OR 0.72, 95% CI 0.59, 0.87) was related to TTH. Considering MA and MO, frequent travelling (OR 2.2, 95% CI 1.59, 2.99), food items (OR 2.2, 95% CI 1.35, 3.51) and changes in weather conditions and temperature (OR 1.75, 95% CI 1.27, 2.41) exhibited a significant positive association with MA. The present study demonstrated that precipitant-dependent attacks are frequent among both migraineurs and tension-type headachers. Lifetime migraineurs experienced headache attacks preceded by triggering factors more frequently than tension-type headachers. MA was more frequently associated with precipitating factors than MO. We suggest that some triggering factors may contribute to the higher occurrence of precipitant-dependent headache attacks in susceptible individuals.     

A nationwide population-based study of tension-type headache in Brazil

Objectives.— To estimate the 1-year prevalence of tension-type headache (TTH) and the degree of the association of TTH with some sociodemographic characteristics of a representative sample of the adult population of Brazil.
Methods.— This was an observational, cross-sectional, population-based study. We conducted telephone interviews on 3848 people, aged 18-79 years, randomly selected from the 27 states of Brazil. Trained lay interviewers administered the structured questionnaire. It included questions about the sociodemographic characteristics of the population, as well as questions about headache. The degree of the association was calculated through prevalence ratios, adjusted with Poisson regression by gender, age, years of education, marital status, household income, job status, body mass index (BMI), and physical exercise.
Results.— The estimated 1-year gender- and-age-adjusted prevalence of TTH was 13.0% (95% CI: 11.8-14.2%); 15.4% in males and 9.5% in females. The prevalence of probable TTH was 22.6% (95% CI: 21.1-24.1%). Most (86.2%) subjects reported episodic TTH; 6.4% had chronic TTH. The prevalence was higher at 18-29 years of age (16.2%). TTH was 1.6 times more prevalent in men, and 1.54 times more in subjects with more than 11 years of education. There was no significant association of TTH with marital or job status, household income, BMI, and physical activity.
Conclusion.— This is the first nationwide epidemiological study of TTH in Brazil. The overall prevalence of TTH in Brazil is low, at 13%. TTH is significantly more prevalent in males and subjects with higher education level.     

Serotonin metabolism in chronic tension-type headache

Serotonergic neurons play a major role in the regulation of pain and may therefore also be involved in the pathophysiology of tension-type headache. Platelets are important in the regulation of the free serotonin level in plasma and may be a model of serotonergic neurons. The aim of the present study was to investigate the peripheral serotonin (5HT) metabolism in patients with chronic tension-type headache. The 5HT levels in platelets and in plasma, the beta-thromboglobulin (ß-TG) levels in plasma, and the urinary excretion of 5-hydroxyindoleacetic acid (5HIAA) were measured in 40 patients with chronic tension-type headache and in 40 healthy controls. The platelet uptake index was calculated as the ratio between platelet 5HT and plasma 5HT levels. There were, no significant differences in platelet 5HT, plasma 5HT ß-TG, or 5HIAA between patients and controls. The platelet uptake index was significantly lower in patients 243 (136–367) than in controls 352 (202–508), p =0.03. Our results indicate that the peripheral 5HT metabolism is largely normal in patients with chronic tension-type headache.     

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

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

Epidemiology of tension-type headache in Santiago, Chile: a prevalence study

Objective: To describe the importance of tension-type headache (TTH) in Santiago, Chile, by analyzing its prevalence, clinical features, and impact by age, gender, and socioeconomic status, using widely accepted international diagnostic criteria. Methods: In 1993, a representative sample of 1540 adults (older than 14) of the province of Santiago were interviewed using a standard questionnaire. A total of 1385 (89.9% response rate) subjects responded to the survey. Initially, a designated member of each household responded to the questionnaire. Subsequently, each household member with headache was asked to respond to questions about the severity, frequency, location, duration, associated symptoms, and impact in work and social activities of their most frequent headaches. TTH diagnoses were determined in accordance with the International Headache Society criteria of 1988. Results: Total prevalence was found to be 26.9% (95% CI: 24.6–29.3%); 35.2% in females (95% CI: 31.7–38.8%) and 18.1% in males (95% CI: 15.2–21.3%). The prevalence of episodic TTH was 24.3% (95% CI: 22.1–26.7%) and of chronic TTH 2.6% (95% CI: 1.8–3.6%). Overall, and by subtype, prevalence was significantly higher in females (ratio 1:9). There was no significant variation in prevalence by socioeconomic or age group except in chronic TTH, in which there was an increase with age. Conclusions: TTH is a prevalent condition in a sample of adults of Santiago, similar to that reported in previous studies using similar methodologies. Overall, TTH represents 72.3% of all recurrent headaches.     

Physiotherapy for tension-type headache: a controlled study

The role of non-pharmacological therapies in the preventive treatment of tension-type headache (TTH) is still an object of debate. The primary aim of this study was therefore to investigate the therapeutic effect of physiotherapy in properly classified patients with TTH in a controlled trial. Fifty patients with TTH, 26 with episodic, frequent (ETTH) and 24 with chronic TTH (CTTH) fulfilling the International Headache Society classification criteria were included in the study. After a 4-week run-in period, they were randomized to either an 8-week period of standardized physiotherapy (group 1) or to an 8-week observation period followed by an identical course of physiotherapy (group 2); after the physiotherapy all patients were followed for a 12-week follow-up period. We then evaluated the number of days with headache, severity and duration of the headache attacks, and drug consumption for symptomatic treatment before and after the course of physiotherapy. Forty-eight patients completed the study. The average number of days with headache per 4-week period was reduced from 16.3 days at baseline to 12.3 days in the last 4 weeks of treatment [from 14.5 days to 10.5 days (P < 0.001) in group 1 and from 18.1 days to 14.1 days (P < 0.001) in group 2]. Severity and duration of headache as well as drug consumption were unchanged throughout the study. Analysing the response to treatment separately in the various subgroups, we found that the number of responders was significantly higher among patients with CTTH vs. patients with ETTH (P < 0.002) and in females vs. males (P < 0.02). No differences were found between patients with and without disorder of pericranial muscles. We conclude that a standardized physiotherapy programme has a good therapeutic effect, albeit on a restricted group of patients.     

Photophobia and phonophobia in tension-type and cervicogenic headache

Light and sound-induced discomfort and pain thresholds were measured in 26 patients with cervicogenic headache, in 40 patients with tension-type headache, and in 100 headache-free controls. Neither headache group was significantly different as to photophobia and phonophobia, but both were significantly more sensitive to light and sound than controls ( p <0.0001), even when patients were tested in the headache-tree period ( p <0.05). Episodic and chronic tension-type headache had similar photo- and phonophobia thresholds ( p ≥0.7). Tension-type headache patients were more photo- and phonophobic during headache than outside attack ( p <0.05), but this was not true for cervicogenic headache ( p ≥0.56). In cervicogenic headache patients, photophobia ( p <0.05) but not phonophohia ( p =0.28) was greater on the symptomatic side than on the non-symptomatic side.     

Muscular disorders in tension-type headache

In order to evaluate the diagnostic criteria for muscular disorders in tension-type headache, pericranial muscle tenderness and pressure pain thresholds were studied in a random sample population of 735 adults aged 25–64. In addition, quantitative EMGs were recorded in 547 of these subjects. The correlation between the three diagnostic tests was assessed and the discriminality and cut-off points were analysed using Receiver Operating Characteristics analysis. Local tenderness from the temporal muscles was closely related to the total tenderness scores from 14 pairs of muscles. In chronic tension-type headache, tenderness was positively related to EMG and inversely related to pain thresholds. In the episodic form the total tenderness score was inversely related to pain thresholds, whereas no significant relation to EMG was noted. The Receiver Operating Characteristics curves indicated that tenderness recorded by manual palpation was the most specific and sensitive test, whereas EMG and pain thresholds were of limited diagnostic value. Eighty-seven percent of subjects with the chronic, and 66% of subjects with the episodic form were found to have a "muscular disorder" defined as increased tenderness recorded by either manual palpation or pressure algometry and/or increased EMG levels. However, muscle tenderness increased significantly during pain, so the headache state should be considered in future studies. Suggestions for revision of the present diagnostic criteria for muscular disorders are given.     

Prevalence of migraine, tension-type headache, and other headaches in Hong Kong

OBJECTIVE: To assess the prevalence of migraine and other headaches in Hong Kong in 1998. BACKGROUND: A community-based prevalence survey of headache was carried out from July 1992 to March 1993, and the prevalence rates were 1% for migraine, 2% for tension-type headache, and 1% for other headaches. A similar survey was carried out in May and June 1998 to interview individuals aged 15 years or older. Recurrent headache was defined as having two or more headaches unrelated either to influenza or a common cold within the past 12 months. METHODS: Respondents with recurrent headache were offered a personal interview for clinical validation. Of 3156 randomly selected individuals, 1436 responded. RESULTS: Headache was due to influenza or a common cold in 270 (18.8%) respondents; recurrent headache affected 533 (37.1%) respondents. The overall prevalence rates were 4.7% for migraine, 26.9% for tension-type headache, and 5.5% for other headaches. Clinical validation was available for 72 respondents. After adjustment for possible misclassification, the estimated prevalence rates became 12.5% for migraine, 18.7% for tension-type headache, and 6.0% for other headaches. There was a female preponderance for all types of headache with a peak in the 25- to 34-year-age group for tension-type headache. CONCLUSIONS: All types of headache were more common in the 1998 study, and the prevalence rates were closer to those of Western communities.     

Pressure pain threshold and pain tolerance in episodic tension-type headache do not depend on the presence of headache

Pressure pain thresholds and responses to painful mechanical stimuli were obtained from 20 subjects with episodic tension-type headaches (TTH). Tender points in the temporalis and trapezius muscles were studied, along with two nontender points, one in the temporalis and one on the Achilles tendon. Two examinations were performed, one during and one without a headache, and results were compared. No significant differences were found in either variable for any tested points. The data demonstrate that the sensitivity level of these points does not differ based on the presence or absence of TTH. This suggests that the muscle sensitivity in TTH is constant. The observation that the sensitivity levels of both tender and nontender points did not vary suggests that the underlying mechanism or effect of TTH is not restricted to tender muscles.     

Prevalences of migraine and tension-type headache in adolescent girls of Shiraz (southern Iran)

OBJECTIVE: To determine the prevalences of migraine and tension-type headache in teenaged girls attending schools in Shiraz (southern Iran). BACKGROUND: Studies of headache prevalence are numerous, and findings have varied according to the specific population and region involved. No data are available regarding headache prevalence among Iranian teenagers. METHODS: A random sample of 1868 teenaged girls (aged 11 to 18 years) was evaluated, and 507 subjects reported headache. The headache disorders were classified on the basis of a clinical interview, general physical and neurologic examinations, and the diagnostic criteria of the International Headache Society. Logistic regression was used for data analysis. RESULTS: Overall prevalence rate for migraine was 6.1% (95% CI, 5.0 to 7.2) and for tension-type headache, 12.1% (95% CI, 10.6 to 13.6). Migraine and tension-type headache were significantly associated. CONCLUSIONS: It is concluded that exposition of subjects to sunlight, type of food, and a family history of headache had most significant effects on occurrence of migraine and tension-type headaches.     

Stress-induced pain and muscle activity in patients with migraine and tension-type headache

We recorded deep pain and surface electromyographic (EMG) responses to stress in 22 migraineurs during headache-free periods, 18 patients with tension-type headache (TTH), and 44 healthy controls. Sixty minutes of cognitive stress was followed by 30 min relaxation. EMG and pain (visual analogue scale) in the trapezius, neck (splenius), temporalis and frontalis areas were recorded. TTH patients had higher pain responses in temporalis and frontalis (with similar trends for trapezius and splenius) and more potentiation of pain during the test than controls. Migraine patients developed more pain in the splenius and temporalis than controls. Muscle pain responses were more regional (more pain in the neck and trapezius compared with the temporalis and frontalis) in migraine than in TTH patients. TTH patients had delayed pain recovery in all muscle regions compared with controls, while migraine patients had delayed pain recovery in a more restricted area (trapezius and temporalis). EMG responses were not different from controls in headache patients, and EMG responses did not correlate with pain responses. TTH patients had delayed EMG recovery in the trapezius compared with controls and migraine patients. These results support the concept that (probably central) sensitization of pain pathways and the motor system is important in TTH. Less pronounced and more regional (either peripheral or central) trigeminocervical sensitization seems to be important in migraine. Surface-detectable muscular activation does not seem to be causal for pain during cognitive stress either in migraine or in TTH.     

Interrelation of chronic tension-type headache with and without medication overuse and migraine in the general population: the Akershus study of chronic headache

We studied the interrelation of chronic tension-type headache with and without medication overuse (CTTH) and migraine in a random sample of 30 000 persons aged 30–44 years. They received a mailed questionnaire. Those with a possible chronic headache were interviewed by neurological residents. The International Classification of Headache Disorders was used. A total of 386 persons had CTTH. Compared with the general population, men had a 2.8-fold and women a 2.4-fold significantly increased risk of migraine without aura (MO). The risk of migraine with aura (MA) was not increased. The mean age at onset of CTTH was significantly higher in those with than in those without co-occurrence of MO. Bilateral MO attacks were significantly more frequent in those with age at onset of CTTH prior to age at onset of MO compared with those with age at onset in reverse order. CTTH and MO are interrelated, possibly in a complex matter. In contrast, CTTH and MA are not interrelated.     

Blink reflex in migraine and tension-type headache

The blink reflex was studied in 19 patients with migraine, 10 patients with tension-type headache, and 30 healthy controls. Significantly lower values of R2 and R2' amplitude and size were found in the migraine group, compared with the healthy control group. The differences were independent of the stimulation side (headache or nonheadache) and highly significant (P<0.001). The abnormalities of R2 and R2' amplitude and size were found only during the headache phase of migraine, being normal between migraine attacks. R1 latency and amplitude were normal in all patients. The blink reflex was normal in all the patients with tension-type headache. Subcutaneous injection of sumatriptan in 10 of the 19 migraineurs, during the headache phase, restored R2 and R2' amplitude and size values to normal. Our findings indicate that the brain stem interneuron part of the blink reflex arc may be diffusely suppressed in migraine, only during the headache phase. Furthermore, blink reflex may be an objective laboratory method to monitor the effectiveness of specific drugs proposed for the treatment of migraine.     

Use and abuse of analgesics in tension-type headache

Eighty patients suffering from tension-type headache for an average of 21 years were asked to report on all drugs they had ever taken (type, dosage, duration of intake, efficacy) or were taking currently. The patients had consumed on average 6.3 different drugs. The cumulative doses of derivatives of para-aminophenol, pyrazolone, and salicylic acid in some cases reached a maximum of several kilograms. Most drugs were classified by the patients as "moderately effective". The rating "very effective" was assigned primarily to barbiturates; however, barbiturates are no longer used as components of compound analgesic drugs in Austria. At the time of investigation, patients consumed 2.5 (mean) different drugs, primarily as compound preparations. Seventeen patients (21%) showed signs of possible analgesics- or ergotamine-induced headache and were therefore advised to undergo withdrawal therapy. Our results show that patients with tension-type headache are at considerable risk of becoming drug-dependent and of acquiring analgesics-induced headache.     

Menstrual tension-type headache: evidence for its existence

OBJECTIVE: To determine whether menstrual tension-type headache is a real disorder. BACKGROUND: An appendix was included in the second edition of the International Classification of Headache Disorders by the International Headache Society. Diagnostic criteria are proposed in this appendix for 2 types of menstrual migraine: pure menstrual migraine without aura and menstrually related migraine without aura. References to menstrual tension-type headache do not appear in this classification. METHODS: In a neurological outpatient clinic 165 patients were identified in whom headache was related to menstruation and the criteria of the International Classification of Headache Disorders for menstrual migraine adapted to menstrual tension-type headache were applied. RESULTS: Twenty-one patients met the criteria of menstrual tension-type headache, 6 for pure menstrual tension-type headache, and 15 for menstrually related tension-type headache. CONCLUSION: Menstrual tension-type headache is a real condition that should be recognized in the International Classification of Headache Disorders.     

Blink reflex R2 amplitudes in cervicogenic headache, chronic tension-type headache and migraine

Blink reflex R2 amplitude was investigated in seven patients with cervicogenic headache (CEH), 12 patients with chronic tension-type headache, 23 patients with migraine (10 with aura) and 17 headache-free controls. Standard electrical stimulation of the supraorbital nerve was applied and the response was recorded from the ipsilateral and the contralateral orbicularis oculi muscles. Low R2 amplitude was found in CEH patients compared with control subjects. Headache is unilateral in CEH and the ipsilateral and contralateral responses after stimulation on the painful side were most depressed. R2 amplitude was not significantly affected in migraine and tension headache patients. The results suggest that lower brainstem excitability is reduced in CEH. A state of hypoactivity may be present in caudal trigeminal nucleus neurons on the symptomatic side.     

Plasma serotonin increase during episodes of tension-type headache

The mechanisms of tension-type headache remain to be determined. Biochemical abnormalities have been rarely demonstrated. We performed a controlled study of 5-hydroxytryptamine (SHT) in platelet poor plasma obtained from 13 female patients during and between episodes of tension-type headache. The 5HT concentration in patients free of headache was not different from controls, whereas a significant increase in 5HT concentration was seen during headache ( p < 0.02.). This finding is attributed to release of 5HT from platelets or disordered 5HT metabolism during headache attacks, possibly related to pain in the latter case. We conclude that 5HT may be involved in the pathogenesis of tension-type headache but by different mechanisms than migraine.     

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.