Treating the root cause of tension-type headache: when analgesics address the symptom but not the disorder

Introduction: Tension-type headache (TTH) is very common, with a lifetime prevalence in the general population ranging in different studies between 30% and 78%. TTH, divided into episodic and chronic types, introduced in the manual "International Classification of Headache Disorders"(ICHD-I), is of practical importance. Infrequent episodic headaches (no more than once a month) may not require drug therapy, but, on the contrary, frequent forms may require expensive treatment. Objective: To study the state of cerebral hemodynamics and cerebrovascular reactivity in patients with Tension-type headache and evaluate the efficacy of treatment with Phenibite using Doppler ultrasound. Materials and Methods: A retrospective analysis of the results of ultrasound dopplerography of the anterior, middle and posterior cerebral arteries (ACA, MCA and PCA), Vertebral and Basal (VA, BA) arteries was performed in 188 patients with TTH. Among them are infrequent episodic TTH - 68 (36,2%) patients, frequent episodic TTH - 64 (34,0%) patients, chronic TTH - 56 (29,8%) patients. The age of the subjects was 18-45 years, among them 85 (45.2%) men and 103 (54.8%) women. The maximum systolic velocity (Vs), the end diastolic velocity (Vd), the resistance and pulsativity indexes (RI, PI) in all vessels were determined. Patients were given consent to participate in the study. Results: Infrequent episodic (IFE) TTH were recorded in 86.4% of cases, frequent episodic (FE) — in 88.9%, and chronic (Ch) TTH — in 81.6% of cases. Bilateral TTH was noted in 39.2%, frontal localization - in 35.6%, in the occipital region - in 25–7% of cases. The asymmetry of the maximum systolic blood flow velocity (Vs) in the paired arteries within 20-30% was considered a violation of cerebral hemodynamics, which was detected in 38.7% of patients. An increase in Vs was noted in all cerebral vessels, especially in patients with FE TTH and chronic Ch TTH compared with the control group. In patients with IFE TTH the average value of RcFMt was 1.24±0.03, in patients with FE TTH - 1.25±0.02, in patients with Ch TTH - 1.27±0.03. In patients with TTH, hyper-responsiveness to hypercapnic test was detected: RcCO2 was 1.43±0.05 in the group with FE TTH; 1.39±0.07 in the group of Ch TTH and 1.37±0.04 in the group of IFE TTH, which indicates a tendency for the tension of the vasodilator regulation mechanism even in clinically insignificant forms of TTH. In the study of reactivity to the O2-test, a hyporeactive response was observed in the groups with FE TTH and Ch TTH (0.38±0.04 and 0.35±0.05, respectively. The treatment with Phenibut carried out in a step-by-step manner - during the first week the drug was applied at a dose of 250 mg 2 times a day, over the next 6 weeks the dose increased to 500 mg 2 times a day, then the dose was reduced back to 250 mg 2 times a day. Among patients with FE TTH, the frequency of headache decreased from 5.7±2.3 to 3.6±2.1 days/month, and in patients with Ch TTH - from 22.8±1.7 to 17.7±1,3 days/month (P<0,05). Influence of the drug was manifested at the initially increased RcFMt and RcCO2. A decrease in initially elevated RcCO2 was noted in all (FE TTH, ChTTH, IFETTH) clinical groups. However, this decrease was not statistically significant. Conclusion: In patients with TTH, an increase in the Vs is more often recorded, their asymmetry in the middle cerebral artery. Hyperreactivity on CO2-load is typical for patients with chronic TTH, and reflects the mobilization of metabolic regulation of cerebral blood flow. Conducting FMt was the most informative method for detecting autoregulatory disorders mainly in patients with IFE TTH. FE TTH in patients is characterized by the presence of a hyperactive reaction to hypercapnic and orthostatic tests, probably due to mobilization of humoral-metabolic and neurogenic links of regulation. In the group of patients with chronic TTH prevails hyporeactivity for hyperventilation test, reflecting the depletion of vasoconstriction reserve. The use of Phenibut(Noophen® (JSC Olainfarm Latvia in the treatment of TTH is accompanied by a decrease in the frequency of pain, and of pericranial muscle tone, most pronounced in patients with FE TTH. It's effectiveness is evident in the normalization of the coefficients of cerebrovascular reactivity in a patients with chronic TTH. The minimal statistical significance was observed on the dynamics of blood flow only in the VA.

Tension-type and migraine-type headaches are the most common chronic paroxysmal disorders of childhood. The goal of this study was to compare regional cerebral volumes and diffusion in tension-type and migraine-type headaches against published controls. Patients evaluated for tension-type or migraine-type headache without aura from May 2014 to July 2016 in a single center were retrospectively reviewed. Thirty-two patients with tension-type headache and 23 with migraine-type headache at an average of 4 months after diagnosis were enrolled. All patients underwent DWI at 3T before the start of pharmacotherapy. Using atlas-based DWI analysis, we determined regional volumetric and diffusion properties in the cerebral cortex, thalamus, caudate, putamen, globus pallidus, hippocampus, amygdala, nucleus accumbens, brain stem, and cerebral white matter. Multivariate analysis of covariance was used to test for differences between controls and patients with tension-type and migraine-type headaches. There were no significant differences in regional brain volumes between the groups. Patients with tension-type and migraine-type headaches showed significantly increased ADC in the hippocampus and brain stem compared with controls. Additionally, only patients with migraine-type headache showed significantly increased ADC in the thalamus and a trend toward increased ADC in the amygdala compared with controls. This study identifies early cerebral diffusion changes in patients with tension-type and migraine-type headaches compared with controls. The hypothesized mechanisms of nociception in migraine-type and tension-type headaches may explain the findings as a precursor to structural changes seen in adult patients with chronic headache.

SYNOPSISMuscle contraction headaches are assumed to be associated with relative ischemia in head muscles due to sustained contractions of these muscles. The present study examined whether an abnormally high degree of relative ischemia occurs during such contractions which were experimentally induced in various types of headache patients. Sustained fatiguing contractions at 50% of the maximum EMG amplitude were carried out in the frontalis, corrugator supercilii, and temporalis muscles. The rate of change of the power spectrum of the surface EMG was measured during the contractions. This measure may be considered as an indirect indication of the degree of relative ischemia. Patients with muscle contraction headaches, migraine, or mixed muscle contraction‐migraine headaches did not show a faster spectral shift in any of the three muscles than a group of non‐headache control subjects. Muscle contraction and mixed headache patients even showed significantly slower spectral shifts in the frontalis muscle. These results suggest that muscle contraction headaches are not associated with an abnormally high degree of relative ischemia during the sustained contractions which are believed to underlie this type of headaches.

SYNOPSISThe relation of migraine to atopy was studied. 89 cases of migraine and 27 muscle contraction headache has serum IgE levels determined. In addition, 504 patients were questioned about personal and family history of atopy. There were 73 muscle contraction headache, 55 cluster headache, 70 classical migraine, 189 common migraine and 117 mixed muscle contraction and migraine headache in this group. Elevated serum IgE levels were found in 5.7% of migraine and 3.7 % of muscle contraction headache patients. The incidence is not significantly different from non‐atopic general population. The prevalence of atopic disorders in migraine patients and their relatives did not differ from that found in patients with muscle contraction headache. This study does not support the concept that migraine is an IgE‐mediated hypersensitivity state.

SYNOPSISThe purpose of this study was to conduct a controlled comparison of tension and migraine headache under several experimental conditions.Ten subjects from each of the following diagnostic groups ‐ tension headache, migraine headache, and healthy controls ‐ were observed under conditions of unstructured relaxation, mild stress, and recovery from stress. Forearm and forehead muscle potential, peripheral temperature, electrodermal response, heart rate, and systolic and diastolic blood pressure were monitored during these sessions. In addition, ratings of pain were obtained, and booklets II and III of the Edwards Personality Inventory were completed by each subject. The hypotheses that tension headache is associated with increased frontalis muscle tension and that migraine headache is associated with increased vasomotor activity were not supported with respect to resting levels, response to physical or psychological stress, or in relationship to pain. Personality differences between the three groups were observed. Migraine subjects appeared to be more perfectionistic and success‐oriented than the other groups: and tension headache subjects, more anxious and insecure. It was suggested that although personality differences indicate the existence of two distinct disorders, physiological variables that were believed to be basic to the pathophysiology of these headaches (e.g. frontalis EMG in tension headache) do not distinguish these two types of headache.

Introduction. Tension-type headache (TTH) represents a widespread and recurrent disease in adults, children, and adolescents, adversely affecting the quality of life, learning achievements, and social functioning. In recent publications, a high incidence of comorbid disorders in patients with TTH is discussed, in particular sleep disorders. The aim of the study was to assess the nature and prevalence of sleep disorders in children and adolescents with frequent episodic TTH and chronic TTH. Materials and methods. One hundred fifty patients aged from 8 years to 16 years 11 months with TTH were examined. Of them, 91 (49 boys, 42 girls) had frequent episodic TTH, 59 (26 boys, 33 girls) had chronic TTH. There was used Sleep Disturbance Scale for Children including 26 questions for parents. Results. The present study confirms the high incidence of sleep disorders among TTH children and adolescents. TTH was diagnosed in 129 (86.0%) out of 150 patients. The most frequently diagnosed varying degrees of severity (clinically relevant and borderline, when assessing sleep disorders in children) were insomnia (disorders of initiating and maintaining sleep) - in 65.3% of patients (including 60.4% with frequent episodic TTH and 72.9% with chronic TTH), excessive somnolence - in 74.7% (67.1% and 86.4%), sleep breathing disorders - in 26.7% (23.1% and 32.2%), disorders of arousal/nightmares - in 46.0% (42.9% and 50.8%), sleep-wake transition disorders - in 65.3% (67.1% and 62.7%), sleep hyperhidrosis - in 31.3% (26.4% and 39.0%). Thus, all sleep disorders (except for sleep-wake transition disorders) were significantly more common among the patients with chronic TTH. At the same time, in the subgroup of patients with TTH and any sleep disorders, significantly more prominent indicators of the frequency, the intensity of TTH and its negative impact on the daily activity were revealed, compared to patients with TTH lacking sleep disorders. Conclusion. The results of the assessment of children and adolescents with TTH show that when planning preventive therapy for TTH and evaluating its results, not only main clinical characteristics of TTH should be taken into account, but also the manifestations and severity of comorbid disorders, including sleep disorders observed in most patients with TTH. The revealed prevalence of various sleep disorders in the subgroup of patients with chronic TTH confirms that sleep disorders and anxiety disorders refer to significant risk factors for the transition of TTH to a chronic form, and such patients need more active multimodal treatment.

Introduction Frequent intermittent headache is prevalent in today's society. Differential diagnosis can be challenging in the common headache types of migraine, tension-type and cervicogenic headache, as there can be considerable symptomatic overlap. Cervical musculoskeletal dysfunction is considered to be the underlying cause of cervicogenic headache, but neck pain and tenderness are common accompaniments of migraine and tension-type headache. There is little knowledge of whether or not cervical musculoskeletal impairment is associated with the neck pain of these headache types, to justify the administration of treatments such as manipulative therapy and specific neck exercise. The current physical impairment criteria for the classification of cervicogenic headache are largely non-specific. It was reasoned that diagnosis of this headache form might be improved with a more comprehensive understanding of the precise nature of impairment in the cervical articular, muscular and sensorimotor systems. The basic aims of this study were twofold namely, to investigate if there was a pattern of cervical musculoskeletal impairment which more precisely characterized cervicogenic headache and to investigate whether cervical musculoskeletal impairment accompanied other frequent intermittent headache types such as migraine and tension-type headache, whether suffered as a single headache or one of multiple headaches. Methods One hundred and ninety six subjects with frequent intermittent headache and 57 non-headache control subjects participated in this study. Eighty-eight subjects reported a single headache and 108 reported two or more headache types. All headache subjects completed a questionnaire inclusive of items for the classification of migraine, tension-type headache IHS (1988) and cervicogenic headache (Sjaastad et al 1998). Two investigators who were blind to the results of the physical examination later classified headaches independently. The tests of the cervical musculoskeletal system included measurement of range of movement and manual examination of the cervical segments, performance in the cranio-cervical flexion test (CCFT), the strength of the flexor and extensor muscles, cross sectional area (CSA) of the selected neck extensor muscles and a measure of cervical kinaesthetic sense. Results Using the questionnaire, there was a 67% agreement between the two examiners for classification of subjects with a single headache and a 45% agreement for headache classification in the presence of multiple headaches. The analysis of the single headache cohort revealed significant differences in the measures of cervical musculoskeletal impairment between the cervicogenic headache subjects, those with other headache types and control subjects. Cervicogenic headache subjects were found to have a higher incidence of upper cervical joint dysfunction as determined by manual examination, reduced range of motion in extension and rotation, higher RMS EMG amplitudes in the sternocleidomastoid and scalene muscles in the CCFT, lesser cervical flexor and extensor strength and decreased muscle CSA in the rectus capitis posterior major and semispinalis capitis ipsilateral to pain (all pl0.001). No differences were found in tests of cervical kinaesthetic sense. Importantly, no differences were found in any test between the migraine, tension-type headache and control subjects (pg0.05). A pattern inclusive of upper cervical joint dysfunction, reduction in cervical extension and performance in the CCFT characterized cervicogenic headache with 100.0% sensitivity and 94.4% specificity. When the discriminant variables were applied to the data of the subjects with multiple headaches, it was found that musculoskeletal impairment was not present in multiple headaches unless a cervicogenic headache was one of the headache types. Conclusions This study has shown that cervicogenic headache is characterized by a pattern of musculoskeletal impairment which can enhance the accuracy for its classification in the presence of symptomatic overlap with other headache types. Cervical musculoskeletal impairment is not present in migraine and tension-type headaches and appears not to be the source of any neck pain or tenderness which might accompany these headaches. No support can be given to the use of manipulative therapy and specific neck exercises in the management of these latter frequent intermittent headache types.

Persistent post-traumatic headache remains a poorly understood clinical entity. Although there are currently no accepted therapies for persistent post-traumatic headache, its clinical symptoms, which primarily resemble those of migraine or tension-type headache, often serve to guide treatment. However, evidence-based justification for this treatment approach remains lacking given the paucity of knowledge regarding the characteristics of these two major persistent post-traumatic headache phenotypes and their etiology. We compared clinical features and quantitative sensory testing profiles between two distinct cohorts of persistent post-traumatic headache subjects that exhibited symptoms resembling either migraine (n = 15) or tension-type headache (n = 13), as well as to headache-free subjects that had suffered traumatic brain injury (n = 19), and to healthy controls (n = 10). We aimed to determine whether the two persistent post-traumatic headache subgroups could be discriminated based on additional clinical features, distinct quantitative sensory testing profiles, or the interaction of pain severity with the level of post-traumatic stress disorder. Persistent post-traumatic headache subjects with migraine-like symptoms reported that bright light and focused attention aggravated their pain, while stress and nervousness were reported to aggravate the headache in subjects with tension-type headache-like symptoms. Quietness was better in alleviating migraine-like persistent post-traumatic headache, while anti-inflammatory medications provided better relief in tension-type headache-like persistent post-traumatic headache. The two persistent post-traumatic headache subgroups exhibited distinct quantitative sensory testing profiles with subjects exhibiting tension-type headache-like persistent post-traumatic headache displaying a more pronounced cephalic and extracephalic thermal hypoalgesia that was accompanied by cephalic mechanical hyperalgesia. While both persistent post-traumatic headache subgroups had high levels of post-traumatic stress disorder, there was a positive correlation with pain severity in subjects with tension-type headache-like symptoms, but a negative correlation in subjects with migraine-like symptoms. Distinct persistent post-traumatic headache symptoms and quantitative sensory testing profiles may be linked to different etiologies, potentially involving various levels of neuropathic and inflammatory pain, and if confirmed in a larger cohort, could be used to further characterize and differentiate between persistent post-traumatic headache subgroups in studies aimed to improve treatment.

To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic). This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain. When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated. Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation. Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Background: Tension and migraine headaches are the most prevalent types of headaches. Some emotional and psychological factors are associated with these headaches. Objectives: To elucidate the nature of individual differences in emotion regulation and repetitive negative thinking among patients with tension headaches and migraine and compare it with normal subjects. Materials & Methods: In this cross-sectional, comparative study, the participants consisted of patients with tension headaches and migraine referring to the two neurology clinics in Isfahan City, Iran from 2019 to 2020. A diverse sample of patients (n =240) completed the difficulties in emotional regulation scale and perseverative thinking questionnaire. The Chi-square tests, Fisher’s exact test, GLM (generalized linear model), Tukey post hoc test, and LSD (least significant difference) test were used to analyze the obtained data in SPSS V. 21. Results: The results indicated that patients with a high level of repetitive negative thinking reported increased difficulties in emotional regulation and impulse control, limited access to emotion regulation strategies, and lack of emotional clarity (P<0.05). Moreover, the tension headaches group showed a higher level of difficulties in emotional regulation and repetitive negative thinking than the migraine and control groups (P<0.001). Conclusion: Weak emotional regulation and repetitive negative thinking are associated with migraine and, especially tension headaches. Therefore, therapeutic plans based on emotion regulation and thinking problems should be considered as a complementary and necessary treatment for these types of headaches.

BackgroundHeadache disorders are the most common complaints worldwide. Migraine, tension type and cluster headaches account for majority of primary headaches and improvise a substantial burden on the individual, family or society at large. There is a scanty data on the prevalence of primary headaches in sub-Saharan Africa in general and Ethiopia in particular. Moreover there is no population based urban study in Ethiopia. The purpose of this study is to determine the prevalence and burden of primary headaches in local community in Addis Ababa, Ethiopia.MethodsCross-sectional sample survey was carried out in Addis Ketema sub city, Kebele 16/17/18 (local smallest administrative unit). Using systematic random sampling, data were collected by previously used headache questionnaire, over a period of 20 days.ResultsThe study subjects were 231 of which 51.5% were males and 48.5% were females. The overall one year prevalence of primary headache disorders was 21.6% and that for migraine was 10%, migraine without aura 6.5% migraine with aura was 2.6% and probable migraine was 0.9%. The prevalence of tension type of headache was found to be 10.4%, frequent episodic tension type headache was 8.2% followed by infrequent tension type headache of 2.2%. The prevalence of cluster headache was 1.3%. The burden of primary headache disorders in terms of missing working, school or social activities was 68.0%. This was 78.3% for migraineurs and 66.7% for tension type headache. Majority 92.0% of primary headache cases were not using health services and 66.0% did not use any drug or medications during the acute attacks and none were using preventive therapy.ConclusionPrevalence and burden of primary headache disorders was substantial in this community. Health service utilization of the community for headache treatment was poor.

Homeopathic Treatment of Headaches: A Systematic Review of the Literature

To identify natural subtypes of tension-type headache (TTH) based on clinical characteristics. Tension-type headache is generally recognized as a bilateral, non-pulsating headache of mild-to-moderate intensity, with minimal accompanying symptoms. However, diverse symptomatology can be present with current diagnostic criteria. This study was a cross-sectional, secondary analysis of data previously collected from a nationwide population-based web survey data on headache and sleep, conducted in South Korea in October 2020. Categorical variables for TTH diagnostic criteria according to the third edition of the International Classification of Headache Disorders were analyzed to determine the natural subtypes of TTH. Of 3030 participants, 954 were identified with TTH. A four-class model was selected as optimal, revealing subtypes named "classic TTH," "severe TTH," "unilateral TTH," and "TTH with photophobia," comprising 413 (43.3%), 66 (6.9%), 376 (39.4%), and 99 (10.4%) individuals, respectively. The most common, "classic TTH," featured typical bilateral (413/413 [100.0%]), non-pulsatile headaches (220/413 [53.3%]) of mild-to-moderate intensity (400/413 [96.9%]). The "severe TTH" class exhibited the highest headache intensity (moderate headache intensity, 35/66 [53.0%]), and the greatest impact of headache (mean [± standard deviation, SD] six-item Headache Impact Test [HIT-6] score, 55.1 [6.0]). The "unilateral TTH" class was primarily mild headache intensity (277/376 [73.7%]) and lowest impact of headache (mean [SD] HIT-6 score 48.8 [8.3]). "TTH with photophobia" involved exclusive photophobia (99/99 [100%]) and was second to "severe TTH" in headache intensity (moderate intensity, 43/99 [43.4%]) and impact of headache (mean [SD] HIT-6 score 53.2 [8.1]). Of 954 total TTH participants, 56.7% were not "classic TTH" subtype and 51.4% had unilateral headache. We identified four TTH subgroups, each with unique clinical features, providing additional insights into TTH subtypes.

BackgroundMigraine, tension type headache (TTH), and hypothyroidism are clinical problems that affect patient daily activities and quality of life.ObjectivesThe purpose of this study was to investigate the potential association between hypothyroidism in patients with migraine and TTH.Patients and methodsTwo hundred and twelve patients with migraine and TTH and one hundred control subjects underwent clinical evaluation, assessment of thyroid hormones, and thyroid ultrasound.ResultsSubclinical and overt hypothyroidism were significantly higher in patients with migraine and TTH (P = 0.001) than control subjects. Patients with migraine and TTH showed significantly more abnormal thyroid gland morphology than healthy control (P = 0.027). Hypothyroidism is significantly expressed in chronic TTH more than TTH with infrequent or frequent TTH (P = 0.009).ConclusionsPatients having migraine and TTH more prone to develop hypothyroidism when compared with control group. Also patients with chronic TTH are susceptible to develop hypothyroidism (either subclinical or overt) when compared with patients having frequent or infrequent TTH.

Existing criteria for the diagnosis of headache do not indicate which clinical features are most important to establish or exclude primary headache diagnoses. To determine the value of history taking in the evaluation of patients with primary headache syndromes. A MEDLINE search of English-language studies published since 1966 and a hand search of bibliographies from retrieved articles. Included studies cited the sensitivity of clinical and historical features for the diagnosis of migraine, tension-type, and cluster headaches. Studies were classified according to their use of the International Headache Society criteria or other criteria as the reference standard for diagnosis. The features most predictive of migraine, when compared with tension-type headache, are nausea, photophobia, phonophobia, and exacerbation by physical activity. Positive likelihood ratios (95% confidence intervals) are 19.2 (15.0-24.5), 5.8 (5.1-6.6), 5.2 (4.5-5.9), and 3.7 (3.4-4.0), respectively. Headache precipitants are present equally in patients with migraine and tension-type headache, with the exception of food triggers, which confer a positive likelihood ratio of 3.6 (2.8-4.6) for the diagnosis of migraine. Visual aurae are present in 84% of patients with migraine with aura. Cluster headache is strictly unilateral, is periorbital in 80% of patients, and lasts less than 1 hour in 54% of patients. The features most predictive of the diagnosis of migraine, when compared with tension-type headache, are nausea, photophobia, phonophobia, exacerbation by physical activity, and an aura. Cluster headache is a distinct clinical syndrome.