Pericranial Muscle Tenderness Research Articles

Alexithymia Increases Pericranial and Cervical Muscle Tenderness in Women with Migraine.

Background/Objectives: Alexithymia is characterized by a deficit in identifying and communicating feelings. Emerging evidence suggests that alexithymia is highly prevalent in migraine, in a complex interplay with psychiatric comorbidity. Pericranial/cervical muscle tenderness is a remarkable clinical feature in a large proportion of migraine patients. This pilot study aimed at investigating the relationship between alexithymia and pericranial/cervical muscle tenderness in female migraineurs. Methods: A total of 42 female patients fulfilling the diagnostic criteria for migraine were enrolled into this pilot, observational, cross-sectional study after informed consent was obtained. Each patient underwent a psychological assessment to identify any alexithymia by means of TAS-20, anxiety/mood comorbidity (by means of STAI-Y1 STAI-Y2, BDI-II), and migraine-related disability (by means of HIT-6), and a physical cranial/cervical musculoskeletal examination. Palpation of pericranial and cervical muscles was carried out in the standardized manner. A Cumulative Muscle Tenderness (CUM) score (0-6) was calculated for each patient. A multivariate analysis was performed to investigate any association amongst the TAS-20 score, the CUM score, and the following covariates: BDI-II, STAI-Y1, STAI-Y2, and HIT-6 scores, age, disease duration, monthly migraine days, and average head pain intensity in the previous three months. Results: Overall, 35.6% of the sample had alexithymia. The multivariate analysis detected a linear and independent relationship between the TAS-20 and CUM scores, with a statistically significant (p = 0.017) association. Conclusions: This pilot study suggests that alexithymia plays a role in increasing pericranial/cervical muscle tenderness in migraine, independently from psychiatric comorbidity. A novel therapeutical approach, targeting alexithymia, may well reduce muscular tenderness in female migraineurs.

Pericranial Muscle Stiffness, Pain Thresholds, and Tenderness during a Treatment Cycle of OnabotulinumtoxinA for Chronic Migraine Prevention

Background: Treatment with OnabotulinumtoxinA (BoNT-A) is effective as a preventive treatment for chronic migraine (CM). Preclinical studies suggest that the mechanism of action of BoNT-A in migraine is based on blocking unmyelinated C fibers. We aimed to investigate whether the muscle-relaxing effect of BoNT-A is associated with the preventive mechanism in patients with chronic migraine by measuring the stiffness, pain thresholds, and tenderness of the BoNT-A-applied muscles. Methods: A total of 22 patients with CM who were already in BoNT-A treatment participated in this longitudinal prospective study. Pericranial muscle stiffness was measured using ultrasound shear wave elastography, which measures the speed of shear waves propagating through the muscle. Pressure pain thresholds (PPT) were obtained via algometry, and muscle tenderness was measured via manual palpation. Measurements were made before BoNT-A injections and six weeks after the treatment. The measurements were performed while the muscles were maximally relaxed. The patients also completed daily diaries on headache and neck pain. Results: No change was observed in muscle stiffness (p = 0.737) or pericranial muscle tenderness (p = 0.400). The PPT over the trapezius muscles increased from 250 kPa before treatment to 304 kPa six weeks after treatment (p = 0.027). No change was observed on the temporalis muscles (p = 0.200) nor the non-dominant index finger (p = 0.067). BoNT-A decreased neck pain (p = 0.008) and headache (p = 0.007). Conclusions: The findings suggest that BoNT-A leads to the desensitization of cutaneous and muscle nociceptors in the head and neck regions, whereas muscle relaxation might not be an important part of the anti-migraine effect.

The curative effect of fire needling combined with filiform needling on tension-type headache and its effect on the tenderness of pericranial muscles.

To observe the curative effect of fire needling pricking pericranial tender points combined with filiform needling on tension-type headache (TTH) and its effect on pericranial muscle tenderness, and explore the correlation between changes of headache symptoms and pericranial muscle tenderness in TTH, to analyze the influence of pericranial muscle tenderness on TTH. A total of 41 TTH patients in the treatment group and 38 TTH patients in the control group completed the study. The patients in the treatment group were treated with fire needling at pericranial tender points combined with filiform needling at Baihui (GV20), Sishencong (EX-HN1), Shenting (GV24), Touwei (ST8) and Fengchi (GB20). The patients in the control group were only treated with the same filiform needling as the treatment group. Patients in the two groups were treated twice a week for 8 weeks. Before and after treatment, the days of headache onset, the number and distribution of pericranial muscle tender points were recorded, the degree of headache was evaluated by visual analogue scale and the threshold of pericranial muscle tender points were measured. The correlations between the changes of the days and degree of headache onset and the changes of the number and threshold of pericranial muscle tender points were analyzed. The effective rates in the two groups were calculated. Compared with those before treatment, the days of headache onset and the degree of headache were decreased (P<0.05) in the two groups；the number of pericranial muscle tender points was decreased (P<0.05) and the tenderness threshold was increased (P<0.05) in the treatment group. After treatment, compared with the control group, the days of headache onset, the degree of headache, and the number of pericranial muscle tender points were decreased (P<0.05), and the tenderness threshold was increased (P<0.05) in the treatment group. The decrease of the days and degree of headache was positively correlated with the decrease of number and the increase of tenderness threshold of pericranial muscle tender points (P<0.05). The effective rate in the treatment group was 87.80% (36/41), which was higher than 57.89% (22/38) in the control group (P<0.05). The most common anatomic location of tender points in baseline was superior trapezius muscle, followed by sternocleidomastoid muscle, superior nuchal line, temporal muscle, masseter muscle, etc. The fire needling at the pericranial muscle tender points combined with filiform needling on TTH patients can significantly improve the clinical symptoms and reduce the pericranial muscle tenderness. The pericranial muscle tenderness is an important factor in the pathogenesis of TTH.

Особенности болевого синдрома у пациентов с эпизодической и хронической головной болью напряжения

Актуальность. Головная боль напряжения (ГБН) — наиболее распространенный в популяции тип головной боли (ГБ). Некоторые исследования показали, что мышечное напряжение значительно возрастает с увеличением частоты ГБН, болезненность мышц может расти во время приступов ГБ. Высказано предположение, что непрерывный ноцицептивный вклад периферических миофасциальных структур может вызвать центральную сенсибилизации и, возможно, хронизацию ГБ. Целью исследования было изучение особенностей болевого синдрома у пациентов с эпизодической и хронической головной болью напряжения. Материалы и методы. Было обследовано 108 пациентов (55 мужчин, 53 женщины) с диагнозами «частая эпизодическая головная боль напряжения» (ЭГБН) (группа I, n = 64) и «хроническая головная боль напряжения» (ХГБН) (группа II, n = 44). Проводилось клинико­неврологическое обследование, пальпация перикраниальных и шейных мышц с обеих сторон с подсчетом числа болезненности перикраниальных мышц (ЧБПМ) и числа болезненности мышц шеи (ЧБМШ) для каждого пациента и их среднее значение в группе. Для оценки субъективной выраженности боли использовался метод визуальной аналоговой шкалы (ВАШ), для качественной характеристики боли — болевой опросник Мак­Гилла. Результаты. Пациенты обследованных групп по интенсивности ГБ по ВАШ существенно не отличались, показатель был в пределах умеренного с тенденцией к более выраженному в группе II. В обеих группах при пальпации перикраниальных и шейных мышц с обеих сторон болезненность при пальпации в основном была в пределах от слабой до умеренной, кроме трапециевидной и ременной мышц головы, где болезненность носила характер от умеренной до выраженной. В группе I по сравнению с группой II выявлено достоверное превышение показателя ЧБПМ и ЧБМШ слева, ЧБПМ справа и не отмечено различий между ЧБМШ групп I и II справа. У пациентов с ЭГБН выраженность мышечной болезненности снижалась с возрастом, были выше показатели, описывающие сенсорные и психоэмоциональные характеристики боли, выявлена положительная корреляционная связь между болезненностью перикраниальных мышц и интенсивностью и частотой ГБ в месяц. У пациентов с ХГБН обнаружены корреляционные связи между интенсивностью, средней продолжительностью ГБ в месяц и сенсорными и психоэмоциональными характеристиками боли, что может свидетельствовать о вовлечении центральных и периферических ноцицептивных механизмов в патогенез хронической ГБН. Выводы. Наличие мышечной болезненности, сенсорные и психоэмоциональные характеристики ГБ необходимо учитывать при планировании лечебных и реабилитационных стратегий, что будет препятствовать прогрессированию и хронизации ГБ и способствовать повышению качества жизни пациентов.

Clinical observation of warming acupuncture and moxibustion at the temples combined with Deanxit in the treatment of tension headache with anxiety and depression: a retrospective study.

Tension-type headache (TTH), also called muscle contraction headache or neurological headache, is mainly characterized by chronic and persistent bilateral headache in the neck and a severe sense of restraint in the head. This study aims to analyze the effect of warming acupuncture and moxibustion at temples combined with Deanxit on tension headache. A total of 252 patients with anxiety and tension headache were randomly divided into routine group and study group. The study group was treated with Dailixin on the basis of warm acupuncture and moxibustion. The headache score, pericranial muscle tenderness score, therapeutic effect, tension headache attack times and duration, HAMD and HAMA scores were analyzed before and after treatment. The effective cure rate of the study group was significantly higher than that of the routine group. The pericranial muscle tenderness scores of the study group were significantly lower than those of the routine group. Furthermore, the headache degree score, number of attacks, and duration of the study group after treatment were significantly lower than those of the routine group. And the HAMD and HAMA scores in the study group was significantly lower than those in the routine group. The use of warming acupuncture and moxibustion at temples combined with Deanxit in the treatment of tension headache significantly reduces the number and duration of headache attacks and decreases the degree of headache.

Hypovitaminosis D effect on pericranial muscle dysfunction in women with chronic tension headache

Background. Nowadays there are a large number of studies revealing the significance of hypovitaminosis D in chronic pain conditions and diseases, in which musculoskeletal factors are dominant in the formation of pain. In chronic tension type headache (CTTH) pathogenesis the role of muscular factor is well-established. However there is insufficient data regarding the interrelations between hypovitaminosis D, headache and pericraial muscle dysfunction (PMD) in CTTH.Objective. To investigate the effect of vitamin D level on PMD and cephalgia parameters in CTTH.Methods. One hundred twenty women with CTTH aged 25 to 55 years were enrolled. Evaluated parameters were the following: pericranial muscle tenderness (PMT), headache frequency (HF), headache duration (HD), headache intensity (HI). Vitamin D level measured by 25-hydroxyvitamin D [25(OH)D] of serum blood samples.Results. Number of CTTH with DPM cases in the group of vitamin D deficiency (serum level of 25(OH)D less than 20 ng/mL) was equal to one in normal vitamin group (higher than 30 ng/mL), p &gt; 0.05. Greater degree of DPM was identified in vitamin D deficiency than in normal level: total PMT score 5.0 vs 3.0 score (р &lt; 0.001). At the same time significant difference was observed in cephalgia parameters between groups of deficiency and normal vitamin D level: HF 28.0 and 23.0 days per month (р &lt; 0.001), HD 14.5 and 10.0 hours per day respectively. Also daily headache was associated with vitamin D deficiency with a risk ratio 4.4 (95 % CI: 1.4–14,0) as compared to the normal level. Middle-power negative correlation was noted between serum vitamin D levels and total PMT score (Spearman’s r = –0.55; р &lt; 0,001), HF (r = –0.65; р &lt; 0,001) and HD (r = 0.67; р &lt; 0,001).Conclusion. Vitamin D deficiency leads to increased degree of pericraial muscle dysfunction in CTTH women. That may result in rising central sensitization and finally be a reason of more severe headache.

Sleep quality in women with chronic tension type headache: an observational study

To investigate sleep quality parameters and their correlations with clinical characteristics in chronic tension type headache (CTTH). One hundred and sixty-one women with CTTH were enrolled. Sleep quality and Pittsburgh Sleep Quality Index components, headache frequency (HF), headache duration (HD), headache intensity (HI), pericranial muscle tenderness (PMT), widespread pain index (WPI), anxiety and depression were evaluated. The prevalence of poor sleep quality (PSQI total score >5) was 94%. PSQI total score was significantly correlated (p<0.001) with HF (r=0.39), HI (r=0.36), PMT (r=0.32), WPI (r=0.52), and depression (r=0.54). Daytime dysfunction, the decrease in subjective sleep quality and the decrease in habitual sleep efficiency from mild to severe sleep disturbance were most prevalent: 70%, 69%, and 61%, respectively. Each of these parameters was correlated positively with characteristics of pain frequency and intensity. The relative insufficiency of sleep quantity had the prevalence 2.23 times as high as reduced sleep duration: 61% and 27%, respectively (p<0.001). CTTH is characterized by the decrease in sleep quality parameters, the main of which are Daytime dysfunction, Subjective sleep quality and Habitual sleep efficiency. Patients with CTTH characterize their sleep as: 1) of «bad» subjective quality, 2) non-restorative, 3) due to the relative insufficiency of its quantity.

Ictal neck pain investigated in the interictal state - a search for the origin of pain.

Neck pain is reported in more than 50% of migraine patients during migraine attacks and may be an important source to migraine pain. To investigate phenotypical differences between migraine patients with and without ictal neck pain in the interictal phase. Additionally, to prospectively examine the association between pericranial muscle tenderness and the impending migraine attack. Migraine patients (n = 100) and controls (n = 46) underwent a semi-structured interview and sensory testing interictally. Pericranial muscle tenderness was determined using total tenderness score and local tenderness score. The occurrence of migraine attacks was then prospectively recorded for the following seven days. Patients with ictal neck pain had increased tenderness of pericranial neck muscles compared to migraine patients without (p = 0.023). Ictal neck pain was not associated with migraine localization, tension-type headache, or markers of central sensitization. Prospective data of 84 patients showed that tenderness of trigeminal sensory innervated muscles increased the migraine attack rate (p = 0.035). The distinction of migraine patients based on the occurrence of ictal neck pain could indicate migraine subtypes and possible involvement of peripheral tissue in the pathophysiology. Whether treatment responses differ among these groups would be fascinating. Additionally, we found that cephalic muscle tenderness is a risk factor for an impending migraine attack.

Migraine Awareness in Italy and the Myth of "Cervical Arthrosis".

The primary aim of this study was to assess the degree of awareness migraine patients had of their condition. The secondary aims were to evaluate the frequency of an incorrect diagnosis of "cervical arthrosis" in patients unaware of having migraine and to compare the clinical features, diagnostic investigation, and treatment strategies between the 2 subgroups of migraineurs, that is, those with and without the incorrect diagnosis of "cervical arthrosis." Patients, between 18 and 65 years, were consecutively referred to 5 Headache Centers in 2 Italian regions for a first visit. They fulfilled the diagnostic criteria for migraine (with/without aura, episodic/chronic) and were enrolled in this cross-sectional study. Each patient underwent a specific cranial/cervical musculoskeletal clinical examination. A total of 117/250 subjects (46.8%) were unaware that they suffered from migraine. In these unaware subjects, the most frequently reported diagnosis was "cervical arthrosis" in 34/117 (29.1%), followed by tension-type headache in 23/117 (19%). The cervical region was the most common site of pain onset in the so-called "cervical arthrosis" group (52.9%, P<.0001), where also more pericranial (58.8%; P=.041) and neck (70.6%; P=.009) muscle tenderness, restricted range of cervical vertical (47.1%; P<.001), and lateral (29.4%; P=.040) movements were reported. More "cervical arthrosis patients" had been referred to an Emergency Department (88.2%; P=.011) and had undergone more cervical spine radiography (23.5%; P=.003) and magnetic resonance imaging (20.6%; P=.044). While they had used fewer triptans (11.8%; P=.007) and received less pharmacological prophylaxis (2.9%; P=.004). In our sample, there were high misdiagnosis rates for migraine sufferers in Italy. The most common misdiagnosis, that is, "cervical arthrosis," led to misuse of healthcare facilities and had a negative impact on the migraine treatment.

Neck pain in episodic migraine: a cross-sectional study.

Purpose: It has been reported that neck pain is more prevalent in episodic migraineurs (EM) than in the general population. Subjects with episodic migraine exhibited widespread hypersensitivity in cranio-cervical region. Our objectives were to explore the potential factors associated with the presence of neck pain for EM, and whether there were differences in pericranial muscle tenderness between EM with and without neck pain.Patients and methods: Fifty EM with neck pain (34.76±8.04) and 50 age- and sex-matched EM without neck pain (34.26±9.39) were enrolled. The characteristics of headaches and some lifestyle factors were assessed in two groups. The migraine disability score and neck disability index were also recorded. During migraine-free period, cranio-cervical muscle tenderness scores and mechanical pain threshold were assessed for all patients.Results: There were no significant differences in pain intensity (p=0.44), migraine disability (p=0.71), duration (p=0.44) or frequency (p=0.85) of headache between EM with and without neck pain. The lifestyle factors including smoking, alcohol, coffee, body mass index≧23kg/m2, poor sleeping (<8 h/day) and time spent on TV and computers (>2 h/day) were not associated with the presence of neck pain in this study. Compared with EM without neck pain, those with neck pain had higher neck tenderness (p<0.01) and higher cephalic tenderness scores (p<0.01). Neck Disability Index scores were positively correlated with neck and total muscle tenderness scores.Conclusion: There was a significant difference in cranio-cervical muscle tenderness scores between EM with and without neck pain. For EM, the factors studied in the current research seemed not associated with the onset of neck pain, and further studies including other factors are needed.

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.

Upregulation of inflammatory gene transcripts in periosteum of chronic migraineurs: Implications for extracranial origin of headache.

Chronic migraine (CM) is often associated with chronic tenderness of pericranial muscles. A distinct increase in muscle tenderness prior to onset of occipital headache that eventually progresses into a full-blown migraine attack is common. This experience raises the possibility that some CM attacks originate outside the cranium. The objective of this study was to determine whether there are extracranial pathophysiologies in these headaches. We biopsied and measured the expression of gene transcripts (mRNA) encoding proteins that play roles in immune and inflammatory responses in affected (ie, where the head hurts) calvarial periosteum of (1) patients whose CMs are associated with muscle tenderness and (2) patients with no history of headache. Expression of proinflammatory genes (eg, CCL8, TLR2) in the calvarial periosteum significantly increased in CM patients attesting to muscle tenderness, whereas expression of genes that suppress inflammation and immune cell differentiation (eg, IL10RA, CSF1R) decreased. Because the upregulated genes were linked to activation of white blood cells, production of cytokines, and inhibition of NF-κB, and the downregulated genes were linked to prevention of macrophage activation and cell lysis, we suggest that the molecular environment surrounding periosteal pain fibers is inflamed and in turn activates trigeminovascular nociceptors that reach the affected periosteum through suture branches of intracranial meningeal nociceptors and/or somatic branches of the occipital nerve. This study provides the first set of evidence for localized extracranial pathophysiology in CM. Ann Neurol 2016;79:1000-1013.

The use of conventional transcutaneous electrical nerve stimulation in chronic facial myalgia patients.

The aim of this study was to evaluate the efficacy of conventional TENS in women affected by chronic facial myalgia. The study was performed on 49 women affected by chronic facial myalgia randomly allocated in the TENS group (34 women) and the control group (15 women). The subjective level of pain was assessed by the Visual Analogue Scale indicating the mean (VAS MEAN), the maximum (VAS MAX) and the current intensity of pain (VAS NOW). The level of pain at the muscular palpation sites was assessed by the Pericranial Muscle Tenderness Score (PTS) and the Cervical Muscle Tenderness Score (CTS). The TENS therapy lasted for 10weeks, and data were collected at baseline, after 5, 10, 15 and 25weeks. The differences between groups before and after treatment were compared with the Mann-Whitney and the Kolmogorov-Smirnov tests. The intra-group differences were compared with the one-way ANOVA test. The results showed that the VAS MEAN, VAS MAX, PTS and CTS were significantly reduced in the TENS group compared to the control group after 10weeks of TENS (p<0.05). The intra-group analysis revealed a decreasing tendency of VAS MEAN, VAS MAX, VAS NOW, PTS and CTS in the TENS group in a 25-week period (p<0.05). The study demonstrated the efficacy of conventional TENS in patients with chronic facial myalgia and the decrease in both subjective and objective pain. Conventional TENS is a safe, non-invasive, easy-to-administer therapy for chronic facial myalgia.

Tinnitus and its relationship with muscle tenderness in patients with headache and facial pain.

This study aimed to examine tinnitus prevalence in patients with different types of headache and the relationship between tinnitus and the pericranial muscle tenderness and cervical muscle tenderness scores. A cross-sectional study was conducted of 1251 patients with migraine and/or myogenous pain, arthrogenous temporomandibular joint disorders and tension-type headache. Standardised palpation of the pericranial and cervical muscles was carried out and univariable and multivariable analysis was used to measure the odds ratio of suffering tinnitus by the different diagnoses and muscular tenderness grade. A univariable analysis showed that myogenous pain, pericranial muscle tenderness and cervical muscle tenderness scores, sex, and age were associated with tinnitus. When a multivariable model including only age, sex and a headache diagnosis was used, myogenous pain, migraine and age were found to be associated with tinnitus. When muscle tenderness scores were also included, only the cervical muscle tenderness and pericranial muscle tenderness scores were found to be significantly associated with tinnitus. In a population of patients with headache and craniofacial pain, tinnitus was related to increased cervical muscle tenderness and pericranial muscle tenderness scores, rather than to any particular form of headache.

Pericranial tenderness in chronic tension-type headache: the Akershus population-based study of chronic headache.

BackgroundMost knowledge on chronic tension-type headache (CTTH) is based on data from selected clinic populations, while data from the general population is sparse. Since pericranial tenderness is found to be the most prominent finding in CTTH, we wanted to explore the relationship between CTTH and pericranial muscle tenderness in a population-based sample.MethodsAn age- and gender-stratified random sample of 30,000 persons aged 30-44 years from the general population received a mailed questionnaire. Those with a self-reported chronic headache were interviewed and examined by neurological residents. The questionnaire response rate was 71% and the interview participation rate was 74%. The International Classification of Headache Disorders II was used. Pericranial muscle tenderness was assessed by a total tenderness score (TTS) involving 8 pairs of muscles and tendon insertions. Cross-sectional data from the Danish general population using the same scoring system were used for comparison.ResultsThe tenderness scores were significantly higher in women than men in all muscle groups. The TTS was significantly higher in those with co-occurrence of migraine compared with those without; 19.3 vs. 16.8, p = 0.02. Those with bilateral CTTH had a significantly higher TTS than those with unilateral CTTH. The TTS decreased significantly with age. People with CTTH had a significantly higher TTS compared to the general population.ConclusionsPeople with CTTH have increased pericranial tenderness. Elevated tenderness scores are associated with co-occurrence of migraine, bilateral headache and low age.Whether the increased muscle tenderness is primary or secondary to the headache should be addressed by future studies.

Muscle tenderness and psychiatric comorbidity: a vicious cycle in migraine chronicization.

Muscle tenderness and psychiatric comorbidity: a vicious cycle in migraine chronicization.

Musculoskeletal physical outcome measures in individuals with tension-type headache: A scoping review

Individuals with tension-type headache (TTH), in addition to headache pain, typically suffer from pericranial muscle tenderness and increased cervical muscle tone. Physical and physiological outcomes related to musculoskeletal function, however, are not commonly assessed in clinical studies and not systematically proposed as outcome measures in headache-related practice guidelines. To review which musculoskeletal outcomes are used in the clinical assessment of patients with TTH and which are associated with headache pain and related dysfunction. Literature searches were performed in MEDLINE, PubMed, the Cochrane databases and EMBASE using terms relating to musculoskeletal physical outcomes in TTH. Twenty-six studies met selection criteria. Physiological outcomes typically reported in laboratory studies were trigger points, pressure pain threshold, range of motion and tenderness. A greater number of trigger points and lower pressure pain threshold were reported in patients with episodic TTH in comparison with healthy subjects. Individuals with chronic TTH, when compared with non-headache controls, consistently showed a greater number of trigger points, a lower value of pressure pain threshold and a more severe forward head posture. Musculoskeletal outcomes, such as trigger points, pressure pain threshold and forward head posture should inform TTH pathophysiology, diagnosis and interdisciplinary patient care.

Pericranial muscle tenderness in a population based sample of chronic tension-type headache. The Akershus study of chronic headache

Methods This is a cross-sectional population-based study. An ageand sex-stratified sample of 30,000 persons, aged 30–44 years, residing in eastern Akershus County was in 2005 drawn from the National Personal Registry. The study population received a posted questionnaire. Those with self-reported chronic headache were invited to Akershus University Hospital. All headaches were classified according to the explicit diagnostic criteria of the ICHD-II. The response rate to the questionnaire was 71%, and the rate of participation in the interview was 74%. A total tenderness score (TTS) was used to investigate pericranial tissue tenderness. 8 pairs of muscles and tendon insertions were palpated. The 4-point (0-3) scale at each location and values from left and right sides were summed to a total score. For comparison, cross-sectional data from the Danish general population using the same instruments were used. Results Those with CTTH had a high TTS compared with the general population. In males, the TTS decreased significanly with age. In women, a significant relationship between headache intensity and TTS was found. Parameters like headache frequency, duration, co-occurrence of medication overuse and migraine had no significant influence on the TTS.

Botulinum toxin type-A in the prophylactic treatment of medication-overuse headache: a multicenter, double-blind, randomized, placebo-controlled, parallel group study

Medication-overuse headache (MOH) represents a severely disabling condition, with a low response to prophylactic treatments. Recently, consistent evidences have emerged in favor of botulinum toxin type-A (onabotulinum toxin A) as prophylactic treatment in chronic migraine. In a 12-week double-blind, parallel group, placebo-controlled study, we tested the efficacy and safety of onabotulinum toxin A as prophylactic treatment for MOH. A total of 68 patients were randomized (1:1) to onabotulinum toxin A (n = 33) or placebo (n = 35) treatment and received 16 intramuscular injections. The primary efficacy end point was mean change from baseline in the frequency of headache days for the 28-day period ending with week 12. No significant differences between onabotulinum toxin A and placebo treatment were detected in the primary (headache days) end point (12.0 vs. 15.9; p = 0.81). A significant reduction was recorded in the secondary end point, mean acute pain drug consumption at 12 weeks in onabotulinum toxin A-treated patients when compared with those with placebo (12.1 vs. 18.0; p = 0.03). When we considered the subgroup of patients with pericranial muscle tenderness, we recorded a significant improvement in those treated with onabotulinum toxin A compared to placebo treated in both primary (headache days) and secondary end points (acute pain drug consumption, days with drug consumption), as well as in pain intensity and disability measures (HIT-6 and MIDAS) at 12 weeks. Onabotulinum toxin A was safe and well tolerated, with few treatment-related adverse events. Few subjects discontinued due to adverse events. Our data identified the presence of pericranial muscle tenderness as predictor of response to onabotulinum toxin A in patients with complicated form of migraine such as MOH, the presence of pericranial muscle tenderness and support it as prophylactic treatment in these patients.Electronic supplementary materialThe online version of this article (doi:10.1007/s10194-011-0339-z) contains supplementary material, which is available to authorized users.

Cervicogenic headache in the general population: The Akershus study of chronic headache

The objective was to study the prevalence of cervicogenic headache (CEH) in the general population. An age- and gender-stratified random sample of 30,000 persons aged 30-44 years received a mailed questionnaire. Those with self-reported chronic headache were interviewed by neurological residents. The criteria of the Cervicogenic Headache International Study Group and the International Classification of Headache Disorders, second edition, were applied. The questionnaire response rate was 71% and the participation rate of the interview was 74%. The prevalence of CEH was 0.17% in the general population, with a female preponderance. Fifty per cent had co-occurrence of medication overuse and 42% had co-occurrence of migraine. The pericranial muscle tenderness score was significantly higher on the pain than non-pain side (p < .005). The cervical range of motion was significantly reduced compared to healthy controls (p < .005). The mean duration of CEH was eight years. Based on patients' self-reports, greater occipital nerve (GON) blockage and cryotherapy was reported effective in 90% of those who had this procedure, while other treatment alternatives were reported less effective.