Pericranial Muscles Research Articles

Alexithymia, anger and psychological distress in patients with myofascial pain: a case-control study

Aims: The aim of this study was to investigate psychological distress, anger and alexithymia in a group of patients affected by myofascial pain (MP) in the facial region.Methods: 45 MP patients [mean (SD) age: 38.9 (11.6)] and 45 female healthy controls [mean (SD) age: 37.8 (13.7)] were assessed medically and psychologically. The medically evaluation consisted of muscle palpation of the pericranial and cervical muscles. The psychological evaluation included the assessment of depression (Beck Depression Inventory—short form), anxiety [State-Trait Anxiety Inventory Form Y (STAI-Y)], emotional distress [Distress Thermometer (DT)], anger [State-Trait Anger Expression Inventory—2 (STAXI-2)], and alexithymia [Toronto Alexithymia Scale (TAS)].Results: the MP patients showed significantly higher scores in the depression, anxiety and emotional distress inventories. With regard to anger, only the Anger Expression-In scale showed a significant difference between the groups, with higher scores for the MP patients. In addition, the MP patients showed significantly higher alexithymic scores, in particular in the Difficulty in identifying feelings (F1) subscale of the TAS-20. Alexithymia was positively correlated with the Anger Expression-In scale. Both anger and alexithymia showed significant positive correlations with anxiety scores, but only anger was positively correlated with depression.Conclusion: A higher prevalence of depressive and anxiety symptoms associated with a higher prevalence of alexithymia and expression-in modality to cope with anger was found in the MP patients. Because the presence of such psychological aspects could contribute to generate or exacerbate the suffering of these patients, our results highlight the need to include accurate investigation of psychological aspects in MP patients in normal clinical practice in order to allow clinicians to carry out more efficacious management and treatment strategies.

Toxina botulínica tipo A en la migraña crónica refractaria: experiencia en uso compasivo preautorización

Chronic migraine is very disabling, with medication overuse commonly associated. The recent approval of botulinum toxin-A -OnabotulinumtoxinA (OnabotA)- means a hallmark.To describe our experience in compassionate use before approval.35 cases with chronic migraine assessed between July 2009-December 2011 in a specialized headache consultation. 100 U of OnabotA were injected in 21 points over the facial and pericranial muscles, according to a modified PREEMPT protocol. We determined before and after treatment: number of episodes and migraine days; pain intensity and days of disability extracted from MIDAS score, and data regarding drug intake. After follow-up, new injections were given at intervals dictated by individualized response timing. Therapeutic response was considered when: intensity of pain was reduced to a half o ≥ 4 VAS points, or the number of monthly days of pain descended ≥ 7/month, or the case converted to non-drug overuser.In 27 cases (80%) it was proved clinical improvement. This effect was confirmed by: a reduction in headache severity, reflected as much in pain intensity (VAS scale < 0.001) as in the number of days with disability (3.2 vs 0.4, p < 0.001); an improvement in the number of monthly days of pain (19.8 vs 13.8, p < 0.05; a significant decrease in the number of cases of medication overuse (69% vs 13%, p < 0.01). Mean duration of effect was 15 weeks and mean follow-up 9.8 months.OnabotA disclosed efficacy as prophylactic treatment of chronic migraine. It is mainly expressed as a reduction of pain intensity. Medication overuse also descended. Adverse events were sparse.

Botulinum Neuro-Toxin Type-A In The Treatment Of Chronic Tension Type Headache Associated With Pericranial Tenderness

Both peripheral and central nociceptive mechanisms are responsible in chronic TTH. Analgegics are used in the acute treatment of chronic TTH and antidepressants are used in prophylactic treatment. However, further studies are needed to bring out new treatment options. The aim of our study is to investigate the effectiveness of Botulinum Neuro-toxin Type-A (BoNTA) in the treatment of chronic TTH associated with pericranial tenderness (PT). 14 patients with chronic TTH with PT were included in the study. 50 units Botox(®) injection was applied to the pericranial muscles (5 units for each muscles bilaterally: frontal, temporal, semispinalis capitis, spenius capitis and trapezius muscles) for each patient. Severity of headache was evaluated by VAS (Visual Analogue Scale) and number of days with headache per month were recorded before treatment and 2nd and 4th months after treatment. Number of days with headache per month were 19.57 ± 3.25 before treatment, 15.28 ± 4.37 at the 2nd month after treatment and 15.78 ± 3.90 at the 4th month after treatment. Severity of headache was 65.71 ± 9.16 before the treatment, 50.71 ± 13.56 at the 2nd month after treatment and 54.28 ± 10.35 at the 4th month after treatment (p<0.05). Frequency and severity of headache before treatment were significantly decreased at the 2nd month after treatment and this significance continued at the 4th month after treatment (p<0.05). BoNTA treatment may be usefull in the treatment of patients with chronic TTH associated with PT.

The role of pericranial muscles in the succesful management of episodic tension type headache

Peripheral and central nociceptive mechanisms are responsible for the development of Tension Type Headache (TTH). Analgesics are frequently used in the treatment of acute TTH. Antidepressants are used in prevention. In this study, the therapeutic efficacy of local application of lidocaine was investigated in Episodic Tension Type Headache (ETTH) patients. ETTH patients with pericranial tenderness (n=20, Group 1) and without pericranial tenderness (n=20, Group 2) were included in our study. Three sessions of local injection of 1% lidocaine were performed in both groups. Two-sided intramuscular injections of 1 mL were applied for each patient. The muscles treated were the frontal, temporal, masseter, sternokloidomastoid, semispinalis capitis, splenius capitis and trapezius muscles. Patients were evaluated in 1st, 2nd, and 3rd months. The number of painful days per month and pain intensities were recorded according to Visual Analog Scale (VAS) before and after the treatment. 11 male and 29 female patients were included in the study. The mean ages of Group 1 and Group 2 were 35.95 ± 9.85 (18-53) and 34.85 ± 10.04 (20-54) years, respectively. There was no difference between the groups in terms of age, gender, pain frequency and pain intensity (p>0.05). The frequency and severity of pain was significantly lower in pericranial-sensitive ETTH patients at the 1st, 2nd, and 3rd months after local lidocaine injections compared to ETTH patients having pericranial tenderness (p<0.05). Local lidocaine application can be used as an effective method in the treatment of ETTH patients with pericranial tenderness.

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.

Comparison of clinical characteristics of migraine and tension type headache.

Context:Migraine and tension type headache (TTH) are two most common types of primary headaches. Though the International Classification of Headache Disorders-2 (ICHD-2) describes the diagnostic criteria, even then in clinical practice, patients may not respect these boundaries resulting in the difficulty in diagnosis of these pains.Materials and Methods:This cross-sectional study involved 50 subjects in each of the two groups – migraine and TTH – after screening for the inclusion and exclusion criteria. Diagnosis was made according to the ICHD-2 criteria. Their clinical history was taken in detail and noted in a semi-structured performa. They were examined for the presence of a number of factors like pericranial tenderness and muscle parafunction. Statistical analysis was done with the help of SPSS v 11.0. To compare the non-parametric issues, chi-square test was run and continuous variables were analyzed using independent sample t test.Results:In general, migraineurs had progressive illness (χ2=9.45; P=0.002) with increasing severity (χ2=21.86; P<0.001), frequency (χ2=8.5; P=0.04) and duration of each headache episode (χ2=4.45; P=0.03) as compared to TTH subjects. Along with the headache, they more commonly suffered orthostatic pre-syncope (χ2=19.94; P<0.001), palpitations (42%vs.18% among TTH patients; χ2=6.87; P=0.009), nausea and vomiting (68% vs. 6% in TTH; χ2=41.22; P<0.001, and 38% vs. none in TTH; χ2=23.45, P<0.001, respectively), phonophobia (χ2=44.98; P<0.001), photophobia (χ2=46.53; P<0.001), and osmophobia (χ2=15.94; P<0.001). Their pain tended to be aggravated by head bending (χ2=50.17; P<0.001) and exercise (χ2=11.41; P<0.001). Analgesics were more likely to relieve pain in migraineurs (χ2=21.16; P<0.001). In addition, post-headache lethargy was more frequent among the migraineurs (χ2=22.01; P<0.001). On the other hand, stressful situations used to trigger TTH (χ2=9.33; P=0.002) and muscle parafunction was more common in TTH patients (46% vs. 20%; χ2=7.64; P=0.006). All the cranial autonomic symptoms were more common in migraineurs as compared to TTH subjects (conjunctival injection: χ2=10.74, P=0.001; lacrimation: χ2=17.82, P<0.001; periorbital swelling: χ2=23.45, P<0.001; and nasal symptoms: χ2=6.38, P=0.01).Conclusion:A number of symptoms that are presently not included in the ICHD-2 classification may help in differe-ntiating the migraine from the TTH.

Pericranial muscle dysfunction in primary headache and its correction

The paper deals with a role of muscle dysfunction in primary headache disorders, such as migraine and tension-type headache (TTH). It considers terminology, the contribution of pericranial muscle dysfunction to the clinical picture and chronicity of migraine and TTH, their comorbid association, and the involvement of muscle tension in the pathophysiology of TTN. Approaches to treating muscle tension in patients with primary headache disorders are discussed and a role of myorelaxants in the correction of muscle dysfunction is emphasized.

Massage on the trigger points of neck muscles for tension-type headache

Seventy two patients with tension type headache (TTH) were divided randomly into two groups: massage group was treated with massage on the trigger points of neck muscles, and control group was treated with drugs.The frequency, duration, severity of TTH, use of painkiller and electromyography of pericranial muscle (temporalis muscle and masseter muscle ) were recorded before and after treatment.The frequency, duration and severity of TTH, the frequency of painkiller use, and amplitude and frequency on electromyography of pericranial muscles in massage groups after treatment were reduced significantly (P ＜0.05 ) .In summary, massage on the trigger points in neck muscles has significant therapeutic effects for TTH. Key words: Massage; Tension-type headache

Neurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition)

A large number of instrumental investigations are used in patients with non-acute headache in both research and clinical fields. Although the literature has shown that most of these tools contributed greatly to increasing understanding of the pathogenesis of primary headache, they are of little or no value in the clinical setting. This paper provides an update of the 2004 EFNS guidelines and recommendations for the use of neurophysiological tools and neuroimaging procedures in non-acute headache (first edition). Even though the period since the publication of the first edition has seen an increase in the number of published papers dealing with this topic, the updated guidelines contain only minimal changes in the levels of evidence and grades of recommendation. (i) Interictal EEG is not routinely indicated in the diagnostic evaluation of patients with headache. Interictal EEG is, however, indicated if the clinical history suggests a possible diagnosis of epilepsy (differential diagnosis). Ictal EEG could be useful in certain patients suffering from hemiplegic or basilar migraine. (ii) Recording evoked potentials is not recommended for the diagnosis of headache disorders. (iii) There is no evidence warranting recommendation of reflex responses or autonomic tests for the routine clinical examination of patients with headache. (iv) Manual palpation of pericranial muscles, with standardized palpation pressure, can be recommended for subdividing patient groups but not for diagnosis. Pain threshold measurements and EMG are not recommended as clinical diagnostic tests. (v) In adult and pediatric patients with migraine, with no recent change in attack pattern, no history of seizures, and no other focal neurological symptoms or signs, the routine use of neuroimaging is not warranted. In patients with trigeminal autonomic cephalalgia, neuroimaging should be carefully considered and may necessitate additional scanning of intracranial/cervical vasculature and/or the sellar/orbital/(para)nasal region. In patients with atypical headache patterns, a history of seizures and/or focal neurological symptoms or signs, MRI may be indicated. (vi) If attacks can be fully accounted for by the standard headache classification (IHS), a PET or SPECT scan will normally be of no further diagnostic value. Nuclear medical examinations of the cerebral circulation and metabolism can be carried out in subgroups of patients with headache for the diagnosis and evaluation of complications, when patients experience unusually severe attacks or when the quality or severity of attacks has changed. (vii) Transcranial Doppler examination is not helpful in headache diagnosis. Although many of the examinations described in the present guidelines are of little or no value in the clinical setting, most of the tools, including thermal pain thresholds and transcranial magnetic stimulation, have considerable potential for differential diagnostic evaluation as well as for the further exploration of headache pathophysiology and the effects of pharmacological treatment.

Chronic Tension Type Headache and the Impact of Myofascial Trigger Point Release in the Short Term Relief of Headache

Purpose: This study investigated the effect of myofascial release in relieving the symptoms of Chronic TensionType Headache (CTTH) Methods: The study used a convenience sampling pretest-post test design. 31 people (7men and 24 women, age range 18-58 years, mean age 32 years) with CTTH participated in the study. The headachesample was screened for MTrP in the cranial and pericranial muscles and was treated with myofascial releasetherapy. The outcomes were measured in terms of the number of headache days in a week and the headache painlevel measured in visual analog scale (VAS). Analysis: The analysis was done using paired ‘t’ test at 95%confidence interval Results: The study showed significant improvements in reduction of the number of headachedays (p < 0.001) and the headache pain level (p < 0.001) following treatment. Conclusion and Implications:Myofascial release therapy to the trigger points in people with CTTH has a positive influence in decreasing painintensity and frequency in CTTH sufferers. In future, during management of CTTH screening for myofascialtrigger points and concomitant treatment using myofascial release could be considered.

Botulinumtoxin bei Kopfschmerzen: Ende eines langen Weges?

Botulinum-Toxin Typ A hat sich schon lange in der Neurologie als ein sinnvolles Therapeutikum etabliert, dieses gilt v. a. in der Behandlung der fokalen Dystonien, aber auch der Behandlung der Spastik im Bereich der oberen Extremität. Schon relativ früh wurde dabei auch berichtet, dass sich assoziierte Schmerzen bessern, sodass in den letzten 10 Jahren eine Reihe von Studien zu der Wirksamkeit von Botulinumtoxin in der Prophylaxe von primären Kopfschmerzen durchgeführt wurde, auch begründet durch die generell ausgezeichnete Verträglichkeit. Im Gegensatz zu der primären Annahme stellte sich im Verlauf heraus, dass gerade der Spannungskopfschmerz, der immer im Zusammenhang mit einem wenigstens zeitweilig erhöhten Muskeltonus gesehen wird, nicht von der Behandlung profitiert, sondern eher Patienten mit einer hochfrequenten episodischen Migräne. In 2 großen Studien mit insgesamt 1400 Patienten konnte zuletzt gezeigt werden, dass Patienten mit einer chronischen Migräne, also an mehr als 15 Tagen im Monat Kopfschmerzen und dabei eindeutige Migräneattacken, signifikant von der perikraniellen Injektion von Botulinumtoxin gegenüber der Injektion von Kochsalz (Placebo) profitieren. Bei allen Studien ist auffällig, dass schon die Placeboinjektion zu einer z. T. wesentlichen Verbesserung der Symptomatik führt. Botulinumtoxin scheint aber neben diesem unspezifischen Therapieeffekt zusätzlich noch einen spezifischen Effekt bei Patienten mit häufiger (chronischer) Migräne zu besitzen.

Electromyogenic artifacts and electroencephalographic inferences revisited

Recent years have witnessed a renewed interest in using oscillatory brain electrical activity to understand the neural bases of cognition and emotion. Electrical signals originating from pericranial muscles represent a profound threat to the validity of such research. Recently, McMenamin et al. (2010) examined whether independent component analysis (ICA) provides a sensitive and specific means of correcting electromyogenic (EMG) artifacts. This report sparked the accompanying commentary Olbrich et al. (2010), and here we revisit the question of how EMG can alter inferences drawn from the EEG and what can be done to minimize its pernicious effects. Accordingly, we briefly summarize salient features of the EMG problem and review recent research investigating the utility of ICA for correcting EMG and other artifacts. We then directly address the key concerns articulated by Olbrich and provide a critique of their efforts at validating ICA. We conclude by identifying key areas for future methodological work and offer some practical recommendations for intelligently addressing EMG artifact.

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.

Pain sensitivity in children with frequent episodic tension type headache

In the current issue of Cephalalgia, Fernandezde-las-Penas and colleagues report decreased pressure pain thresholds in children with frequent episodic tension-type headache (TTH). The degree of pain hypersensitivity was similar at pericranial and extracranial locations. The finding of wide-spread pressure pain hypersensitivity, also at non-symptomatic locations, suggests that the central nervous system is sensitised in these children. The study is important because, for the first time, it examines wide-spread pressure pain sensitivity in children with frequent episodic TTH. Only 25 children with frequent episodic TTH were investigated. The findings should, therefore, be confirmed in other studies, and also other types of nociceptive stimuli should be investigated. However, the study has several strengths: (i) the diagnosis was ensured though headache diaries; (ii) a well-defined group was investigated, i.e. only children with frequent headaches (8–14 days per month); and (iii) investigations were performed in a blinded design. The results of Fernandez-de-las-Penas and colleagues are in line with the findings from numerous studies performed in the last two decades in adults with TTH (1). These studies initially demonstrated that patients with episodic TTH had increased tenderness of their pericranial muscles and normal general pain sensitivity, while patients with chronic TTH had both increased pericranial tenderness and a generalised, wide-spread pain hypersensitivity (2). After the division of episodic TTH into infrequent and frequent subtypes in the second edition of the International Classification of Headache Disorders in 2004 (3), several studies have demonstrated also that patients with frequent episodic TTH have a generalised pain hypersensitivity (4,5). The studies of pain sensitivity in TTH led to the hypothesis that nociceptive input from pericranial myofascial tissues is important for the development of single episodes of TTH, while continuous nociceptive input from these structures may lead to increased excitability of nociceptive pathways and impaired pain inhibition in the central nervous system and, thereby, to headache chronification (2). This has been supported not only by a number of cross-sectional pain studies (1), but also by imaging studies (6), neurophysiological studies (7–9) and pharmacological studies (10,11). Most importantly, a recent longitudinal 12-year follow-up study (12) demonstrated that subjects who developed episodic TTH had increased pericranial myofascial tenderness but normal general pain sensitivity at follow-up, whereas subjects who developed chronic TTH had normal pain sensitivity at baseline but developed increased central pain sensitivity at follow-up. The investigators concluded that increased pain sensitivity is a consequence of frequent TTH, not a risk factor, and that central sensitisation plays an important role for the chronification of TTH (12). The present study by Fernandez-de-las-Penas and colleagues suggests that central sensitisation can occur already in childhood and underlines the need for further research into the mechanisms responsible for headache chronification. Two major targets for future treatment strategies should be to: (i) identify the source of peripheral nociception in order to prevent the development of central sensitization and, thereby, the conversion of episodic into chronic TTH; and (ii) reduce established central sensitisation.

Central mechanisms of stress-induced headache

Stress is the most commonly reported trigger of an episode of chronic tension-type headache (CTTH); however, the causal significance has not been experimentally demonstrated to date. Stress may trigger CTTH through hyperalgesic effects on already sensitized pain pathways in CTTH sufferers. This hypothesis could be partially tested by examining pain sensitivity in an experimental model of stress-induced headache in CTTH sufferers. Such examinations have not been reported to date. We measured pericranial muscle tenderness and pain thresholds at the finger, head and shoulder in 23 CTTH sufferers (CTH-S) and 25 healthy control subjects (CNT) exposed to an hour-long stressful mental task, and in 23 CTTH sufferers exposed to an hour-long neutral condition (CTH-N). Headache developed in 91% of CTH-S, 4% of CNT, and 17% of CTH-N subjects. Headache sufferers had increased muscle tenderness and reduced pain thresholds compared with healthy controls. During the task, muscle tenderness increased and pain thresholds decreased in the CTH-S group compared with CTH-N and CNT groups. Pre-task muscle tenderness and reduction in pain threshold during task were predictive of the development and intensity of headache following task. The main findings are that stress induced a headache in CTTH sufferers, and this was associated with pre-task muscle tenderness and stress-induced reduction in pain thresholds. The results support the hypothesis that stress triggers CTTH through hyperalgesic effects on already increased pain sensitivity in CTTH sufferers, reducing the threshold to noxious input from pericranial structures.

Effect of Systemic Monosodium Glutamate (MSG) on Headache and Pericranial Muscle Sensitivity

We conducted a double-blinded, placebo-controlled, crossover study to investigate the occurrence of adverse effects such as headache as well as pain and mechanical sensitivity in pericranial muscles after oral administration of monosodium glutamate (MSG). In three sessions, 14 healthy men drank sugar-free soda that contained either MSG (75 or 150 mg/kg) or NaCl (24 mg/kg, placebo). Plasma glutamate level, pain, pressure pain thresholds and tolerance levels, blood pressure (BP), heart rate and reported adverse effects were assessed for 2 h. No muscle pain or robust changes in mechanical sensitivity were detected, but there was a significant increase in reports of headache and subjectively reported pericranial muscle tenderness after MSG. Systolic BP was elevated in the high MSG session compared with low MSG and placebo. These findings add new information to the concept of MSG headache and craniofacial pain sensitivity.

Application of ICHD-II Criteria for Headaches in a TMJ and Orofacial Pain Clinic

The aim of this study was to identify and diagnose headache in a temporomandibular joint and orofacial pain clinic population using the second edition of The International Classification of Headache Disorder criteria. In 502 temporomandibular disorder and orofacial pain patients, 246 patients (49%) were diagnosed with tension-type headache (TTH), followed by migraine without aura (14.5%), probable migraine (12.9%), migraine with aura (7%), probable TTH (4.8%) and cluster headache (0.2%). The prevalence of headaches was compared between male and female patients, and the prevalence of migraine was found to be higher in women than in men. In evaluating by age, the prevalence of migraine was highest in patients in their 20s and 30s and declined as age increased above 40. TTH showed the highest rate throughout all age groups, but it also decreased as age increased. In this study, the prevalence of migraine was lower than that reported in Dr Kim et al.'s study, and the prevalence of TTH much higher than that reported in the previous study. Of the headache patients, 81.1% presented with masseter muscle pain and 47.8% with temporal muscle pain. This finding suggests that pericranial muscle pain may be an inducing factor of primary headache.

Fibromyalgia Comorbidity in Primary Headaches

Fibromyalgia syndrome (FMS) is a chronic pain condition of unknown aetiology characterized by diffuse pain and tenderness at tender points. The aim of the study was to assess the prevalence and clinical features of FMS in the different forms of primary headaches, in a tertiary headache centre. Primary headache patients (n = 217) were selected and submitted to the Total Tenderness Score, anxiety and depression scales, Migraine Disability Assessment, allodynia questionnaire, Short Form 36 Health Survey and the Medical Outcomes Study-Sleep Scale. In patients with FMS, the Multidimensional Assessment of Fatigue, the Pain Visual Analog Scale, the Manual Tender Point Survey and the Fibromyalgia Impact Questionnaire were employed. FMS was present in 36.4% of patients and prevailed significantly in tension-type headache and in patients with higher headache frequency. Headache frequency, pericranial muscle tenderness, anxiety and sleep inadequacy were especially associated with FMS comorbidity. In the FMS patients, fatigue and pain at tender points were significantly correlated with headache frequency. FMS seems increasingly prevalent with increased headache frequency, for the facilitation of central sensitization phenomena favoured by anxiety and sleep disturbances.

Mechanical Allodynia and Hyperalgesia in Nerve and Muscles in Chronic Tension-Type Headache

Evidence suggests that the most prominent finding in chronic tension-type headache (CTTH) is an increased tenderness to palpation of pericranial muscle tissues. Furthermore, lowered pain detection and tolerance thresholds found in CTTH suggest both allodynic and hyperalgesic response to pressure stimulation. Nevertheless, whether this mechanical hypersensitivity is a primary or a secondary phenomenon to CTTH is not clear. One recent study has demonstrated that pain sensitivity is a consequence not a causative factor of CTTH. Additionally, nerve tissues have also been found to be sensitized in CTTH. Recent evidence is modifying previous knowledge about relationships between muscle tissues and CTTH, since it has been found that trigger points, but not tender points, are responsible for peripheral nociceptive inputs in CTTH. An updated pain model suggests that headache perception can be explained by referred pain from active trigger points in the craniocervical muscles, mediated through the spinal cord and the trigeminal nucleus caudalis rather than only tenderness (tender points) of the muscles themselves.

Randomised study of botulinum toxin type A (BoNT/A) in the treatment of chronic tension type headache

Introduction : Tension-type headache (TTH) is the most common form of headache, with a lifetime prevalence of up to 30% in general population. Symptoms may vary in typology and intensity and include constriction, sense of pressure and tightness. Despite a significantly high prevalence in the general population, little studies have been performed considering etiology of the syndrome, and also considering treatment. Pathophysiological mechanisms may include the central nervous system, producing increased tension in the pericranial muscles and pain. By blocking the presynaptic cholinergic nerve terminal, interfering with acetylcholine exocitosis, BoNT/A could address this feature because of a myorelaxant effect. Material and methods : Sixty patients were selected for treatment, and signed a detailed informed consent. Diagnosis of TTH was posed with the criteria advocated by the International Headache Society. Twenty-eight patients were males. Patients were randomised in three groups of 20 patients (A, B, and C). All the groups received 80–150 IU BoNT/A: Group A was injected at fixed points, Group B was injected with a “follow the pain” pattern, determining together with the patient the optimal points for injection. Group C was treated with the “follow the pain” feature plus a dedicated exercise program. Results were evaluated considering “verbal rating” scale (VRS), registering any improvement of symptoms severity. Results : After 3 months of treatment, 9 out of the 20 patients included in Group A (45%), 13 in Group B (65%) and 16 (80%) in Group C documented an improvement of their symptoms at the VRS. These differences reached statistical significance, and also drug intake (mainly NSAIDs and tricyclic agents) was diminished during the study period (although not reaching statistically significant difference among the three groups). Conclusions : BoNT/A injection may be a valid treatment modality for TTH, especially when combined to adjunctive physiotherapy, and when using a “follow the pain” pattern of injection. However, in order to obtain this treatment modality, a dedicated follow-up of the patient by an experienced operator is necessary.