Multimodal treatment, including extracorporeal shock wave therapy, for refractory chronic tension-type headache: a case report.

BACKGROUND: Few reports have described multidisciplinary treatment, including extracorporeal shock wave therapy, for patients with refractory chronic tension-type headache. In this study, we conducted multidisciplinary treatment for a patient with chronic tension-type headache who suffered from chronic headache refractory to treatment. CASE PRESENTATION: The patient was a 45-year-old Japanese male suffering from 20 years of headache. As his headache had worsened recently, he visited a local clinic. With the diagnosis of suspected tension-type headache, its treatment was unsuccessful and he was referred to our hospital. The neurology department confirmed the tension-type headache and prescribed another medication, but he showed no improvement. Then, the patient was referred to the rehabilitation medicine department for consultation. At the initial visit, we identified multiple myofascial trigger points in his bilateral posterior neck and upper back regions. At the initial visit, he was prescribed 10 mL of 1% lidocaine injected into the muscles in these areas. In addition, he received 2000 extracorporeal shock wave therapy into bilateral trapezius muscles, and was instructed to take oral Kakkonto extract granules, benfotiamine, pyridoxine hydrochloride, and cyanocobalamin. Cervical muscle and shoulder girdle stretches and exercises were also recommended. At follow-up treatment visits, we used extracorporeal shock wave therapy to bilateral trapezius muscles, which led to immediate pain relief. After 11 weeks, he was not taking any medication and his headache was subjectively improved and his medical treatment ended. CONCLUSION: A patient with chronic tension-type headache refractory to regular treatment was successfully treated with a multimodal approach including extracorporeal shock wave therapy in addition to standard treatment. For patients with tension-type headache accompanied by myofascial trigger points, it may be recommended to promptly consider aggressive multimodal treatment that includes extracorporeal shock wave therapy.

Status of diagnosis and preventative treatment for primary headache disorders: real-world data of unmet needs in China.

BACKGROUND: Headache disorders are widely prevalent and pose a considerable economic burden on individuals and society. Globally, misdiagnosis and inadequate treatment of primary headache disorders remain significant challenges, impeding the effective management of such conditions. Despite advancements in headache management over the last decade, a need for comprehensive evaluations of the status of primary headache disorders in China regarding diagnosis and preventative treatments persists. METHODS: In the present study, we analyzed the established queries in the Survey of Fibromyalgia Comorbidity with Headache (SEARCH), focusing on previous diagnoses and preventative treatment regimens for primary headache disorders. This cross-sectional study encompassed adults diagnosed with primary headache disorders who sought treatment at 23 hospitals across China between September 2020 to May 2021. RESULTS: The study comprised 2,868 participants who were systematically examined. Migraine and tension-type headaches (TTH) constituted a majority of the primary headache disorders, accounting for 74.1% (2,124/2,868) and 23.3% (668/2,868) of the participants, respectively. Medication overuse headache (MOH) affected 8.1% (231/2,868) of individuals with primary headache disorders. Over half of the individuals with primary headache disorders (56.6%, 1,624/2,868) remained undiagnosed. The previously correct diagnosis rates for migraine, TTH, TACs, and MOH were 27.3% (580/2,124), 8.1% (54/668), 23.2% (13/56), and 3.5% (8/231), respectively. The misdiagnosis of "Nervous headache" was found to be the most prevalent among individuals with migraine (9.9%, 211/2,124), TTH (10.0%, 67/668), trigeminal autonomic cephalalgias (TACs) (17.9%, 10/56), and other primary headache disorders (10.0%, 2/20) respectively. Only a minor proportion of individuals with migraine (16.5%, 77/468) and TTH (4.7%, 2/43) had received preventive medication before participating in the study. CONCLUSIONS: While there has been progress made in the rate of correct diagnosis of primary headache disorders in China compared to a decade ago, the prevalence of misdiagnosis and inadequate treatment of primary headaches remains a veritable issue. As such, focused efforts are essential to augment the diagnosis and preventive treatment measures related to primary headache disorders in the future.

Classification of pediatric headache cases referred to a neurology department.

BACKGROUND: Headaches are very common in children. The patients often have mild symptoms, but on occasion may have severe, secondary headaches. The present study aimed to clarify the details of children with headaches seen at the outpatient clinic of a pediatric neurological department. METHODS: The present, retrospective observational study was conducted at a tertiary pediatric hospital in Japan and enrolled children referred to the neurology department outpatient clinic for headache between April 2018 and March 2021. RESULTS: In total, 113 cases of headache were examined; of these, 99 (87.6%) were primary headaches, one case (0.9%) was a secondary headache, and 13 (11.5%) were unclassified or unspecified. There were 46 cases (40.7%) of tension-type headache (TTH), both confirmed and suspected, 30 cases (26.5%) of migraine, and 23 cases (20.4%) of a combination of the TTH and migraine. One case of secondary headache was attributed to an infection. Arachnoid cysts were found in seven patients (7.8%). Acute drug treatments were administered to 93 patients (82.3%), with acetaminophen being the most common drug, followed by ibuprofen. Prophylactic drug treatments were administered to 39 patients (34.5%), with goreisan (a Chinese herbal medicine containing Alisma orientale, Poria cocos, Polyporus umbellatus, Atractylodes lancea, and Cinnamomum cassia) being the most common (41%). CONCLUSIONS: Few cases of secondary headache and none of emergency headache were diagnosed. The prevalence of arachnoid cysts was higher than in the general pediatric population, suggesting that arachnoid cysts might be associated with headache.

Nociplastic pain: towards an understanding of prevalent pain conditions.

Nociplastic pain is the semantic term suggested by the international community of pain researchers to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage. The mechanisms that underlie this type of pain are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles. The symptoms observed in nociplastic pain include multifocal pain that is more widespread or intense, or both, than would be expected given the amount of identifiable tissue or nerve damage, as well as other CNS-derived symptoms, such as fatigue, sleep, memory, and mood problems. This type of pain can occur in isolation, as often occurs in conditions such as fibromyalgia or tension-type headache, or as part of a mixed-pain state in combination with ongoing nociceptive or neuropathic pain, as might occur in chronic low back pain. It is important to recognise this type of pain, since it will respond to different therapies than nociceptive pain, with a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections.

Diagnosis and Management of Headache: A Review.

IMPORTANCE: Approximately 90% of people in the US experience headache during their lifetime. Migraine is the second leading cause of years lived with disability worldwide. OBSERVATIONS: Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that tension-type headache affected 38% of the population, while migraine affected 12% and was the most disabling. Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes. Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine. Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties. Acute treatments with gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1% to 4% of patients. A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors. Preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which reduce migraine by 1 to 3 days per month relative to placebo. CONCLUSIONS AND RELEVANCE: Headache disorders affect approximately 90% of people during their lifetime. Among primary headache disorders, migraine is most debilitating and can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.

Does menstruation-related headache occur exclusively in women with migraine?

To determine the relation between headache and menstruation in women with migraine and the use of estrogen by these women. This was a prospective, cross-sectional, observational study with group comparison, using non-random sample and convenience. We interviewed 79 women diagnosed with migraine or tension-type headache (TTH), according to the ICHD-3, regarding the relation between headache and menstruation. Of the 79 women with headache, 60 (76%) had migraine and 19 (24%) had episodic TTH. The most frequent subtype of migraine was without aura (54/60, 90%). The age ranged from 18 to 42 years, with an average of 22.6 ± 4.1 years. Migraine affected women aged 22.4 ± 3.6 years, whereas in TTH, the age was 23.0 ± 5.4 years. Menstruation-related headache occurred in 41.9% of women with migraine and in only 6.3% of those with TTH. These differences were significant (χ2 = 5.2; p = 0.022). Of the five women diagnosed with migraine with aura, two used estrogen. Menstruation-related headache predominates in women with migraine and often women with migraine with aura use estrogen.

Headache in the Older Population: Causes, Diagnoses, and Treatments.

PURPOSE OF REVIEW: Primary headaches are less common and differ in presentation in older versus younger individuals. Secondary headaches become more common among older patients. RECENT FINDINGS: Diagnosis and management of headaches in those > 65 years are discussed. Migraine and tension-type headaches are rarely new onset in this age group and should be a diagnosis of exclusion. In older individuals, migraine is more likely to be bilateral with less sensory sensitivities. Migraine aura may present without headache; careful assessment is needed to exclude stroke. Other primary headaches discussed include cough, hypnic, and other headaches. Secondary causes discussed include giant cell arteritis, trigeminal post-herpetic neuropathy, sleep apnea, cardiac cephalgia, cervicogenic pain, vascular etiologies, medications, and burning-mouth syndrome. In older individuals, primary headaches are diagnoses of exclusion, and treatment is affected by comorbidities and polypharmacy. Secondary headaches are a major consideration requiring appropriate workup. Many treatments can safely be offered regardless of age.

Screening Family and Psychosocial Risk in Pediatric Migraine and Tension-Type Headache: Validation of the Psychosocial Assessment Tool (PAT).

OBJECTIVE: To present data on psychometric properties of the Psychosocial Assessment Tool 2.0_General (PAT), a brief screener for psychosocial risk in families of youth with medical conditions, in youth with headache. BACKGROUND: Emotional and behavioral disturbances, parent distress, and poor family functioning are common among youth with recurrent migraine and tension-type headache; however, tools to comprehensively screen family and psychosocial risk in youth with headache are not currently available. The PAT could address an important gap by facilitating identification of psychosocial treatment needs among youth with headache. DESIGN AND METHODS: Youth with recurrent migraine (with and without aura; chronic migraine) or tension-type headache (episodic and chronic) completed the PAT and validated measures of adolescent emotional and behavioral functioning, parent emotional functioning, and family functioning at baseline (n = 239; 157 from neurology clinic, 82 from the community) and 6-month follow-up (n = 221; 146 from neurology clinic, 75 from the community). RESULTS: Internal consistency for the PAT Total score was strong (α = .88). At baseline, the PAT Total score was significantly associated in the expected direction with established measures of child emotional and behavioral functioning (r = .62), parent anxiety and depressive symptoms (r = .49; r = .53, respectively), and family functioning (r = .21). Predictive validity was demonstrated by a significant association between PAT Total scores at baseline with child emotional and behavioral functioning (r = .64), parent anxiety (r = .37), parent depression (r = .42), and family functioning (r = .26) at 6-month follow-up. CONCLUSIONS: The PAT is a promising tool for screening psychosocial risk that could facilitate identification of psychosocial treatment needs among youth with recurrent headache at risk for poor outcomes.

Association of bruxism and anxiety symptoms among military firefighters with frequent episodic tension type headache and temporomandibular disorders / Associação de bruxismo e sintomas de ansiedade em bombeiros militares com cefaleia do tipo tensional episódica frequente e desordens temporomandibulares

ABSTRACT Objective To assess the presence of bruxism and anxiety among military firefighters with frequent episodic tension-type headache and painful temporomandibular disorders (TMDs). Methods The sample consisted of 162 individuals aged 18 to 55 years divided into four groups. Headache was diagnosed in accordance with the International Classification of Headache Disorders-III. The Research Diagnostic Criteria for Temporomandibular Disorders questionnaire was used to classify TMDs and awake bruxism; sleep bruxism was diagnosed in accordance with the International Classification of Sleep Disorders-3; and anxiety was classified using the Beck Anxiety Inventory. In statistical models, a significance level of 95% was used. The chi-square test was used to assess anxiety. Results Associations were found among frequent episodic tension-type headache, painful TMDs, awake bruxism and anxiety (p < 0.0005). Sleep bruxism was not a risk factor (p = 0.119) except when associated with awake bruxism (p = 0.011). Conclusion Anxiety and awake bruxism were independent risk factors for developing frequent episodic tension-type headache associated with painful TMDs; only awake bruxism was a risk factor for frequent episodic tension-type headache with non-painful TMDs.

RESUMO Objetivo Avaliar a presença de bruxismo e sintomas de ansiedade entre bombeiros militares com cefaleia do tipo tensional episódica frequente (CTTEF) e desordens temporomandibulares Dolorosas (DTMs). Métodos A amostra foi composta por 162 indivíduos com idade entre 18 e 55 anos divididos em quatro grupos. A CTTEF foi diagnosticada de acordo com o ICHD-III. O RDC / TMD foi usado para classificar as DTMs e o bruxismo acordado; o bruxismo do sono foi diagnosticado de acordo com o ICSD-3; e a ansiedade foi classificada usando o Inventário de Ansiedade de Beck. Nos modelos estatísticos, utilizou-se um nível de significância de 95%. O teste Qui-quadrado avaliou a ansiedade. Resultados Associações foram encontradas entre CTTEF, DTMs dolorosas, bruxismo diurno e ansiedade (p < 0,0005). O bruxismo do sono não foi fator de risco (p = 0,119), mas quando associado à atividade diurna (p = 0,011). Conclusão Ansiedade e bruxismo diurno foram fatores de risco independentes para o desenvolvimento de CTTEF associado a DTMs dolorosas. Apenas o bruxismo diurno foi fator de risco para CTTEF com DTMs não dolorosas.

Myofascial trigger points in migraine and tension-type headache.

BACKGROUND: A myofascial trigger point is defined as a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. It has been suggested that myofascial trigger points take part in chronic pain conditions including primary headache disorders. The aim of this narrative review is to present an overview of the current imaging modalities used for the detection of myofascial trigger points and to review studies of myofascial trigger points in migraine and tension-type headache. FINDINGS: Different modalities have been used to assess myofascial trigger points including ultrasound, microdialysis, electromyography, infrared thermography, and magnetic resonance imaging. Ultrasound is the most promising of these modalities and may be used to identify MTrPs if specific methods are used, but there is no precise description of a gold standard using these techniques, and they have yet to be evaluated in headache patients. Active myofascial trigger points are prevalent in migraine patients. Manual palpation can trigger migraine attacks. All intervention studies aiming at trigger points are positive, but this needs to be further verified in placebo-controlled environments. These findings may imply a causal bottom-up association, but studies of migraine patients with comorbid fibromyalgia syndrome suggest otherwise. Whether myofascial trigger points contribute to an increased migraine burden in terms of frequency and intensity is unclear. Active myofascial trigger points are prevalent in tension-type headache coherent with the hypothesis that peripheral mechanisms are involved in the pathophysiology of this headache disorder. Active myofascial trigger points in pericranial muscles in tension-type headache patients are correlated with generalized lower pain pressure thresholds indicating they may contribute to a central sensitization. However, the number of active myofascial trigger points is higher in adults compared with adolescents regardless of no significant association with headache parameters. This suggests myofascial trigger points are accumulated over time as a consequence of TTH rather than contributing to the pathophysiology. CONCLUSIONS: Myofascial trigger points are prevalent in both migraine and tension-type headache, but the role they play in the pathophysiology of each disorder and to which degree is unclarified. In the future, ultrasound elastography may be an acceptable diagnostic test.

Distinguishing neurocysticercosis epilepsy from epilepsy of unknown etiology using a minimal serum mass profiling platform.

Neurocysticercosis is associated with epilepsy in pig-raising communities with poor sanitation. Current internationally recognized diagnostic guidelines for neurocysticercosis rely on brain imaging, a technology that is frequently not available or not accessible in areas endemic for neurocysticercosis. Minimally invasive and low-cost aids for diagnosing neurocysticercosis epilepsy could improve treatment of neurocysticercosis. The goal of this study was to test the extent to which patients with neurocysticercosis epilepsy, epilepsy of unknown etiology, idiopathic headaches and among different types of neurocysticercosis lesions could be distinguished from each other based on serum mass profiling. For this, we collected sera from patients with neurocysticercosis-associated epilepsy, epilepsy of unknown etiology, recovered neurocysticercosis, and idiopathic headaches then performed binary group comparisons among them using electrospray ionization mass spectrometry. A leave one [serum sample] out cross validation procedure was employed to analyze spectral data. Sera from neurocysticercosis patients was distinguished from epilepsy of unknown etiology patients with a p-value of 10-28. This distinction was lost when samples were randomized to either group (p-value = 0.22). Similarly, binary comparisons of patients with neurocysticercosis who has different types of lesions showed that different forms of this disease were also distinguishable from one another. These results suggest neurocysticercosis epilepsy can be distinguished from epilepsy of unknown etiology based on biomolecular differences in sera detected by mass profiling.

Hints on Diagnosing and Treating Headache.

BACKGROUND: Headache, like dizziness, is one of the more common presenting complaints in outpatient care and in the emergency room. More than 200 varieties of headache have been described, and the false impression may arise that the diagnosis and treatment of these syndromes is a highly challenging task. METHODS: This review is based on pertinent articles retrieved by a selective search in PubMed. RESULTS: In primary headache, the headache is not a symptom but a disease in its own right. There are four types of primary headache: migraine, tension headache, trigeminal autonomic cephalalgia, and other primary headache disorders. By definition, the physical examination is normal, including the neurological examination. Secondary headache, in contrast, is a symptom of another disease (e.g., a tumor or cerebral hemorrhage). Triptans and nonsteroidal anti-inflammatory drugs (NSAID) are the drugs usually given for the acute treatment and prophylaxis of migraine. In tension headache, NSAID are given acutely, and tricyclic drugs for prophylaxis. There are various options for the treatment of trigeminal autonomic cephalalgia syndromes such as cluster headache and paroxysmal hemicrania. For group 4 headaches (other primary headache disorders), the treatment must be chosen on an individual basis; indomethacin is often effective. CONCLUSION: If the patient is clearly suffering from none of the four types of primary headache, the problem must be a headache of a secondary nature, potentially reflecting a dangerous underlying disease. The treatment of headache is usually successful and thus highly rewarding for physicians of all medical specialties.

The effect of myofascial release and microwave diathermy combined with acupuncture versus acupuncture therapy in tension-type headache patients: A pragmatic randomized controlled trial.

BACKGROUND AND PURPOSE: Nonpharmacological therapies for tension-type headache (TTH) and cervicogenic cephalalgia are often a treatment choice, despite the weak to moderate evidence. The aim of this study was to compare the effectiveness of an acupuncture/stretching protocol versus acupuncture/stretching plus physiotherapy techniques, in patients with TTH cephalalgia. METHODS: A single-blind, prospective, multicentre, randomized controlled trial was designed considering the pragmatic situation of administering such protocols and treating the 44 headache patients participating in this study. The patients were randomly assigned in 2 treatment groups (control group, n = 20, acupuncture/stretching; experimental group, n = 24, acupuncture/stretching plus physiotherapy) and completed 10 treatment sessions within 4 weeks with measurements taking place before treatment, after the fifth treatment and after the 10th treatment. The mechanical pressure pain threshold (PPT) was considered as the main outcome measure, using a mechanical algometer to measure 7 bilateral somatic points. Acupuncture in both groups included 17-20 acupuncture points, whereas stretching was initially taught and subsequently self-administered (self-stretches), following a standardized set of movements of the cervical spine. Physiotherapy consisted of microwave diathermy and myofascial release with hands-on techniques. RESULTS/FINDINGS: An improvement was noted in both groups/treatments regarding the main outcome measure PPT, all the way from the first to fifth and the 10th treatment, at all measuring sites and at all measurements in both groups (p < .001). When comparing the 2 groups, differences were noted after the 10th treatment (p < .05). DISCUSSION: In conclusion, patients with TTH headache were benefited from acupuncture and stretching but further PPT improvements were evidenced when physiotherapy hands-on techniques were added. In clinical terms, the combination of physiotherapy in the form of myofascial release and microwave diathermy with acupuncture and stretching in order to improve the analgesic effect (PPT) is strongly recommended.

Development and psychometric validation of the headache screening questionnaire - Dutch Version.

BACKGROUND: Headache is a common disorder which may lead to substantial socio-economic loss. Treatment options include self-management strategies, medication and physiotherapy. Physiotherapists need to be able to screen for the presence of migraine and tension-type headache (TTH), so they can adjust their treatment strategies to the type of headache. A quick screening questionnaire to recognize migraine and TTH in the physiotherapy practice is needed. OBJECTIVE: The aim of this study was to create a headache screening questionnaire based on the ICHD-3 beta criteria for migraine and TTH, and to establish its content and criterion validity. DESIGN: A cross-sectional design was used during the validation phase of the study. METHODS: A screening questionnaire was developed for migraine and TTH. Content validity was checked by the research group and a headache research expert. For validation of this questionnaire, patients from the headache clinic of the Canisius Wilhelmina Hospital in Nijmegen were recruited. The outcome of the questionnaire was compared to the ICHD-3 beta diagnosis of the headache specialist. For criterion validity, sensitivity, specificity, likelihood ratios, and positive- and negative predictive values were calculated. RESULTS: A 10-item questionnaire has been developed: the Headache Screening Questionnaire. For validation of the Dutch version (HSQ-DV), 105 patients were included in the study. The sensitivity and specificity were 0.89 and 0.54 respectively for probable migraine, and for probable TTH 0.92 and 0.48 respectively. CONCLUSION: The HSQ-DV is a sensitive screening tool to detect patients with probable migraine and probable TTH.

Association of Upper Eyelid Ptosis Repair and Blepharoplasty With Headache-Related Quality of Life.

IMPORTANCE: Headache can be a functional indication for ptosis repair and blepharoplasty. OBJECTIVE: To evaluate the changes in headache-related quality of life in patients who underwent upper eyelid ptosis repair or blepharoplasty. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted among 108 patients who underwent standard upper eyelid blepharoplasty and 44 patients who underwent ptosis repair (levator resection, Müller muscle resection, or frontalis suspension) for obscuration of the superior visual field at an ophthalmology clinic's oculoplastic department from September 1, 2014, to September 1, 2015. A validated headache-related quality-of-life survey, the Headache Impact Test-6 (HIT), was administered preoperatively and postoperatively to patients who had tension-type headache. The minimum time interval after the operation was 3 months (mean, 13.5 weeks; range, 12-17 weeks). MAIN OUTCOMES AND MEASURES: Postoperative HIT scores, decline in HIT scores, and marginal reflex distance test 1 scores. RESULTS: Of the 108 patients (66 women and 42 men; mean [SD] age, 49.8 [10.7] years) who underwent blepharoplasty and the 44 patients (26 women and 18 men; mean [SD] age, 45.6 [17.8] years) who underwent ptosis repair, 38 (35.2%) and 28 (63.6%), respectively, had symptoms of tension-type headaches. In both groups, the mean (SD) postoperative HIT scores were statistically significantly better than the preoperative HIT scores (blepharoplasty group: preoperative score, 55.9 [6.6] vs postoperative score, 46.4 [9.0]; ptosis repair group: preoperative score, 60.0 [7.2] vs postoperative score, 42.3 [9.3]; P = .001). In the patients who underwent ptosis repair, the mean (SD) preoperative HIT score was significantly higher than in those who underwent blepharoplasty (60.0 [7.2] vs 55.9 [6.6]; P = .007) and the postoperative HIT score was significantly lower than those who underwent blepharoplasty (42.3 [9.3] vs 46.4 [9.0]; P = .03). The mean (SD) decline in the HIT score was significantly higher in patients who underwent ptosis repair than in those who underwent blepharoplasty (17.8 [9.9] vs 9.5 [8.6]; P = .002). For patients who underwent ptosis repair, there was a statistically significant negative correlation between the results on the marginal reflex distance test 1 (median, 1.82; minimum, 1.0; maximum, 3.5) and change in the HIT score (median, 18; minimum, 0; maximum, 30) (P = .005; r = -0.645). In patients who underwent ptosis repair, the mean (SD) difference between the preoperative and postoperative HIT scores was significantly higher for the patients who underwent levator resection (3.1 [0.3]) than for those who underwent Müller muscle resection (1.5 [0.7]) and frontalis suspension procedures (1.9 [0.7]) (P = .001). CONCLUSIONS AND RELEVANCE: The operations for ptosis and blepharoptosis provide significant relief for tension-type headache and result in improved headache-related quality of life. As a result, tension-type headache can be a functional indication for upper eyelid blepharoplasty and ptosis repair, especially for patients with lower results on the marginal reflex distance test 1. LEVEL OF EVIDENCE: 3.

Abordagem não-farmacológica na cefaleia do tipo tensional: efeitos da hidroterapia sobre a dor e a qualidade de vida / Non-pharmacological approach in tension-type headache: effects of hydrotherapy on pain and quality of life

Há poucos relatos na literatura de abordagens não-farmacológicas para o tratamento da cefaleia do tipo tensional (CTT), problema comum que gera impacto negativo na vida dos portadores, e nenhum sobre o protocolo de hidroterapia proposto. O objetivo do estudo foi verificar os efeitos da hidroterapia sobre a intensidade da dor e frequência das crises, bem como sua interferência na qualidade de vida dos portadores. Um protocolo de hidroterapia com 12 sessões de 60 minutos em piscina aquecida a 31º, contemplando aquecimento, alongamentos, exercícios aeróbicos e exercícios de relaxamento foi utilizado em três indivíduos com diagnóstico médico de CTT. A terapia promoveu melhora no Headache Impact Test (HIT-6), na Es- cala de sonolência de Epworth e no questionário de disfunção temporomandibular (RDC/TMD). Através do diário de dor de cabeça foi verificada redução da frequência da CTT nos três indivíduos durante a terapia e essa redução foi mantida após trinta dias do tratamento. Um indivíduo apresentou diminuição da intensidade da dor durante e após 30 dias do tratamento. O estudo sugere que a hidroterapia pode ser indicada para diminuir a frequência da CTT, bem como para melhorar a qualidade de vida dos portadores.

There are few reports in the literature of non-pharmacological approaches for the treatment of tension-type headache, common problem that generates significant negative impact on quality of life of patients, and none about therapeutic protocol proposed by this study. The aim of the study was to assess the effects of hydrotherapy on the reduction of pain intensity and frequency of crises and their interference in the quality of life of patients. A hydrotherapy protocol with 12 sessions of 60 minutes in pool heated to 31 degrees contemplating heating, stretching, aerobic and relaxation exercise was applied in three patients with clinical diagnosis of tension-type headache. The therapy promoted improvement in the Headache Impact Test (HIT-6), in the Epworth Sleepiness Scale and in the Temporomandibular Dysfunction Questionnaire (RDC / TMD). Through of a daily of headache a reduction in the frequency of tension-type headache was observed in the three individuals during therapy and this reduction was maintained after thirty days of treatment. An individual had a decrease in pain intensity during and after 30 days of treatment. The study suggests that hydrotherapy can be indicated to decrease the frequency of tension-type headache, as well as to improve the quality of life of individuals.

Serum levels of adiponectin, CCL3/MIP-1α, and CCL5/RANTES discriminate migraine from tension-type headache patients / Níveis séricos de adiponectina, CCL3/MIP-1α, and CCL5/RANTES discriminam pacientes com migrânea e cefaleia do tipo tensional

ABSTRACT Objectives Inflammatory molecules and neurotrophic factors are implicated in pain modulation; however, their role in primary headaches is not yet clear. The aim of this study was to compare the levels of serum biomarkers in migraine and tension-type headache. Methods This was a cross-sectional study. We measured serum levels of adiponectin, chemokines, and neurotrophic factors in patients with migraine and tension-type headache. Depression and anxiety symptoms, headache impact and frequency, and allodynia were recorded. Results We included sixty-eight patients with migraine and forty-eight with tension-type headache. Cutaneous allodynia (p = 0.035), CCL3/MIP-1α (p = 0.041), CCL5/RANTES (p = 0.013), and ADP (p = 0.017) were significantly higher in migraine than in tension-type headache. The differences occurred independently of anxiety and depressive symptoms, frequency and impact of headache, and the presence of pain. Conclusions This study showed higher CCL3/MIP-1α, CCL5/RANTES, and ADP levels in migraine in comparison with tension-type headache. Our findings suggest distinctive roles of these molecules in the pathophysiology of these primary headaches.

RESUMO Objetivos Moléculas inflamatórias e fatores neurotróficos estão implicados na modulação dolorosa, contudo, seu papel nas cefaleias primárias não é claro. O objetivo do presente estudo foi comparar níveis de biomarcadores séricos na migrânea e cefaleia do tipo tensional. Métodos Este foi um estudo transversal, no qual foram avaliados níveis de adiponectina, quimiocinas e fatores neurotróficos em pacientes com migrânea e cefaleia do tipo tensional. Sintomas depressivos e ansiosos, o impacto e a frequência da cefaleia e alodínea foram registrados. Resultados Foram incluídos 68 pacientes com migrânea e 48 pacientes com cefaleia do tipo tensional. A alodínia cutânea (p = 0.035), CCL3/MIP-1α (p = 0.041), CCL5/RANTES (p = 0.013), e adiponectina (p = 0.017) foram maiores na migrânea, independentemente de sintomas depressivos e ansiosos, frequência e impacto da cefaleia. Conclusões Níveis de CCL3/MIP-1α, CCL5/RANTES e adiponectina foram maiores na migrânea do que na cefaleia do tipo tensional, sugerindo papeis distintos destas moléculas na fisiopatologia destas duas cefaleias primárias.

Frontal Headache Caused by Infection of Pneumatized Crista Galli.

We reported a case of infection of pneumatized crista galli presented with frontal headache having similar features suggestive of tension type headache. Although it may be an extremely rare cause of frontal headache, we reviewed reported literatures focusing on the frontal sinus pathologies affecting pneumatized crista galli. This case highlights that both the primary and secondary headache disorders may cause headache in the frontal region, and therefore need to be considered in the differential diagnosis.

Factors Associated with Primary Headache According to Diagnosis, Sex, and Social Group.

BACKGROUND: We previously showed that migraine and tension-type headache (TTH) have a high prevalence that differs markedly between social groups. Here, we aim to identify factors associated with migraine and TTH (possible risk factors) in three social groups to better understand the difference in prevalence between sexes, between different headache diagnoses, and between different social groups. MATERIAL AND METHODS: The study included 3124 persons: 1007 blood donors (484 females, mean age 34.1), 1075 workers in an oil and gas factory (146 females, mean age 40.4), and 1042 medical students (719 females, mean age 20.6). Headache diagnoses and associated factors were identified by direct or telephone interview using a semistructured, validated form. It was administered by a neurologist or by specially trained senior medical students under supervision of a neurologist. RESULTS: We report factors associated with headache according to diagnosis, sex, and social group using multivariate logistic regression analysis. (1) According to diagnosis. Many associated factors were common for migraine and TTH: female sex, arterial hypertension, history of head trauma, and consumption of light alcoholic beverages. To be a student was associated with the highest risk of migraine (OR 6.6; 95% CI 4.2-10.4) and TTH (OR 3.6; 95% СI 2.7-4.8). Low physical activity (OR 1.6; 95% CI 1.0-2.4) and family history of headache (OR 2.1; 95% CI 1.5-2.9) were associated only with migraine. Current smoking and BMI > 25 were negatively associated with migraine and TTH. (2) According to sex. Common factors associated with migraine and TTH in both sexes included history of head trauma, family history of headache, and arterial hypertension. Use of alcohol was different between sexes: in males consumption of strong alcoholic beverages was associated with TTH (OR 1.5; 95% CI 1.0-2.0) and in females consumption of light alcoholic beverages was associated with migraine (OR 3.49; 2.03-6.02) and TTH (OR 3.0; 95% CI 1.93-4.66). Low physical activity was associated with migraine in females (OR 1.9; 95% CI 1.1-3.2). (3) According to social group. Common factors associated with headache in all groups included female sex, family history of headache, history of head trauma, and arterial hypertension. Consumption of light alcoholic beverages was associated with migraine and TTH in blood donors and students. Only two factors were specific to a social group: consumption of strong alcoholic beverages was associated with TTH in blood donors (OR 1.5; 95% CI 1.1-2.1), low physical activity was associated with migraine in students (OR 1.98; 95% CI 1.04-3.74) and with TTH in workers (OR 2.1; 95% CI 1.2-3.7). CONCLUSION: Most of the associated factors were shared by the sexes. The associated factors varied somewhat more between migraine and TTH and between social groups. To be a student was associated with the highest risk of headache. Factors different from those in the present and previous studies should be studied in the future in order to better understand the differences in associated factors according to diagnosis, sex, and social group.

Vitamin D deficiency mimicking chronic tension-type headache in children.

Headache, musculoskeletal pain and vitamin D deficiency, with possible inter-relationship, are common in the general population. We report cases of three premenarchal girls presenting with chronic tension-type headache and generalised body pain. The patients did not show any response to conventional therapy for tension headache. Investigations showed a severe vitamin D deficiency and biochemical osteomalacia in all three patients. The headaches and musculoskeletal pain responded markedly to vitamin D therapy. We suggest that musculoskeletal pain and headache together in a patient may be part of a single symptom complex, with vitamin D deficiency being the possible cause.