Additional Effects of a Physical Therapy Protocol on Headache Frequency, Pressure Pain Threshold, and Improvement Perception in Patients With Migraine and Associated Neck Pain: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the additional effect provided by physical therapy in migraine treatment. DESIGN: Randomized controlled trial. SETTING: Tertiary university-based hospital. PARTICIPANTS: Among the 300 patients approached, 50 women (age range, 18-55y) diagnosed with migraine were randomized into 2 groups: a control group (n=25) and a physiotherapy plus medication group (n=25) (N=50). INTERVENTIONS: Both groups received medication for migraine treatment. Additionally, physiotherapy plus medication patients received 8 sessions of physical therapy over 4 weeks, comprised mainly of manual therapy and stretching maneuvers lasting 50 minutes. MAIN OUTCOME MEASURES: A blinded examiner assessed the clinical outcomes of headache frequency, intensity, and self-perception of global change and physical outcomes of pressure pain threshold and cervical range of motion. Data were recorded at baseline, posttreatment, and 1-month follow-up. RESULTS: Twenty-three patients experienced side effects from the medication. Both groups reported a significantly reduced frequency of headaches; however, no differences were observed between groups (physiotherapy plus medication patients showed an additional 18% improvement at posttreatment and 12% improvement at follow-up compared with control patients, P>.05). The reduction observed in the physiotherapy plus medication patients was clinically relevant at posttreatment, whereas clinical relevance for control patients was demonstrated only at follow-up. For pain intensity, physiotherapy plus medication patients showed statistical evidence and clinical relevance with reduction posttreatment (P<.05). In addition, they showed better self-perception of global change than control patients (P<.05). The cervical muscle pressure pain threshold increased significantly in the physiotherapy plus medication patients and decreased in the control patients, but statistical differences between groups were observed only in the temporal area (P<.05). No differences were observed between groups regarding cervical range of motion. CONCLUSIONS: We cannot assume that physical therapy promotes additional improvement in migraine treatment; however, it can increase the cervical pressure pain threshold, anticipate clinically relevant changes, and enhance patient satisfaction.

Quality of life and health-related disability in children with migraine.

OBJECTIVE: To determine whether migraine interferes with health-related quality of life (HRQL) and the degree of disability caused by this condition in the daily life of children of both genders aged 6-12 years. BACKGROUND: Migraine is a chronic disease with recurrent symptoms that lead to a reduction of daily activity during the crises and during the intercritical periods, with an impact on HRQL. METHODS: The sample consisted of 50 children with migraine without aura being treated at a childhood headache outpatient clinic (study group) and 50 children with no history of headache selected at a pediatric outpatient clinic (control group). The Pediatric Migraine Disability Score questionnaire was applied to the study group in order to determine the disability provoked by headache in daily life, and the Pediatric Quality of Life Inventory 4.0 was applied to both groups to determine HRQL. RESULTS: Children with migraine were absent from school activities, did not perform household tasks, and did not participate in leisure activities for 23.9 days, on average, during the last 3 months because of migraine. Disability was absent or mild in 38% of the children, whereas 14% showed severe disability. HRQL was similar in both groups regarding self-evaluation, whereas it was perceived as being worse by the parents of children with migraine. Children with migraine had a worse school and emotional quality of life as determined by self-perception. According to the perception of the parents, children with migraine had a worse general, physical, and psychosocial quality of life. Absenteeism from school activities, household tasks, and leisure was not correlated with HRQL. CONCLUSION: Although migraine was a cause of school absenteeism, most of the children with migraine showed little or no disability regarding daily life activities and their quality of life was similar to that of children without headache.

A comparison pressure pain threshold in pericranial and extracephalic regions in children with migraine.

BACKGROUND: There is evidence that the pressure pain threshold (PPT) is reduced in children with migraine and that it varies according to age, sex, and region of the body. However, in view of the lack of consensus in the literature, the objective of the present study was to evaluate the PPT in children with migraine of both genders aged 6-12 years. METHODS: Fifty children with migraine without aura and 50 children without headache were studied. The PPT was evaluated using an algometer at nine bilateral anatomical sites. RESULTS: Comparison of children with migraine to children without headache did not show differences in PPT, except for the points of insertion of occipital muscles and the anterior aspect of C5-C7, where the values were lower in the children with migraine. Analysis according to gender revealed that both girls and boys had a lower PPT in at least one region evaluated. CONCLUSION: Comparison of the PPTs between sites revealed that the pericranial and cervical regions showed a lower PPT than the extracephalic sites in children with migraine.

Temporomandibular disorders, sleep bruxism, and primary headaches are mutually associated.

AIMS: To investigate the association among temporomandibular disorders (TMD), sleep bruxism, and primary headaches, assessing the risk of occurrence of primary headaches in patients with or without painful TMD and sleep bruxism. METHODS: The sample consisted of 301 individuals (253 women and 48 men) with ages varying from 18 to 76 years old (average age of 37.5 years). The Research Diagnostic Criteria for Temporomandibular Disorders were used to classify TMD. Sleep bruxism was diagnosed by clinical criteria proposed by the American Academy of Sleep Medicine, and primary headaches were diagnosed according to the International Classification of Headache Disorders-II. Data were analyzed by chi-square and odds ratio tests with a 95% confidence interval, and the significance level adopted was .05. RESULTS: An association was found among painful TMD, migraine, and tension-type headache (P < .01). The magnitude of association was higher for chronic migraine (odds ratio = 95.9; 95% confidence intervals = 12.51-734.64), followed by episodic migraine (7.0; 3.45-14.22) and episodic tension-type headache (3.7; 1.59-8.75). With regard to sleep bruxism, the association was significant only for chronic migraine (3.8; 1.83-7.84). When the sample was stratified by the presence of sleep bruxism and painful TMD, only the presence of sleep bruxism did not increase the risk for any type of headache. The presence of painful TMD without sleep bruxism significantly increased the risk in particular for chronic migraine (30.1; 3.58-252.81), followed by episodic migraine (3.7; 1.46-9.16). The association between painful TMD and sleep bruxism significantly increased the risk for chronic migraine (87.1; 10.79-702.18), followed by episodic migraine (6.7; 2.79-15.98) and episodic tension-type headache (3.8; 1.38-10.69). CONCLUSION: The association of sleep bruxism and painful TMD greatly increased the risk for episodic migraine, episodic tension-type headache, and especially for chronic migraine.

Nocturnal awakening with headache and its relationship with sleep disorders in a population-based sample of adult inhabitants of Sao Paulo City, Brazil.

Our aim was to estimate the prevalence of nocturnal awakening with headache (NAH) in the population of São Paulo City according to gender, age (20-80 years old) and socioeconomic classes and its relationship to sleep disorders, sleep parameters, anxiety, depression, fatigue, life quality and obesity. We used a population-based survey with a representative three-stage cluster sample. Questionnaires and scales were applied face-to-face, and polysomnography was performed in 1101 volunteers, aged 42 ± 14 years, 55% women. The complaint of NAH occurring at least once a week had a prevalence of 8.4%, mostly in women, obese subjects and those aged 50-59 years-old. We observed associations of NAH with insomnia, restless leg syndrome (RLS), nightmares and bruxism, but not obstructive sleep apnea syndrome. In a logistics regression model, risk factors for NAH were female gender, odds ratio (OR) (95% confidence interval [CI]) 4.5 (2.8-7.3); obesity, OR 1.9 (1.1-3.3); age between 50 and 59 years, OR 2.4 (1.2-4.7); severe anxiety, OR 8.1 (3.6-18.1); RLS, 2.7 (1.2-5.6); and nightmares, 2.2 (1.3-3.7). Our study shows that NAH was highly prevalent in the population of São Paulo and suggests that this phenomenon has specific characteristics with specific risk factors: obesity, RLS and nightmares.

Symptoms of temporomandibular disorders in the population: an epidemiological study.

AIMS: To estimate the prevalence of symptoms of temporomandibular disorders (TMD) as a function of age and gender, in a representative urban sample from the Brazilian population. METHODS: A total of 1,230 inhabitants (51.5% women) aged 15 to 65 years were interviewed by a validated phone survey. Sample size had been previously calculated. TMD symptoms were assessed through five questions, as recommended by the American Academy of Orofacial Pain, in an attempt to identify possible TMD. Data were derived by age and gender. Prevalence of each TMD symptom, and of combination of symptoms, was calculated. RESULTS: At least one TMD symptom was reported by 39.2% of the individuals. Pain related to TMD was noted by 25.6% of the population. Temporomandibular joint (TMJ) sound was the most common symptom of TMD, followed by TMJ pain and masticatory muscle pain. All symptoms were more prevalent in women than in men. With men used as the reference, a relative risk (RR) of at least one TMD symptom in women was 1.31 (95% confidence interval [CI] = 1.14 to 1.52). When at least two symptoms were present, the RR was 1.93 (95% CI = 1.49 to 2.51). For three or more TMD symptoms, the RR was 2.49 (95% CI = 1.67 to 3.71). Women were also more likely than men to have TMD pain (RR = 1.78; 9% CI = 1.45 to 2.18). CONCLUSION: Individual symptoms, as well as a combination of TMD symptoms, are prevalent in the Brazilian urban population and are more frequent in women than in men. Additional studies should focus on risk factors for and relevance of TMD for the sufferers.

A new biofeedback approach for the control of awake bruxism and chronic migraine headache: utilization of an awake posterior interocclusal device.

BACKGROUND: The relationship of bidirectional comorbidity between chronic migraine and pain in the cephalic segment led us to evaluate the improvement in reducing the pain in patients diagnosed with chronic migraine headache and awake bruxism, when undergoing treatment with a partial posterior interocclusal device designed for the management and control of awake bruxism through biofeedback. METHODS: Seventy-four patients were evaluated during the following periods: pretreatment, seven, thirty, ninety, one hundred and eighty days, and one year. The evaluation was carried out by measuring the pain in the pretreatment period and pain reduction after awake bruxism treatment, using clinical evaluation and numerical scales for pain. RESULTS: Most of the patients who complained of headache migraine pain, masticatory myofascial pain, temporomandibular joint and neck pain experienced a significant reduction in overall pain, including headaches, between t0 and t30 (p<0.0001). After 30 days of using the device, it was observed that the improvement remained at the same level without any recurrence of pain up to t90. At t180 and t360, it was observed that even with the device withdrawal (at t90) the improvement remained at the same level. CONCLUSION: The utilization of a posterior interocclusal device designed for the management and control of awake bruxism through biofeedback seems to contribute to the reduction of pain (including migraine headache) in the majority of patients, and, even with the device withdrawal (at t90), the improvement remained at the same level, suggesting the patients succeeded in controlling their awake bruxism and consequently the pains.

Anatomic and neuropsychological findings in low-educated cognitively intact elderly from a Brazilian cohort.

In elderly individuals, low educational level may represent a risk factor for the development of dementia and a proxy of cognitive reserve. OBJECTIVE: This study examined the cognitive and neuroanatomic correlates of high versus low educational levels in cognitively healthy community-dwelling older adults in Brazil. METHODS: Fifty-three older adults (mean age: 68±5.3 years) were divided into a "low education" group [LE; 1-4 years of education (N=33)] and "high education" group [HE; >11 years of education (N=20)]. Both groups completed a comprehensive neuropsychological battery and underwent in vivo structural MRI close to the time of testing. RESULTS: Higher educational level increased the chance of having better scores on neuropsychological tests, including verbal and visual delayed recall of information, verbal learning, category fluency, global cognition, and vocabulary. Better scores on these tests were observed in the HE group relative to the LE group. Despite this, there were no group differences between MRI measures. CONCLUSION: Older adults with higher educational levels showed better scores on neuropsychological measures of cognition, highlighting the need for education-adjusted norms in developing countries. Given the absence of differences in structural anatomy between the groups, these findings appear to be best explained by theories of cognitive reserve.

Sabe-se que baixos níveis de educação são comuns em países em desenvolvimento. Em indivíduos idosos, em particular, baixos níveis de educação podem representar um fator de risco para o desenvolvimento de demência. Objetivo: Este estudo examina os correlatos cognitivos e neuroanatômicos de escolaridade alta versus baixa, em idosos cognitivamente saudáveis,vivendo em comunidade no Brasil. Métodos: Cinquenta e três idosos (média de idade: 68±5,3) foram divididos em um grupo de "baixa escolaridade" [LE; 1-4 anos de escolaridade (N=33)] e um grupo de "alta escolaridade" [HE; >11 anos de escolaridade (N=20)]. Ambos os grupos completaram uma bateria neuropsicológica abrangente e foram submetidos à RM estrutural in vivo próximo à testagem. Resultados: O nível educacional aumentou a chance de se obter melhores pontuações em testes neuropsicológicos, incluindo evocação verbal e visual da informação, aprendizagem verbal, fluência de categoria, cognição global e vocabulário. Escores mais altos foram encontrados no grupo HE, em detrimento do LE. Apesar disso, não houve diferenças entre os grupos nas medidas de ressonância magnética in vivo. Conclusão: Idosos com maiores níveis de escolaridade apresentaram melhores pontuações nas medidas neuropsicológicas da cognição, destacando a necessidade de normas ajustadas à educação nos países em desenvolvimento. Não havendo diferenças na anatomia estrutural entre os grupos, os achados parecem ser melhor explicados pelas teorias da "reserva cognitiva".

Cluster headache attacks in a woman previously struck by lightning: pathophysiology of the latent period.

BACKGROUND: Cases of patients who developed cluster headache-like symptoms after different putative causes have been reported, indicating a direct relationship between brain lesion and this particular type of headache. Long term, delayed, neurological sequelae after lightning have also been described. CASE REPORT: We describe the case of a woman who, at the age of 10, was struck by lightning. Six years later she developed cluster headache-like attacks. CONCLUSION: We hypothesize that a relationship between the lightning and the cluster headache-like episodes observed in our patient. This case study may have helped throw some light into the still unknown pathophysiology of this particular type of primary headache.

SUNCT syndrome: report of a possible symptomatic case.

SUNCT is one of the rarest and least known primary headache disorders. Although its pathogenesis has been partially understood by functional neuroimaging and reports of secondary cases, there is limited understanding of its cause. We report a case of SUNCT in a 54-years-old man, that could not be strictly classified as secondary SUNCT; however, the time lag of pain onset suggests a new theory in which neuroplasticity could be involved in the origin and duration of the pain in SUNCT syndrome.

Analysis of the cranio-cervical curvatures in subjects with migraine with and without neck pain.

OBJECTIVE: To investigate the differences in head and cervical spine alignment between subjects with migraine and healthy people. DESIGN: A cross-sectional, observational study. PARTICIPANTS: Fifty subjects with migraine and 50 matched healthy controls. MAIN OUTCOMES MEASURES: The presence of neck pain and neck pain-related disability was assessed. Four angles (high cervical angle, low cervical angle, atlas plane angle and cervical lordosis Cobb angle) as well as four distances (anterior translation distance, C0 to C1 distance, C2 to C7 posterior translation and hyoid triangle) were calculated using digitalised radiographs and analysed using K-Pacs® software. RESULTS: Subjects with migraine reported a longer history of neck pain symptoms, and higher pain intensity and neck-pain-related disability than controls (P<0.01). Patients exhibited a smaller anterior translation distance (mean difference: 4.9mm, 95% confidence interval 1.8 to 8.8; P<0.001) and hyoid triangle (difference: 3.0mm, 95% confidence interval 1.0 to 5.0; P=0.02) than healthy controls. When the presence or the absence of neck pain was included in the analysis, the differences did not change. Differences in anterior translation and hyoid triangle distances were considered clinically relevant for subjects with migraine suffering from neck pain. CONCLUSION: Subjects with migraine exhibited straightening of cervical lordosis curvature. The presence of neck pain did not influence head posture in subjects with and without migraine.

Relationship Between Active Trigger Points and Head/Neck Posture in Patients with Migraine.

OBJECTIVE: To investigate the relationship between the presence of active trigger points (TrPs), craniocervical posture, and clinical features (frequency, intensity, and duration) in patients with migraine. DESIGN: A cross-sectional study. METHODS: Fifty patients with migraine (90% women; age, 34.1 years) participated. Clinical data regarding migraine (frequency, intensity, and duration) were obtained. Trigger points were bilaterally explored in the following muscles: masseter, suboccipital, temporalis (anterior, medium, and posterior fibers), sternocleidomastoid, upper trapezius, and splenius capitis. Eight measures of head and neck posture were obtained from radiographs using the K-Pacs software. RESULTS: Individuals with migraine showed active and latent TrPs in all the muscles, the suboccipital, upper trapezius, sternocleidomastoid, and temporalis muscles being the most affected. The results showed a relationship between the number of active TrPs and several x-ray outcomes, suggesting that the higher number of active TrPs was positively associated with a reduction in cervical lordosis and head extension of the head on the neck. No association between the number of active TrPs and clinical features of migraine was seen. CONCLUSION: Our study supports the hypothesis that active TrPs are associated with reduced cervical lordosis and head extension in individuals with migraine.

Cervico-occipital Posture in Women With Migraine: A Case-Control Study.

STUDY DESIGN: Case-control study. BACKGROUND: Previous studies have assessed forward head posture in patients with migraine using photographs. To date, no study has compared postural differences using both radiographs and photographs. OBJECTIVE: To determine the differences in head extension posture between women with migraine and healthy women assessed with radiographic and photographic measures. METHODS: Thirty-three women (mean ± SD age, 32 ± 11.3 years) with migraine and 33 matched controls (age, 33 ± 12.6 years) participated. Radiographs were used to measure the high cervical angle (HCA), the angle between the most inferior line from the occipital surface to the posterior portion of C1 and the posterior surface of the odontoid process of C2, and the vertical distance between C0 and C1 (C0-C1). Photographs and commercially available software were used to assess the craniovertebral angle (CVA). RESULTS: None of the outcomes differed significantly between women with migraine and control participants. Outcomes for women with migraine were HCA, 66.1° (95% confidence interval [CI]: 64.2°, 68.1°); CVA, 46.1° (95% CI: 45.0°, 47.1°); and C0-C1, 8.5 mm (95% CI: 7.7, 9.2). Outcomes for the control group were HCA, 67.9° (95% CI: 66.5°, 69.3°); CVA, 44.5° (95% CI: 43.2°, 45.7°); and C0-C1, 8.7 mm (95% CI: 7.9, 9.4). Relationships between the frequency (r = -0.42, P = .01, R (2) = 10%) of migraine and the HCA were found. CONCLUSION: This study demonstrated that women with migraine did not exhibit forward head posture compared to women with no history of headache in either radiographic or photographic postural analysis. However, there was a weak association of the frequency of migraine attacks with a variation in the HCA as assessed by radiographs. LEVEL OF EVIDENCE: Differential diagnosis/symptom prevalence, level 4.

Recommendations for the treatment of migraine attacks - a Brazilian consensus.

In this article, a group of experts in headache management of the Brazilian Headache Society developed through a consensus strategic measurements to treat a migraine attack in both the child and the adult. Particular emphasis was laid on the treatment of migraine in women, including at pregnancy, lactation and perimenstrual period.

[Influence of education on the neuropsychological assessment of the elderly: application and analysis of the results from the Mattis Dementia Rating Scale (MDRS)]. / Influência da escolaridade na avaliação neuropsicológica de idosos: aplicação e análise dos resultados da Escala de Mattis para Avaliação de Demência (Mattis Dementia Rating Scale-MDRS).

OBJECTIVE: To assess the influence of low education and illiteracy on the evaluation of dementia by the Mattis Dementia Rating Scale (MDRS). METHOD: We applied the MDRS to 62 normal elderly subjects (64-77 years), divided into five groups according to schooling, i.e., 15-16 years, 11-12 years, 8-9 years, 4 years, and illiterate. The MDRS covers the study of five subscales and the sum of their scores may represent the degree of cognitive impairment. RESULTS: A significant difference (p < 0.05) in performance on this scale was observed among the subgroups in relation to education on 12 items, 5 subscales (illiterates < all other groups and 15-16 years > 4 and 8 years of schooling, p < or = 0.001) and the total MDRS score (illiterates < all others and 4 and 8 years < 15-16 years, p < 0.001). No significant correlations where found for age and, regarding gender, the differences were significant in only one item. CONCLUSION: Education interfered with individual performance on the MDRS. Illiteracy is a determinant factor of lower MDRS scores that could generate diagnostic errors.

A new biofeedback approach for the control of awake bruxism and chronic migraine headache: utilization of an awake posterior interocclusal device / Uma nova abordagem via biofeedback para o controle do bruxismo de vigília e de enxaqueca crônica: utilização de um dispositivo interoclusal posterior em vigília

ABSTRACT Background: The relationship of bidirectional comorbidity between chronic migraine and pain in the cephalic segment led us to evaluate the improvement in reducing the pain in patients diagnosed with chronic migraine headache and awake bruxism, when undergoing treatment with a partial posterior interocclusal device designed for the management and control of awake bruxism through biofeedback. Methods: Seventy-four patients were evaluated during the following periods: pretreatment, seven, thirty, ninety, one hundred and eighty days, and one year. The evaluation was carried out by measuring the pain in the pretreatment period and pain reduction after awake bruxism treatment, using clinical evaluation and numerical scales for pain. Results: Most of the patients who complained of headache migraine pain, masticatory myofascial pain, temporomandibular joint and neck pain experienced a significant reduction in overall pain, including headaches, between t0 and t30 (p<0.0001). After 30 days of using the device, it was observed that the improvement remained at the same level without any recurrence of pain up to t90. At t180 and t360, it was observed that even with the device withdrawal (at t90) the improvement remained at the same level. Conclusion: The utilization of a posterior interocclusal device designed for the management and control of awake bruxism through biofeedback seems to contribute to the reduction of pain (including migraine headache) in the majority of patients, and, even with the device withdrawal (at t90), the improvement remained at the same level, suggesting the patients succeeded in controlling their awake bruxism and consequently the pains.

RESUMO Introdução: A relação de comorbidade bidirecional entre enxaqueca crônica e dor no segmento cefálico nos levou a avaliar a melhora na redução da dor em pacientes diagnosticados com cefaleia crônica de enxaqueca e bruxismo de vigília, quando submetidos a tratamento com dispositivo interoclusal posterior parcial projetado para o manejo e o controle do bruxismo acordado através de biorretroalimentação (biofeedback). Métodos: Setenta e quatro pacientes foram avaliados durante os seguintes períodos: pré-tratamento, sete, trinta, noventa e cento e oitenta dias, e um ano. A avaliação foi realizada por meio da avaliação da dor no período pré-tratamento e redução da dor após o tratamento do bruxismo de vigília, através de avaliação clínica e escalas numéricas de dor. Resultados: A maioria dos pacientes que se queixou de dor de cabeça com enxaqueca, dor miofascial mastigatória, articulação temporomandibular e dor no pescoço sofreu uma redução significativa na dor geral, incluindo dores de cabeça, entre t0 e t30 (p<0,0001). Após 30 dias de uso do dispositivo, observou-se que a melhora permaneceu no mesmo nível, sem recorrência da dor até t90. Em t180 e t360, observou-se que, mesmo com a retirada do dispositivo (em t90), a melhoria permaneceu no mesmo nível. Conclusão: A utilização de um dispositivo interoclusal posterior projetado para o controle do bruxismo de vigília através de biofeedback parece contribuir para a redução da dor (incluindo enxaqueca) na maioria dos pacientes, e, mesmo com a retirada do dispositivo (t90), a melhora manteve-se no mesmo nível, sugerindo que os pacientes conseguiram controlar o seu bruxismo de vigília e a dor associada a esse hábito.

Epidemiology of chronic pain in the office of a pain specialist neurologist.

OBJECTIVE: The objective of the present report was to describe the working experience of a pain specialist neurologist after concluding a medical residency program on neurology, area of concentration pain. METHOD: A retrospective study was conducted for one year in the office of a pain specialist neurologist. Patients older than 18 years with chronic pain according to the criteria of the International Association for the Study of Pain, were included. Demographic data, chronic pain data and the treatments instituted were investigated. RESULTS: A total of 241 medical records were reviewed, mean patient age was 52.4 years and 79 (66.9%) were women, and the mean score on a numeric pain scale was 8.69. The diagnoses were headaches (74.6%), neuropathic pain (17%) and ostheomuscular pain (8.2%). We did not detect cancer pain. Patients received medication and procedures of anesthetic blockade. CONCLUSION: This data can guide new medical residency programs on Neurology, area of concentration pain, to plan activities and studies.

Headache Attributed to Masticatory Myofascial Pain: Clinical Features and Management Outcomes.

AIMS: To describe the characteristics of headaches attributed to temporomandibular disorders (TMD) and assess the effects of two management strategies used for the management of TMD on headache intensity and frequency. METHODS: The initial sample (n=60) of this randomized controlled trial comprised patients with masticatory myofascial pain according to the Research Diagnostic Criteria for TMD (RDC/TMD), and headache. The patients were divided into two groups: group 1 received only counseling for behavioral changes, and group 2 received counseling and an occlusal appliance. A 5-month follow-up period included three assessments. TMD-related headache characteristics, eg, headache intensity (scored on a visual analog scale [VAS]) and frequency were measured by a questionnaire. Two-way analysis of variance, chi-square, Friedman, and Mann-Whitney tests were used to test for differences considering a 5% significance level. RESULTS: The main clinical features of headache attributed to masticatory myofascial pain were the long duration (≥4 hours), frontotemporal bilateral location, and a pressing/tightening quality. Forty-one subjects (group 1, 17 subjects; group 2, 24 subjects) were included in the final analysis. There was a reduction in headache intensity and frequency, with no significant differences between groups (P>.05). The mean (±SD) baseline VAS was 7.6 (±2.2) for group 1 and 6.5 (±1.6) for group 2; final values were 3.1 (±2.2) (P<.001) and 2.5 (±2.3) (P<.001), respectively. CONCLUSION: Headache attributed to masticatory myofascial pain was mainly characterized by long duration, frontotemporal bilateral location, and a pressing/tightening quality. Also, counseling and behavioral management of masticatory myofascial pain improved headache, regardless of the use of an occlusal appliance.