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

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

Effectiveness of an educational and physical programme in reducing headache, neck and shoulder pain: a workplace controlled trial.

This study was an 8-month controlled trial to evaluate the effectiveness of a workplace educational and physical programme in reducing headache and neck and shoulder pain. Central registry office employees (n = 192; study group) and 192 peripheral registry office and central tax office employees (controls) in the city of Turin, Italy were given diaries for the daily recording of pain episodes. After 2 months, the study group only began the educational and physical programme. The primary end-point was the change in frequency of headache and neck and shoulder pain expressed as the number of days per month with pain, and as the proportion of subjects with a >or= 50% reduction of frequency (responder rate). The number of days of analgesic drug consumption was also recorded. Diaries completed for the whole 8 months were available for 169 subjects in the study group and 175 controls. The baseline frequency of headache (days per month) was 5.87 and 6.30 in the study group and in controls; frequency of neck and shoulder pain was 7.12 and 7.79, respectively. Mean treatment effects [days per month, 95% confidence interval (CI)] on comparing the last 2 months vs. baseline were: headache frequency -2.45 (-3.48, -1.43); frequency of neck pain -2.62 (-4.09, -1.16); responder rates (odds ratio, 95% CI) 5.51 (2.75, 11) for headache, 3.10 (1.65, 5.81) for neck and shoulder pain, and 3.08 (1.06, 8.90) for days with analgesic drug consumption. The study suggests that an educational and physical programme reduces headache and neck and shoulder pain in a working community.

A comparative analysis of personality profile and muscle tenderness between chronic migraine and chronic tension-type headache.

This study was aimed at comparing the personality profile, the psychiatric comorbidity (depression and anxiety) and the tenderness of the pericranial and cervical muscles in women with chronic migraine (CM) and chronic tension-type headache (CTTH). Forty-one CM and 34 CTTH women were enrolled. A clinical evaluation (according to SCID-I) and a psychometric assessment (MMPI-2, STAI-1 and STAI-2) were performed. After palpation, a Pericranial muscle Tenderness Score (PTS) and a Cervical Muscle Tenderness Score (CTS) were calculated. No significant difference was detected in MMPI-2, STAI-1, STAI-2, PTS and CTS scores between the two groups. Anxiety and depression were present in 80% of CM and in 63% of CTTH women. We did not find any significant difference either in the personality profile or in the muscle tenderness between CM and CTTH patients. This similarity points to a role of these factors, in association with psychiatric comorbidity, in the chronicisation of headache.

Personality traits, depression and migraine in women: a longitudinal study.

Our purpose was to examine the association between personality traits, depression and migraine in the long term. In 56 women with migraine a psychological assessment was carried out to assess the presence of major depression, and the Minnesota Multiphasic Personality Inventory (MMPI) and the State and Trait Anxiety Inventory (STAI) were administered at baseline (T0) and after 6-7 years (T2). Frequency, severity and duration of migraine were recorded at T0, after treatment (T1) and at T2, and their relation to the prevalence of depression and to the MMPI and STAI data was examined (ANOVA, Student's t-test, chi2 analysis, and multiple regression analysis). Pain parameters improved in all patients in T0-T1, but at T2 were higher in patients with depression at T0. The patients whose migraine improved at T2 had, at T0 and T2, significantly lower MMPI and STAI scores. Multiple regression analysis showed a correlation of the MMPI depression score and STAI 1,2 scores at T0 with headache frequency at T2. We conclude that the co-occurrence of migraine, personality changes and depression in women does not appear to influence the results of treatment at short-term, but it seems to be influential on headache history in the long term.

Switch to quetiapine in antipsychotic agent-related hyperprolactinemia.

Novel antipsychotics (clozapine, risperidone, olanzapine, quetiapine) are effective in treating psychotic symptoms, also in neurological disease. Hyperprolactinemia is a side effect related to antipsychotics that can cause galactorrhea, gynecomastia, amenorrhea, anovulation, impaired spermatogenesis, decreased libido and sexual arousal, impotence, and anorgasmia, consequent to removal of tonic dopaminergic inhibition of prolactin secretion via hypothalamic dopaminergic receptor blockade in the tuberoinfundibolar tract. Hyperprolactinemia occurs more frequently during treatment with risperidone and olanzapine compared with clozapine and quetiapine. The therapeutic algorithm to antipsychotic-relatedhyperprolactinemia is the following: reduction in antipsychotic dose, addition of cabergoline, bromocriptine, amantadine, and/or switch to another antipsychotic. We propose switching to quetiapine in symptomatic hyperprolactinemia related to antipsychotics and describe five cases.

MMPI-2 profiles in chronic daily headache and their relationship to anxiety levels and accompanying symptoms.

OBJECTIVES: To examine a group of patients with chronic daily headache using the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2) and to determine whether the data acquired were related to the anxiety levels of the patients, as detected by the Spielberger State-Trait Anxiety Inventory (STAI) 1, 2 and to the presence of a number of accompanying symptoms that are frequently observed in patients with chronic headache. BACKGROUND: In the last decade, the MMPI-2 was released and its items used to develop 15 "content scales." Recently, this instrument was adapted to the Italian population. METHODS: Five men and 30 women with chronic daily headache had a semistructured interview in which the presence of 21 behavioral or somatic symptoms was recorded. The Italian version of the MMPI-2 and the STAI 1, 2 (Italian version) were employed. A configural analysis of the MMPI profiles was performed, and four types were distinguished: "conversion V" (n = 5), elevation of the "neurotic triad" (n = 5), the "emotionally overwhelmed" with scale elevation of the neurotic triad and of several other scales (n = 18), and "the copers" with no scale elevation above 65 (n = 4). Three patients could not be classified. The pain characteristics, the prevalence of accompanying symptoms, and the STAI 1, 2 scores were assessed in all patients and in the different MMPI groups, and the data were statistically analyzed (ANOVA and chi-square analysis). RESULTS: All patients with no MMPI-2 scale elevation showed a tendency to a conversion V profile: in this group, the chronicity was markedly and significantly lower than in all other groups. Moreover, in this group, the STAI 1, 2 scores and the prevalence of some accompanying symptoms were significantly lower than in the other groups. Migraine characteristics did not differ significantly from group to group. CONCLUSIONS: Hysterical traits were observed in a number of patients with chronic daily headache and might constitute a predisposing factor for this condition. With time, the personality profile deteriorates, either through an increase in the hysterical traits or through its transformation, with a parallel increase in anxiety levels and the presence of accompanying symptoms.

The McGill Pain Questionnaire in patients with TMJ pain and with facial pain as a somatoform disorder.

The purpose of this study was to assess the discriminative capacity of the McGill Pain Questionnaire (MPQ) in patients with temporomandibular joint disorders (TMD) or with facial pain disorder as somatoform disorder (referred to as "atypical facial pain") (FP). The MPQ was administered to 57 TMD and 34 FP patients. Weighted MPQ item scores, subscale Pain Rating Indexes (PRI), and total Pain Rating Index were tested for significant differences (Student's t-test), and the frequency of descriptor choice was also analyzed. Furthermore, the data were processed through two systems based on a counter-propagation neural network: the Self-Organizing Map (SOM) system and a cluster-like analysis. In the FP group eleven MPQ item scores and five PRI scores were significantly higher than those of the TMJ group. There was a considerable difference in descriptor choice between the groups. SOM analysis and cluster-like analysis correctly discriminated 85% or more of the patients. In conclusion, the MPQ showed a consistent discriminative capacity between TMD and FP patients.

Personality characteristics and accompanying symptoms in temporomandibular joint dysfunction, headache, and facial pain.

AIMS: Patients with different facial pain/headache pathologies usually complain of numerous accompanying symptoms relative to systemic dysfunctions or to the patient's personality characteristics. The purpose of this work was: (1) to determine the prevalence of accompanying symptoms in groups of patients with temporomandibular joint (TMJ) dysfunction and other types of facial pain or headache disorders, (2) to assess the patients' personality characteristics and anxiety levels, and (3) to see whether significant differences were found between the groups. METHODS: Two hundred forty-three patients were considered. They had TMJ intracapsular disorder (TMJ, n = 71), tension-type headache (TH, n = 52), migraine (M, n = 68), chronic daily headache (CDH, n = 26), or facial pain disorder as somatoform disorder (FP, n = 26). The presence of 23 symptoms was assessed; the Minnesota Multiphasic Personality Inventory (MMPI) and the Spielberger State and Trait Anxiety Inventory (STAI) were administered and the relative scores were calculated. Four different MMPI clusters (depressive, conversive, emotional, coper) were also considered. Intergroup differences were assessed by Chi-square analysis, 1-way analysis of variance, Bonferroni t test, and a logistic regression model and then standardized for gender and age, taking the tension-type headache group as a common reference group. RESULTS: The TMJ group had: (1) a lower prevalence of almost all symptoms; (2) significantly lower scores of several MMPI and of state anxiety; and (3) odds ratio values < 1 for all symptoms except phobias and for emotional, conversive, and depressive MMPI profiles. The FP and CDH groups had the highest prevalence of the majority of symptoms and higher MMPI and STAI scale elevations. CONCLUSION: It is concluded that some types of headache and facial pain seem to correlate with the presence of a number of accompanying symptoms and with some changes in personality. These changes are particularly relevant in patients with chronic daily headache and facial pain disorder. In contrast, patients with TMJ intracapsular disorders tended to show a low prevalence of accompanying symptoms and a normal personality profile.

Chronic daily headache. A clinical and psychological profile before and after treatment.

To assess the clinical and personality characteristics of patients with chronic daily headache before and after treatment, 20 patients were examined and the Minnesota Multiphasic Personality Inventory (MMPI [Italian 356-item abbreviated version]) and the Strait and Trait Anxiety Index 1,2 (STAI) administered. There were two groups: group 1 (n = 6), with a "conversion V" configuration (with elevation of hypochondria and hysteria scales, the depression scale being somewhat lower); and group 2 (n = 13) with elevation of depression and of other MMPI scales. One patient had no scale elevation. STAI 1,2 scores were high in both groups. Several psychosomatic symptoms and some migraine features were present in almost all patients. Occurrence, severity, and duration of headache were recorded regularly and the MMPI and the STAI administered again after treatment. Improvement of headaches and a decrease of several MMPI and STAI 2 scores were observed. However, 12 of 20 patients showed a conversion V configuration after treatment. It is concluded that chronic daily headache was transformed migraine in most cases and was accompanied by anxiety levels in all patients and hysteric traits in some. With time, these patients may develop a depressive disorder. After treatment, hysterical traits are still present at a lower level in those showing these traits before treatment and may be unmasked in those that had depression.

Long-term results in patients with disk displacement without reduction treated conservatively.

Sixty-eight patients (seven men, 61 women) treated for disk displacement without reduction with extraoral mandibular manipulation followed by splint insertion, physical and drug treatment as needed, were re-examined at the end of treatment and after a subsequent period, ranging from 18 to 147 months. Two parameters were considered: 1. degree of spontaneous mandibular opening; and 2. presence of pain (score 1-4). Mean opening was 28.78 mm before treatment, 42.85 mm after treatment and 43.5 mm at long-term (P < .001 after paired T-test and one-way ANOVA). Mean pain level dropped from 2.91 before treatment to 1.22 after treatment and 1.38 at long-term (P < .001 after Friedman non-parametric test). It was concluded, that in the majority of cases, disk displacement without reduction can successfully be treated by conservative means.

A modified extraoral technique of mandibular manipulation in disk displacement without reduction.

A main reason for failure when manipulating a mandible in disk displacement without reduction is a lack of coordination, because of a sudden resistance on the patient's part when fingers are placed in his mouth. This work describes a new extraoral manipulation technique that avoids this problem. Basically, this technique involves three stages. In stage one, the patient performs rhythmic left and right sideways movements unassisted; in stage two, gentle finger pressure is applied by the clinician on the external aspect of the mandible in the same direction as the patient's movements; and in stage three, the mandible is forcefully pulled towards the non-lesion side in strict concomitance with the mandibular movement of the patient towards the same side (Figure 1). Usually a splint is then placed intra-orally for three-to-five months, and physical therapy and exercises are prescribed as needed. The technique described improves the rate of success in the management of permanently displaced disks, so that indication for surgery may drop to close to zero. The chronicity of the lesion does not seem to be an exclusion criteria, provided the lesion still has the characteristics of a disk displacement with reduction and no pseudodisk or degeneration has arisen. Treatment success is confirmed by the improvement of free mandibular and masticatory movements and by the absence of pain.

Personality characteristics before and after treatment of different head pain syndromes.

In order to examine whether, in patients with different types of headache and craniofacial pain, MMPI and STAI scores are significantly different before and after treatment, 114 patients with tension-type headache (n = 34), atypical facial pain (n = 20), temporomandibular joint dysfunction (n = 36), migraine (n = 16), cluster headache (n = 4), chronic paroxysmal hemicrania (n = 2), trigeminal neuralgia (n = 2) were examined. A pain index was calculated (0-10) which quantified pattern, duration and frequency of pain. The Italian MMPI (356 item abbreviated version) and the STAI tests were administered before and after treatment. A paired t-test was used to assess pre- and post-treatment differences, and multiple regression analysis was employed to examine whether such differences correlated with the improvement in the pain index. In the total group after treatment, there was a significant reduction of certain MMPI scores (Hs, D, Hy, Pa, Pt, Sc, Si) and of STAI 1 and 2 scores. Separate analysis confirmed this among women but not among men. No relation was found between MMPI and STAI changes and the degree of improvement as assessed through the pain index. Clinical improvement leads to normalization of MMPI profiles and STAI scores in women. The psychometric data before treatment were not predictive for treatment outcome.

Improvement of masticatory function after orthodontic treatment. Two case reports.

In patients with temporomandibular joints dysfunction (TMD), the masticatory function is often altered in that: (1) the intercuspal position (ICP) is less frequently achieved; (2) the mean vertical displacement from ICP at the end of opening is above normal; and (3) the isometric muscle contraction pattern during closure tends to be suppressed. We describe two cases of growing patients with severe malocclusion, who showed the same functional alterations as patients with TMJ before treatment, and normalization of the masticatory function after orthodontics.

A system for the study of jaw movements.

This paper describes a system to record incisal and condylar movements. It consists of two Charge Coupled Device (CCD) cameras that detect the position of markers fixed to the face, real-time hardware to recognize the markers and software for three-dimensional reconstruction of condylar and mandibular movements. The subject sat upright in front of the cameras and was asked to perform jaw movements. The position of the markers was recorded and the coordinates were fed into the computer and converted to three-dimensional kinematic data by a mathematical algorithm implemented on an AT IBM personal computer. Dedicated software calculated the head movements and the mandibular movements separately and performed a three-dimensional mathematical reconstruction of the movements of the condylar points and the interincisive point, using the geometrical rules of a rigid body. This pilot study describes the pattern from opening, closing, protrusive, and lateral movements as obtained from healthy subjects with good dentition.

Efficacy of meclofenamate sodium versus placebo in headache and craniofacial pain.

Twenty patients were enrolled in a double-blind, placebo-controlled crossover study of meclofenamate sodium in headache and craniofacial pain. There were four observation periods of 15 days each: Period 1 was a wash-out period. In period 2, subjects were randomly assigned to a 15-day regimen of taking two capsules a day of 100mg meclofenamate sodium (group 1) or placebo (group 2). In period 3, group 1 was switched to placebo and group 2 to meclofenamate sodium for the next 15 days. Lastly, the patients took no medication for a further 15 days (period 4). A thermographic record of the craniofacial and neck areas was taken at the end of periods 1 and 4. A record of the pressure threshold and tissue compliance at different sites of the craniofacial, neck and shoulder areas was taken at the end of each period. During the trial, number and duration of painful events were recorded daily by the patients, and the level of pain evaluated on a visual analog scale. Mean data were analyzed for significant difference by ANOVA and paired t-test. During the meclofenamate sodium period, there was a significant decrease of days with painful events compared to the wash-out period in group 1 and compared to the placebo period in group 2. In the majority of patients, the meclofenamate sodium period scored lowest or second-lowest after the follow-up period in mean pain intensity. Data for pressure threshold, although not significant, were indicative of a possible increase during and after intake of meclofenamate sodium.(ABSTRACT TRUNCATED AT 250 WORDS)

MMPI profiles in patients with headache or craniofacial pain: a comparative study.

Our purpose was to examine the MMPI profiles of 157 patients with chronic headache or facial pain. The following diagnostic groups were considered: tension-type headache (n = 44); migraine + cluster headache + chronic paroxysmal hemicrania (20); trigeminal neuralgia (7); atypical facial pain (AFP) (33); temporomandibular joint dysfunction (TMJ) (53). There were two control groups: C1 of 27 healthy individuals and C2 of 18 patients with chronic pain located elsewhere. A "Pain Index" was calculated (0-10) which quantified pattern, duration and frequency of pain. The Italian MMPI abbreviated version was administered to all subjects. One-way Anova, the Duncan test and correlation analysis were performed. Of the diagnostic groups, AFP scored highest and TMJ lowest in all except three scales. In the AFP group, all neurotic scales scored above 70. The Pain Index correlated with higher scores on most scales. Chronic pain may lead to personality alterations, but some features of craniofacial pain correlate with specific personality disturbances.

A computer-based assessment of structural and displacement asymmetries of the mandible.

The purpose of this article was to assess and quantify the different components that can lead to mandibular asymmetry in a person during or at the end of growth and to investigate the extent to which improvement can be obtained in the different situations. Three boys and 17 girls, 8 to 21 years of age, with facial asymmetry and chin deviation were selected. Posteroanterior cephalometric radiographs were taken in intercuspal position. On each radiograph, three mandibular points (menton, gonion or antegonion, and articular point) were selected to define a mandibular area. A vertical axis of reference was also determined. Computer-aided design was employed to develop two systems (A and B) to assess a symmetry degree of the mandible. With system A, the left mandibular area was rotated around the vertical axis of reference, and the degree of the superimposition between the left and right areas was plotted. With system B, the left area was rotated around an axis that ran through menton and was perpendicular to a line connecting the two articular points of the mandible. Also, in this case, the degree of superimposition between the two areas was plotted. With system A, the degree of superimposition was a function of mandibular position and mandibular symmetry. With system B, it was a function of mandibular symmetry only. Thus through comparative examination of the data, assessment of displacement asymmetry and structural asymmetry was possible. In two patients, only displacement asymmetry was present, whereas 14 patients showed various features of structural asymmetry. The patients were treated with orthopedic splints to keep the mandible in a position of symmetry. Orthodontic treatment followed so that the intercuspal position would finally coincide with the position of symmetry. Computer-aided design analysis was performed again after a mean observation period of 41.1 months. In 11 patients an improvement in symmetry was observed with both systems. The patients in whom no improvement of structural asymmetry was observed showed a relatively high degree of symmetry at the beginning or had a considerably higher age than the mean age of the whole group. The clinical implications of the data are discussed.

Thermographic findings in cranio-facial pain.

This work assesses the differences in the thermographic findings in the craniofacial and neck areas between normal individuals and patients with craniofacial pain or headache, and investigates the influence of muscle contraction on such findings. Thermographic records were taken in 10 healthy subjects and 47 patients suffering from craniofacial pain or headache of different kinds. In the patients with painful episodes the record was taken between attacks. In all the normal subjects and in 19 patients lateral thermograms were also taken during and after maximal tooth clenching for three minutes. The majority of the patients, as compared to the normal group, showed some thermal alterations and asymmetry. Such alterations seem to be due both to vascular instability and muscle contraction: these two factors may be variably superimposed in the different conditions. In patients with cluster headache or chronic paroxysmal hemicrania the presence on the symptomatic side of a cold spot along the supraorbital area and/or the inner orbital canthus, was a constant finding. We conclude that thermography is useful as an additional diagnostic means in patients with head and face pain, and that the clenching test may increase the amount of information provided.