Association of mental health symptoms with the migraine-tension-type headache spectrum in the Brazilian longitudinal study of adult health.

OBJECTIVE: To investigate the relationship between mental health symptoms and the migraine-tension-type headache (TTH) spectrum in middle-aged adults from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil study). METHODS: In this cross-sectional analysis (baseline data: 2008-2010), it was evaluated the relationship between each mental health symptom assessed by the Clinical Interview Schedule-Revised (CIS-R) questionnaire and headache subtypes (migraine and TTH) according to international criteria. It was performed binary logistic regression models, with estimated odds ratios (OR) with their respective 95% confidence intervals (CI) adjusted for confounders including migraine attack frequency. RESULTS: Among 13,916 participants, 70.1% reported any major primary headache subtype within the last year. The most common subtype was definite TTH (33.4%), followed by probable migraine (21.0%), definite migraine (8.5%), and probable TTH (7.2%). Our main findings indicated positive associations between anxiety-related symptoms and the migraine-tension type headache (TTH) spectrum with a clear trend toward definite migraine more than tension-type headache. The presence of somatic symptoms presented a high likelihood for the associations with headaches, mainly definite migraine (OR: 7.9, 95% CI: 6.4-9.8), probable migraine (OR: 4.5, 95% CI 3.7-5.4) and probable TTH (OR: 3.0, 95% CI: 2.3-3.8). Other symptoms associated with headache disorders included fatigue, panic, irritability, anxiety symptoms, concentration problems, forgetfulness, depressive symptoms, and worry. The effect of associations remained significant after controlling for headache attack frequency. CONCLUSION: This study provides evidence of consistent associations between mental health symptoms and primary headache disorders, with a higher burden of anxiety-based symptoms observed in people with migraine than those with TTH.

Effects on temporomandibular disorder in the treatment of tension-type headache with acupuncture and therapeutic exercises. A secondary analysis from a randomized controlled trial.

OBJECTIVES: To examine the effects of acupuncture and therapeutic exercise alone and in combination on temporomandibular joint symptoms in tension-type headache and to evaluate the potential interaction of existing temporomandibular dysfunction on the success of headache treatment. DESIGN: Pre-planned secondary analysis of a randomized controlled, non-blinded trial. SETTING: Outpatient clinic of a German university hospital. SUBJECTS: Ninety-six Participants with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups. INTERVENTIONS: Six weeks of acupuncture or therapeutic exercise either as monotherapies or in combination, or usual care. Follow-up at 3 and 6 months. MAIN MEASURES: Subjective temporomandibular dysfunction symptoms were measured using the Functional Questionnaire Masticatory Organ, and the influence of this sum score and objective initial dental examination on the efficacy of headache treatment interventions was analyzed. RESULTS: Temporomandibular dysfunction score improved in all intervention groups at 3-month follow-up (usual care: 0.05 [SD 1.435]; acupuncture: -5 [SD 1.436]; therapeutic exercise: -4 [SD 1.798]; combination: -3 [SD 1.504]; P = 0.03). After 6 months, only acupuncture (-6 [SD 1.736]) showed a significant improvement compared to the usual care group (P < 0.01). Subjective temporomandibular dysfunction symptoms had no overall influence on headache treatment. CONCLUSIONS: Only acupuncture had long-lasting positive effects on the symptoms of temporomandibular dysfunction. Significant dental findings seem to inhibit the efficacy of acupuncture for tension-type headache.

Pure menstrual tension-type headache: demonstration of its existence.

INTRODUCTION AND OBJECTIVE: Menstrual migraine (MM) is widely recognized among the scientific community, with diagnostic criteria included in the appendix of the third edition of the International Headache Classification. However, this classification does not include other primary headaches that may occur during menstruation. Previous retrospective studies suggest the existence of menstrual tension-type headache. Our objective is to prospectively determine the existence of this type of headache and to determine its frequency relative to that of MM. METHODS: This is a descriptive, cross-sectional (case series), prospective, observational study, conducted in a hospital neurology department, using a previously validated ad hoc questionnaire. Participants were recruited by consecutive sampling, applying inclusion and exclusion criteria among women accompanying neurology outpatients, and classified into five groups: pure menstrual tension-type headache, menstrual-related tension-type headache, pure menstrual migraine, menstrual-related migraine and unclassifiable. RESULTS: Ninety-five women (median age of 38.50 years, IQR: 13) were included, with the following group distribution: 13 (13.6%) pure menstrual tension-type headache, 14 (14.7%) menstruation-related tension-type headache, 23 (24.2%) pure menstrual migraine, 44 (46.3%) menstrual-related migraine and 1 unclassifiable. Of these patients, 23% did not treat menstrual headache, but this figure rose to 30.8% in the case of pure menstrual tension-type headache. CONCLUSION: The results confirm the existence of pure menstrual tension-type headache among women who do not seek medical care for this condition. The frequency of this headache is lower than that of MM. This reduced incidence, together with its generally mild nature, may explain the lack of prior recognition.

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.

InfluenCEF study: Clinical phenotype and duration of headache attributed to influenza infection.

INTRODUCTION: Headache is a frequent symptom of infections. We aimed to characterize the clinical phenotype and duration of headache attributed to influenza infection. METHODS: Prospective cohort study done in 53 primary care centers between January and April 2023. Patients were included if they had a confirmed influenza diagnosis, were older than 15 years and had a new-onset headache. Patients' demographics, prior medical history, headache phenotype and duration, associated symptoms and patients' outcomes were assessed. The International Classification of Headache Disorders criteria for headache attributed to a systemic viral infection, migraine and tension-type headache were assessed. RESULTS: Of the 478 patients 75 fulfilled eligibility criteria. The mean age was 43, 56% were men, and 27% had a prior headache history. The headache phenotype was a bilateral headache (52%), with frontal topography (48%), pressing quality (61%), moderate intensity, rhinorrhea (79%), nasal congestion (76%), and photophobia (59%). All patients fulfilled headache attributed to acute systemic viral infection criteria, 43% fulfilled migraine criteria and 31% tension-type headache criteria. The median duration of the headache was four (Inter-quartile range: two-six) days. CONCLUSION: The clinical phenotype of headache attributed to influenza infection was similar to other infections, with more pronounced cranial autonomic symptoms. The headache was an early symptom and was self-limited within a few days.Trial Registration: The study protocol is registered in ClinicalTrial.gov (NCT05704335).

Does Tension Headache Have a Central or Peripheral Origin? Current State of Affairs.

PURPOSE OF REVIEW: The aim of this narrative review is to analyze the evidence about a peripheral or central origin of a tension headache attack in order to provide a further clarification for an appropriate approach. RECENT FINDINGS: Tension headache is a complex and multifactorial pathology, in which both peripheral and central factors could play an important role in the initiation of an attack. Although the exact origin of a tension headache attack has not been conclusively established, correlations have been identified between certain structural parameters of the craniomandibular region and craniocervical muscle activity. Future research should focus on improving our understanding of the pathology with the ultimate goal of improving diagnosis. The pathogenesis of tension-type headache involves both central and peripheral mechanisms, being the perpetuation over time of the headache attacks what would favor the evolution of an episodic tension-type headache to a chronic tension-type headache. The unresolved question is what factors would be involved in the initial activation in a tension headache attack. The evidence that favors a peripheral origin of the tension headache attacks, that is, the initial events occur outside the brain barrier, which suggests the action of vascular and musculoskeletal factors at the beginning of a tension headache attack, factors that would favor the sensitization of the peripheral nervous system as a result of sustained sensory input.

Associations Between Headache (Migraine and Tension-Type Headache) and Psychological Symptoms (Depression and Anxiety) in Pediatrics: A Systematic Review and Meta-analysis.

BACKGROUND: There have been no recent meta-analysis studies on specific psychological symptoms (depression and anxiety) according to the type of primary headache disorder in children and adolescents. OBJECTIVES: We performed a meta-analysis of various psychodiagnostic scales. Psychological symptoms of primary headache disorders have been reported in previous studies. STUDY DESIGN: A systematic review and meta-analysis. METHODS: We conducted systematic reviews using the PubMed, Embase, Cochrane Library, and Scopus databases up to October 19, 2022. Ten studies were selected by applying the inclusion criteria. The psychological symptoms (depression and anxiety) of children and adolescents with migraine and tension-type headache (TTH) were compared with those of healthy controls using scale scores. All statistical analyses of the pooled data were performed using RevMan 5.3 software. RESULTS: Psychodiagnostic tools to assess depression scored higher in patients with migraine than in healthy controls; however, most anxiety-related scores were not significantly different between the migraine and control groups. In contrast, anxiety-related scores were higher in patients with TTH than in healthy controls, but the score to measure the degree of depressive symptoms was not significantly different from the control group in patients with TTH. LIMITATIONS: A limited number of studies for each scale were included. In addition, each scale has different sensitivities and specificities, which may have affected the results. In addition, we did not evaluate the differences in psychological symptoms according to the frequency and severity of headaches. CONCLUSIONS: Depression is more associated with migraine; whereas, anxiety is more associated with TTH than healthy controls. Therefore, the screening and assessment of psychological symptoms should be performed in children and adolescents with primary headache disorders.

Headache and psychological variables as predictors of disability in individuals with primary headache disorders.

OBJECTIVE: To examine the relative contribution of headache symptoms and psychological factors to headache-related disability. BACKGROUND: Both headache symptoms and comorbid psychological factors (psychiatric symptoms and transdiagnostic constructs) negatively impact functioning among individuals with migraine and tension-type headache, but few studies have explored their relative contribution to headache-related disability. We hypothesized that psychiatric symptoms and transdiagnostic variables would afford incremental contribution to disability beyond headache symptoms, and we investigated the moderating role of headache diagnosis on these relationships. METHODS: This cross-sectional study examined data from a southern U.S. university online sample of 1818 young adults (mean [SD] age 19.0 [5.1] years; 74.6% female) who met the International Classification of Headache Disorders, third edition criteria for primary headache disorders (46.6% episodic migraine, 11.6% chronic migraine, 38.3% episodic tension-type headache, 3.5% chronic tension-type headache) and completed measures assessing psychological factors and headache-related disability. Headache, psychiatric symptoms, and transdiagnostic factors were examined in relation to headache-related disability, after controlling for sex. Moderation analyses examined the conditional effect of diagnosis on disability. RESULTS: As predicted, both psychiatric and transdiagnostic symptoms accounted for unique variance in headache-related disability beyond headache symptoms (R2 changes of 2.7% and 2.3%, respectively). Significant three-way interactions revealed the relationship between psychiatric symptoms and disability (b = -3.16, p = 0.002), and between transdiagnostic variables and disability (b = -2.37, p = 0.034). Tests of simple slopes showed greater psychiatric symptoms and transdiagnostic variables were associated with higher levels of disability. However, the associations of these variables with disability were strongest among individuals with chronic tension-type headache (B = 3.93 for psychiatric symptoms and B = 4.62 for transdiagnostic symptoms, both p < 0.001). CONCLUSION: Psychiatric and transdiagnostic factors contribute uniquely to headache-related functional impairment, which may be important for expanding targeted assessment and behavioral interventions.

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.

Neck pain and headache: Pathophysiology, treatments and future directions.

INTRODUCTION: Neck pain is a prevalent neurologic and musculoskeletal complaint in the general population and is often associated with primary headache disorders such as migraine and tension-type headache (TTH). A considerable proportion, ranging from 73% to 90%, of people with migraine or TTH also experience neck pain, and there is a positive correlation between headache frequency and neck pain. Furthermore, neck pain has been identified as a risk factor for migraine and TTH. Although the exact underlying mechanisms linking neck pain to migraine and TTH remain uncertain, pain sensitivity appears to play an important role. People with migraine or TTH exhibit lower pressure pain thresholds and higher total tenderness scores compared with healthy controls. PURPOSE: This position paper aims to provide an overview of the current evidence on the relationship between neck pain and comorbid migraine or TTH. It will encompass the clinical presentation, epidemiology, pathophysiology, and management of neck pain in the context of migraine and TTH. IMPLICATIONS: The relationship between neck pain and comorbid migraine or TTH is incompletely understood. In the absence of robust evidence, the management of neck pain in people with migraine or TTH relies mostly on expert opinion. A multidisciplinary approach is usually preferred, involving pharmacologic and non-pharmacologic strategies. Further research is necessary to fully dissect the linkage between neck pain and comorbid migraine or TTH. This includes the development of validated assessment tools, evaluation of treatment effectiveness, and exploration of genetic, imaging, and biochemical markers that might aid in diagnosis and treatment.

Debate: differences and similarities between tension-type headache and migraine.

Tension-type headache (TTH) and migraine are two common primary headaches distinguished by clinical characteristics according to the 3rd edition of the International Classification of Headache Disorders. Migraine is identified by specific features such as being more prevalent in females, being aggravated by physical activity, certain genetic factors, having photophobia, phonophobia, nausea, vomiting, or aura, and responding to specific drugs. Nonetheless, TTH and migraine share some common characteristics, such as onset occurring in the 20 s, and being triggered by psychological factors like stress, moderate pain severity, and mild nausea in chronic TTH. Both conditions involve the trigeminovascular system in their pathophysiology. However, distinguishing between TTH and migraine in clinical practice, research, and epidemiological studies can be challenging, as there is a lack of specific diagnostic tests and biomarkers. Moreover, both conditions may coexist, further complicating the diagnostic process. This review aims to explore the similarities and differences in the pathophysiology, epidemiology, burden and disability, comorbidities, and responses to pharmacological and non-pharmacological treatments of TTH and migraine. The review also discusses future research directions to address the diagnostic challenges and improve the understanding and management of these conditions.

[Headache in the general practice]. / Kopfschmerzen in der Hausarztpraxis.

Headaches are one of the most frequent causes of consultations in general practice. Of more than 350 known headache tendencies, tension-type headache and migraine are particularly common in general practice. Medication overuse headache (MOH) is also common but rarely diagnosed. The medical consultation with a targeted anamnesis is the cornerstone of the diagnosis and correct classification. A detailed neurological examination completes the basic diagnosis. Additional laboratory and instrumental diagnostics follow in cases of atypical headache or clinical suspicion of secondary headache. This article focuses on the diagnosis and treatment of Tension-type Headache, migraine and Medication Overuse Headache.

Verification of a clinical decision support system for the diagnosis of headache disorders based on patient-computer interactions: a multi-center study.

BACKGROUND: Although headache disorders are common, the current diagnostic approach is unsatisfactory. Previously, we designed a guideline-based clinical decision support system (CDSS 1.0) for diagnosing headache disorders. However, the system requires doctors to enter electronic information, which may limit widespread use. METHODS: In this study, we developed the updated CDSS 2.0, which handles clinical information acquisition via human-computer conversations conducted on personal mobile devices in an outpatient setting. We tested CDSS 2.0 at headache clinics in 16 hospitals in 14 provinces of China. RESULTS: Of the 653 patients recruited, 18.68% (122/652) were suspected by specialists to have secondary headaches. According to "red-flag" responses, all these participants were warned of potential secondary risks by CDSS 2.0. For the remaining 531 patients, we compared the diagnostic accuracy of assessments made using only electronic data firstly. In Comparison A, the system correctly recognized 115/129 (89.15%) cases of migraine without aura (MO), 32/32 (100%) cases of migraine with aura (MA), 10/10 (100%) cases of chronic migraine (CM), 77/95 (81.05%) cases of probable migraine (PM), 11/11 (100%) cases of infrequent episodic tension-type headache (iETTH), 36/45 (80.00%) cases of frequent episodic tension-type headache (fETTH), 23/25 (92.00%) cases of chronic tension-type headache (CTTH), 53/60 (88.33%) cases of probable tension-type headache (PTTH), 8/9 (88.89%) cases of cluster headache (CH), 5/5 (100%) cases of new daily persistent headache (NDPH), and 28/29 (96.55%) cases of medication overuse headache (MOH). In Comparison B, after combining outpatient medical records, the correct recognition rates of MO (76.03%), MA (96.15%), CM (90%), PM (75.29%), iETTH (88.89%), fETTH (72.73%), CTTH (95.65%), PTTH (79.66%), CH (77.78%), NDPH (80%), and MOH (84.85%) were still satisfactory. A patient satisfaction survey indicated that the conversational questionnaire was very well accepted, with high levels of satisfaction reported by 852 patients. CONCLUSIONS: The CDSS 2.0 achieved high diagnostic accuracy for most primary and some secondary headaches. Human-computer conversation data were well integrated into the diagnostic process, and the system was well accepted by patients. The follow-up process and doctor-client interactions will be future areas of research for the development of CDSS for headaches.

Effects of acupuncture and medical training therapy on depression, anxiety, and quality of life in patients with frequent tension-type headache: A randomized controlled study.

OBJECTIVES: To compare the effects of acupuncture and medical training therapy in combination or individually with usual care on quality of life, depression, and anxiety in patients with tension-type headache. METHODS: In this single-center, prospective, randomized, controlled, unblinded trial, 96 adults (38.7(+/-13.3) years of age; 75 females/20 males/one dropout) with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups (n = 24). The treatment groups received six weeks of either acupuncture or medical training therapy as monotherapies or in combination (12 interventions each), or usual care. We assessed depressiveness (PHQ-9), anxiety (GAD-7), and health-related quality of life (SF-12) as secondary outcome parameters at baseline, six weeks, three months, and six months after initiation of treatment. Linear mixed models were calculated. RESULTS: Both, acupuncture (baseline to six-weeks change scores: mean: -2(standard deviation: 2.5 points), three months: -2.4(2.4), six-months -2.7(3.6)) and the combination of acupuncture and medical training therapy (-2.7(4.9), -2.2(4.0), -2.2(4.2)) (each within-group p < .05) significantly reduced depressiveness-scores (PHQ-9) to a greater extent than medical training therapy (-0.3(2.0), -0.5(1.6), -0.9(2.6)) or usual care alone (-0.8(2.9), 0.1(2.8), 0.2(3.6)). We found similar results with anxiety scores and the physical sum scores of the SF-12. No severe adverse events occurred. CONCLUSIONS: Acupuncture and the combination of acupuncture and medical training therapy elicit positive effects on depression, anxiety, quality of life, and symptom intensity in patients with episodic and chronic tension-type headache. Acupuncture appears to play a central role in mediating the therapeutic effects, underscoring the clinical relevance of this treatment. An additive benefit of the combination of both therapies does not appear to be relevant.Trial registration: Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.

Prevalence and self-management of migraine among neurologists and neurology residents in Turkey: do neurologists apply effective rational prophylaxis to their migraines?

AIM: The aim of the study to determine the migraine prevalence and self-management of migraine among the neurologists and neurology residents registered to the Turkish Neurological Society. METHODS: This cross-sectional study includes 851 participants. Based on the "The International Classification of Headache Disorders, 3rd edition" and previous literature, an anonymous questionnaire was prepared and used to collect data online via Google Forms. The link to the study was posted on the website of the Turkish Neurological Society. RESULTS: Women (73.2%) and neurologists (77.4%) made up the majority of the participants. Of the participants, 37.9% met the diagnosis criteria for migraine. Being women and positive family history were associated with migraine compared to the tension-type headache (TTH) (both p values < 0.001). Comparing with the TTH sufferers, migraine significantly hindered work, social, and family life (all p values < 0.001). Participants with migraine had more magnetic resonance imaging (MRI) (47.4%) and electroencephalography (EEG) (4.3%) than those with TTH (both p values < 0.05). Participants with migraine received drug prophylaxis more frequently (20.1%) than those with TTH (2.3%) (p < 0.001), and these drugs were selective serotonin reuptake inhibitors (SSRIs) (7.1%), beta-blockers (5.9%), and serotonin-norepinephrine reuptake inhibitors (SNRIs) (5.3%) (all p values < 0.05). Participants with migraine received non-pharmacological prophylaxis for headache more frequently (25.7%) compared to those with TTH (p < 0.001). CONCLUSIONS: Migraine is common among neurologists and neurology residents. Identifying migraine self-management is important for preventing the loss of work and negative economic and social consequences that migraine may cause in these groups of physicians.

Short-term effects of instrument-assisted soft tissue mobilization compared to algometry pressure release in tension-type headache: a randomized placebo-controlled trial.

PURPOSES: To compare the effectiveness of instrument-assisted soft tissue mobilization (IASTM) and pressure algometry with sham ultrasound (control group) on the clinical measures of headache, pressure pain threshold (PPT) of upper trapezius and suboccipital muscles and cervical alignment in patients with tension type headache (TTH). METHODS: Seventy-two patients with TTH of both genders were randomly allocated to 3 experimental groups: a) the IASTM group (n=24), b) pressure algometry group (n=24), and c) sham ultrasound control group (n=24). Headache frequency and disability, pressure pain threshold of upper trapezius and suboccipital muscles, cervical lordosis angle (CA) and anterior head translation (AHT) were measured four weeks before and after intervention. Moreover, headache frequency was followed up for two more weeks after intervention. RESULTS: Statistically significant improvements (P <0.05; effect size ranges 1.1-1.9) were observed in all outcome measures following IASTM compared to the other two intervention methods. In the IASTM group, the headache frequency decreased from 15 to 2 days/month. Also, headache disability decreased from 19 to 10. Further, CA increased from 17.5° to 31.4° and AHT decreased from 24.1 to 15.5 mm. The pressure algometry group showed significantly lower headache frequency at the follow-up (P < 0.01) than the sham ultrasound control group. However, Similar findings in the other evaluated outcomes were found between the pressure algometry and sham ultrasound control groups (P ˃ 0.05). CONCLUSION: The results of the present study indicate the effectiveness of IASTM in improving headache symptoms and cervical alignment in patients with TTH.

Triggers and clinical changes of childhood primary headache characteristics during COVID-19 pandemic lockdown.

OBJECTIVE: Children with primary headache are particularly vulnerable to the negative impacts of the pandemic due to factors like increased social isolation, disruption of sleep and impairment of healthy diet. We aimed to investigate the clinical changes and triggering factors for childhood primary headaches to demonstrate the impact of the pandemic lockdown. METHOD: Children aged between 60 months and 18 years with headache complaint attending the general outpatient clinic between December 2019 and December 2020 were included in the study. Patients were classified according to ICHD-3 regarding clinical and laboratory data. Primary headaches diagnosed before (December 2019-March 2020) and during the pandemic lockdown (April 2020-December 2020) were divided into two groups as migraine and tension-type headache (TTH). Clinical picture and triggering factors were compared between groups to illustrate the effect of the lockdown. RESULTS: The study included 612 subjects, with 463 patients (76%) classified in the primary headache group and 149 (24%) in the secondary headache group. Among the first group, 267 patients (58%) had migraine and 196 patients (42%) had TTH. Comparisons between before and during the pandemic lockdown showed significant increased frequency of TTH, but no difference in the frequency and duration of migraine. Both screen exposure and sleep pattern changes were found to be significantly increased in the TTH group during the pandemic lockdown. DISCUSSION: We found a significant increase in the attack frequency for TTH patients during the pandemic lockdown. Reduction in screen time is an important strategy in preventing primary headache attacks in children.