Widespread Proprioceptive Acuity Impairment in Chronic Back Pain: A Cross-sectional Study.

OBJECTIVE: To investigate whether proprioceptive accuracy measured with the Joint Position Sense (JPS) in patients with chronic neck and low back pain is impaired exclusively in affected areas or also in distant areas, not affected by pain. DESIGN: Cross-sectional study. SETTING: Interdisciplinary outpatient rehabilitation clinic for back and neck pain. PARTICIPANTS: Patients with chronic neck pain (n=30), patients with chronic low back pain (n=30), and age- and sex-matched asymptomatic control subjects (n=30; N=90). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patients and asymptomatic control subjects completed a test procedure for the JPS of the cervical spine, lumbar spine, and ankle in a randomized order. Between group differences were analyzed with the univariate analysis of variance and associations of the JPS with clinical features using the Pearson's correlation coefficient. RESULTS: Both patients with chronic neck pain (P<.001) and patients with chronic low back pain (P<.01) differed significantly from asymptomatic controls in the JPS of the cervical spine, lumbar spine and ankle joint, regardless of the painful area. No difference was shown between patient groups (P>.05). An association of the JPS with clinical characteristics, however, could not be shown. CONCLUSION: These results suggest widespread impairment of proprioceptive accuracy in patients with chronic and low back pain and a role for central sensorimotor processes in musculoskeletal pain conditions.

Translation, cross-cultural adaptation and measurement proprieties of the German version of the Allodynia Symptom Checklist (ASC-12).

BACKGROUND: Cutaneous allodynia is highly prevalent among migraineurs and is associated with a poor prognosis. The Allodynia Symptom Checklist (ASC-12) is a comprehensive questionnaire to identify the presence and severity of allodynia. Our aim was to translate and adapt the ASC-12 to German and evaluate its measurement properties. METHODS: Following the COSMIN guidelines, 80 migraine patients were enrolled in the study to evaluate the stages of translation (n=30) and measurement propriety assessment (n=50), respectively. After reaching a final version, the German ASC-12 was assessed for structural validity, internal consistency, test-retest reliability, construct validity and absolute agreement, using mechanical and thermal pain thresholds as reference method. RESULTS: The German version of the ASC-12 presented an adequate structural validity compatible with the original version of the questionnaire. Its internal consistency ranged from 0.70 to 0.80 considering the total score and the thermic, static and dynamic mechanic subdomains. The total score presented excellent reliability (ICC: 0.85) with a standard error of measurement of 1.15 points and smallest detectable change of 3.40 points. ASC-12 total scores were correlated with headache intensity (r=0.38, p=0.004), headache disability (r=0.37, p=0.004) and cold pain thresholds (r=0.28, p=0.025). The thermic allodynia ASC-12 scores were correlated with cold (r=0.36, p=0.005) and heat (r=-0.30, p=0.010) pain thresholds, while the static mechanical allodynia ASC-12 scores correlated with mechanical pain threshold (r=0.29, p=0.019) and with mechanical pain sensitivity (r=0.24 to 0.28, p< 0.045). Despite no significant bias between methods, quantitative sensory testing (QST) results and ASC-12 scores tend to disagree. CONCLUSION: The German version of the ASC-12 is available for research and clinical settings and presented adequate measurement proprieties, as the original version. Despite the correlation between the ASC-12 and QST, one method cannot be replaced by the other.

Psychophysical testing in chronic migraine and chronic tension type headache: An observational study.

BACKGROUND: Clinical presentation is the key to the diagnosis of patients with migraine and tension-type headache, but features may overlap when both become chronic. Psychophysical parameters may distinguish both conditions. We aimed to compare psychophysical aspects of patients with chronic migraine, chronic tension-type headache and headache-free controls, and to determine whether these can predict headache frequency. METHODS: An examiner blinded to the diagnosis assessed 100 participants (chronic migraine (n = 38), chronic tension-type headache (n = 31) and controls (n = 31)). Assessed variables included painful area, pressure pain thresholds, temporal summation, cervical range of motion, neck posture, headache and neck impact, quality of life, and kinesiophobia. Comparison between groups was performed with one-way ANOVA and multiple linear regression was used to assess the headache frequency predictors. RESULTS: We found differences of both headache groups compared to controls (p < 0.01), but not between headache groups. Neck disability was a significant predictor of headache frequency for chronic tension-type headache (adjusted R2 = 0.14; ß = 0.43; p = 0.03) and chronic migraine (adjusted R2 = 0.18; ß = 0.51; p < 0.01). CONCLUSIONS: Chronic tension-type headache and chronic migraine showed similar psychophysical results, but were significantly worse when compared to controls. The psychophysical examination did not discriminate between headache types. The variable best explaining headache frequency for both headache types was neck disability.

Postural control impairment in patients with headaches-A systematic review and meta-analysis.

OBJECTIVE: To summarize the evidence regarding static and dynamic balance alterations among patients with headache. METHODS: Electronic databases (PubMed, CINAHL, and Web of Science) were searched by two researchers independently up to September 2021. Two reviewers selected eligible studies, extracted the data, and assessed the quality of evidence using the Downs and Black checklist. Case-control studies were included if they involved balance assessment of any kind of headache, including objective outcome measures of dynamic and static tests such as body sway displacement, limits of stability (LOS), gait, and tandem walk tests. A meta-analysis and post hoc sensitivity analyses were performed when possible. RESULTS: Twenty-two studies (1202 patients with headache and 597 controls) were included in this review and 16 of them in the meta-analysis. Risk of bias ranged from low to moderate among all studies. Greater sway area in static posturography was shown by patients with migraine in comparison to controls, with more consistent differences in more challenging test conditions, such as over a foam surface with eyes closed (difference of 4.8 cm2 , 95% CI: 3.8-5.9). Lower performance of patients with migraine during the tandem walk test (difference of -7.8 cm/s, 95% CI: -9.0 to -6.5) and slower reaction time in the LOS test (difference of 0.3 s, 95% CI: 0.2-0.4) were also verified. There is no evidence of altered sway velocity and length in static posturography among patients with migraine (p > 0.05). The level of evidence is very low for balance alteration of any kind among patients with tension-type and cervicogenic headache owing to the limited number of studies and high heterogeneity. CONCLUSION: This review confirmed the presence of static and dynamic balance alterations among patients with migraine. Future studies with low risk of bias are needed to decrease heterogeneity in methodology and explore the role of subdiagnosis on the balance of patients with headache.

Migraine and balance impairment: Influence of subdiagnosis, otoneurological function, falls, and psychosocial factors.

OBJECTIVE: To assess the balance sensory organization among patients with migraine, considering the influence of migraine subdiagnosis, otoneurological function, falls, and psychosocial factors. BACKGROUND: Migraine has been associated with vestibular symptoms and balance dysfunction; however, neither comprehensive balance assessment nor associated factors for greater impairment have been addressed thus far. METHODS: Patients from a tertiary headache clinic with a diagnosis of episodic migraine with aura (MWA), without aura (MWoA), and chronic migraine (CM) were included for this cross-sectional study (30 patients per group). Thirty headache-free controls (CG) were recruited. Participants underwent a comprehensive evaluation protocol, including the Sensory Organization Test (SOT) and otoneurological examination. Questionnaires about fear of falls, dizziness disability, and kinesiophobia were administered. RESULTS: All migraine groups presented lower composite SOT scores than controls (CG: 82.4 [95% confidence interval (CI): 79.5-85.3], MWoA: 76.5 [95% CI: 73.6-79.3], MWA: 66.5 [95% CI: 63.6-69.3], CM: 69.1 [95% CI: 66.3-72.0]; p < 0.0001). Compared to controls and to MWoA, MWA and CM groups exhibited greater vestibular (CG: 75.9 [95% CI: 71.3-80.4], MWoA: 67.3 [95% CI: 62.7-71.8], MWA: 55.7 [95% CI: 51.2-60.3], CM: 58.4 [95% CI: 53.8-63.0]; p < 0.0001) and visual functional impairment (CG: 89.6 [95% CI: 84.2-94.9], MWoA: 83.2 [95% CI: 77.9-88.6], MWA: 68.6 [95% CI: 63.3-74.0], CM: 71.9 [95% CI: 66.5-77.2], p < 0.0001). Fall events during the assessment were documented more often among patients with migraine (CG: 0.0, interquartile range [IQR], 0.0, 0.0); MWoA: 1.0 [IQR: 1.0, 1.0], MWA: 2.0 [IQR: 1.8, 4.3], CM: 1.0 [IQR: 1.0, 2.0]; p = 0.001). The SOT scores correlated with fear of falls (r = -0.44), dizziness disability (r = -0.37), kinesiophobia (r = -0.38), and migraine frequency (r = -0.38). There was no significant influence of the vestibular migraine diagnosis in the study outcomes when used as a covariate in the analysis (composite score [F = 3.33, p = 0.070], visual score [F = 2.11, p = 0.149], vestibular score [F = 1.88, p = 0.172], somatosensory score [F = 0.00, p = 0.993]). CONCLUSIONS: Aura and greater migraine frequency were related to falls and balance impairment with sensory input manipulation, although no otoneurological alterations were detected. The diagnosis of vestibular migraine does not influence the balance performance. The vestibular/visual systems should be considered in the clinical examination and treatment of patients with migraine.

Offset analgesia is increased intra-orally.

BACKGROUND: Offset analgesia (OA) is commonly used to quantify endogenous pain inhibition. However, the potential role of afferent inputs and the subsequent peripheral factors from different body areas on the underlying mechanisms are still unclear. OBJECTIVES: The aim of this cross-sectional study was to compare the magnitude of OA in four different body areas representing (a) glabrous and non-glabrous skin, (b) trigeminal and extra-trigeminal areas, and (c) intra- and extra-oral tissue. METHODS: OA was assessed at the oral mucosa of the lower lip, the skin of the cheek, the forearm and the palm of the hand in 32 healthy and pain-free participants. OA testing included two trials: (1) a constant trial (30 s of constant heat stimulation at an individualised temperature of Pain50 [pain intensity of 50 out of 100]) and (2) an offset trial (10 s of individualised Pain50 , followed by 5 s at Pain50 + 1°C and 15 s at Pain50 ). Participants continuously rated their pain during each trial with a computerised visual analogue scale. RESULTS: A significant OA response was recorded at the oral mucosa (p < .001, d = 1.24), the cheek (p < .001, d = 0.84) and the forearm (p < .001, d = 1.04), but not at the palm (p = .19, d = 0.24). Significant differences were shown for OA recorded at the cheek versus the mucosa (p = .02), and between palm and mucosa (p = .007), but not between the remaining areas (p > .05). CONCLUSION: This study suggests that intra-oral endogenous pain inhibition assessed with OA is enhanced and supports the role of peripheral mechanisms contributing to the OA response.

Muscle endurance training of the neck triggers migraine attacks.

BACKGROUND: Most migraine patients report neck pain as part of their migraine symptomatology, but it is unknown whether triggering neck pain would induce migraine attacks. Our aim was to assess the occurrence of headache and/or neck pain after an endurance test of the neck muscles among migraineurs and controls. METHODS: Sixty-five patients with migraine and 32 headache-free participants underwent a manual examination of the cervical spine by an assessor blinded towards the diagnosis and were sub-classified according to the appearance or absence of neck pain. Subsequently, the endurance of the neck flexors and extensors was tested three times, in a random order. The maximum sustained duration was recorded and the test was terminated when the subject was unable to maintain the position or reported pain. On the day after the assessment, participants were asked to report the potential occurrence of headache or neck symptoms. RESULTS: None of the controls reported headache after assessment, while migraine-like headache was reported by 42% of the patients with migraine (p < 0.001) after 15.8 h (SD: 10.0). Neck pain was more prevalent in migraineurs compared to controls (45% vs. 16%, p = 0.006). When considering the neck pain subtype, there were no differences among the three profiles regarding neck pain but participants with referred pain to the head reported a migraine attack more often (45%, p = 0.03). CONCLUSION: Patients with migraine are more likely to report neck pain and migraine attacks following a neck muscle endurance test. Participants with neck pain referred to the head during manual examination had a greater prevalence of migraine attacks than those without or with only local pain.

Measurement properties of the Headache Impact Test (HIT-6™ Brazil) in primary and secondary headaches.

BACKGROUND: The Headache Impact Test-6™ is a widely recommended questionnaire to evaluate the impact of headaches. However, its measurement properties were never evaluated in both primary and secondary headaches, and the Brazilian Portuguese version of the questionnaire was never assessed at all. OBJECTIVE: To assess the reliability, and structural and construct validity of the Headache Impact Test-Brazil™ in patients with primary and secondary headaches. METHODS: In total, 132 patients with primary and secondary headaches were included, screened from a headache tertiary clinic. They completed the Headache Impact Test-Brazil™ questionnaire, the 12-Item Short-Form Survey (SF-12), and the Headache Disability Inventory-Brazil. Pearson's correlation analysis was performed among the three questionnaires for validity assessment. One to three weeks after the first application, the Headache Impact Test-Brazil™ was answered again by 67 patients for reliability assessment. RESULTS: The validity sample consisted of 86/132 (65.1%) patients with primary and 46/132 (34.9%) secondary headaches, with mean age of 39.6 (SD: 12.7) years. The reliability sample consisted of 39/67 (58.2%) patients with primary and 28/67 (41.8%) secondary headaches, with mean age of 36.8 (12.5) years. According to the confirmatory factor analysis, the Headache Impact Test-Brazil™ consists of single factor. Its internal consistency was α = 0.97 and the question number 3 had the lowest factor loading (0.31). The Headache Impact Test-Brazil™ exhibited a moderate correlation with both the SF-12 questionnaire (r = -0.64, 95%CI: -0.72 to -0.52, p = 0.001) and the Headache Disability Inventory-Brazil (r = 0.67, 95%CI: 0.56 to 0.75, p = 0.001). The correlation between the Headache Impact Test-Brazil™ and the headache frequency was weak (r = 0.22, 95%CI: 0.04 to 0.39, p = 0.001), and with the headache intensity, moderate (r = 0.44, 95%CI: 0.23 to 0.62, p = 0.001). The Headache Impact Test-Brazil™ test-retest reliability was excellent (ICC = 0.95) with a standard error of 1.58 and a smallest detectable change of 4.38 points. CONCLUSION: The Headache Impact Test-6-Brazil™ can be considered as a valid and reliable tool to assess the impact of several headache types. Future studies may revise the questionnaire items to confirm its redundancy.

Minimal important change and responsiveness of the Migraine Disability Assessment Score (MIDAS) questionnaire.

BACKGROUND: The MIDAS is the most used questionnaire to evaluate migraine-related disability, but its utility to assess treatment response remains unclear. Our aim was to estimate the MIDAS' minimal important change (MIC) value and its responsiveness. METHODS: A total of 103 patients were enrolled in a non-pharmacological, preference-based clinical trial. MIDAS and global rating of self-perceived change (GRoC) scores were collected at baseline, after 5 weeks of treatment, 4-weeks and 3-months follow-up after treatment. Anchor-based approaches were used to establish MIC values and responsiveness. FINDINGS: In all 3 timepoint comparisons, MIDAS presented a MIC of 4.5 points. A moderate positive correlation was identified between the MIDAS change and GRoC scores. The area under the curve ranged from 0.63 to 0.68. CONCLUSIONS: This study showed that MIDAS has a limited responsiveness to change. A change of 4.5 points or more represents a clinically important change for patients with high frequent migraine and chronic migraine receiving non-pharmacological treatment.

The Influence of Photophobia on Postural Control in Patients With Migraine.

BACKGROUND: People with migraine exhibit postural control impairments. These patients also have an increased light sensitivity due to the disease, and it remains during the headache-free period. It is currently unknown if increased lighting levels can alter the balance control, especially in individuals with visual hypersensitivity, such as migraineurs. This study aimed to assess the balance and photophobia of women with migraine and non-headache controls under different light conditions. METHODS: This cross-sectional study consisted of 14 women with migraine (mean ± SD 30.6 ± 8.1 years old) and 14 women without any kind of headache (mean ± SD 27.2 ± 2.8 years old) screened from a tertiary headache clinical hospital and the local community. Quiet standing balance was evaluated during bipodal and unipodal support, under 3 light conditions: ambient (AMB) - 270 lx, visual discomfort threshold (VDT) - 400 lx, and intense visual discomfort (IVD) - 2000 lx. Sway area of the center of pressure was processed and compared between groups. The association of migraine with the risk of presenting a greater imbalance in the discomfort lighting conditions was verified. RESULTS: Compared to the non-headache controls, the migraine group presented greater sway area in bipodal stance under the 3 light conditions (mean difference (95% CI)): AMB 0.81 cm2 (0.19 to 1.43), P = .011; VDT 3.17 cm2 (0.74 to 5.60), P = .001; IVD 5.56 cm2 (2.75 to 8.37), P < .0001. Within-subject analysis showed increased sway area in bipodal stance among all lighting conditions for the migraine group only (mean difference (95% CI)): VDT-AMB 2.20 cm2 (0.23 to 4.18), P = .024; IVD-AMB 4.50 cm2 (2.38 to 6.62), P < .0001, IVD-VDT 2.29 cm2 (0.57 to 4.01), P = .005. The Prevalence Ratio (PR) analysis showed that migraine was associated with the risk of presenting greater imbalance in both bipodal and unipodal standing conditions for both VDT (PR value (95% CI) - bipodal: PR = 4.00 (1.02 to 15.59), P = .045; unipodal: PR = 4.00 (1.43 to 11.15), P = .008), and the IVD (bipodal: PR = 3.33 (1.13 to 9.58), P = .025; unipodal: PR = 5.50 (1.48 to 20.42), P = .010) lighting conditions. CONCLUSION: Photophobia might be a disturbing factor that worsens the balance of patients with migraine during the quiet standing posture.

Subdiagnosis, but not presence of vestibular symptoms, predicts balance impairment in migraine patients - a cross sectional study.

BACKGROUND: Vestibular symptoms and balance changes are common in patients with migraine, especially in the ones with aura and chronic migraine. However, it is not known if the balance changes are determined by the presence of vestibular symptoms or migraine subdiagnosis. Therefore, the aim of this study was to verify if the migraine subdiagnosis and/or the presence of vestibular symptoms can predict balance dysfunction in migraineurs. METHODS: The study included 49 women diagnosed with migraine with aura, 53 without aura, 51 with chronic migraine, and 54 headache-free women. All participants answered a structured questionnaire regarding migraine features and presence of vestibular symptoms, such as dizziness/vertigo. The participants performed the Modified Sensory Organization Test on an AMTI© force plate. The data were analysed using a linear mixed-effect regression model. RESULTS: The presence of vestibular symptoms did not predict postural sway, but the subdiagnosis was a significant predictor of postural sway. Migraine with aura patients exhibited more sway than migraine patients without aura when the surface was unstable. Additionally, we found high effect sizes (ES > 0.79) for postural sway differences between patients with chronic migraine or with aura compared to controls or migraine without aura, suggesting that these results are clinically relevant. CONCLUSIONS: The subdiagnosis of migraine, instead of the presence of vestibular symptoms, can predict postural control impairments observed in migraineurs. This lends support to the notion that balance instability is related to the presence of aura and migraine chronicity, and that it should be considered even in patients without vestibular symptoms.

Presence of vestibular symptoms and related disability in migraine with and without aura and chronic migraine.

OBJECTIVE: To assess the presence and handicap due to vestibular symptoms in three subgroups of patients with migraine and controls. METHODS: Women between 18-55 years old were diagnosed by headache specialists and stratified as migraine with aura (n = 60), migraine without aura (n = 60), chronic migraine (n = 60) and controls (n = 60). Information regarding demographics, headache and vestibular symptoms were collected in this cross-sectional study. The self-perceived handicap related to vestibular symptoms was assessed through the Dizziness Handicap Inventory questionnaire. RESULTS: A total of 85% of women with migraine with aura and chronic migraine had vestibular symptoms contrasted to 70% of the migraine without aura group ( p < 0.05), and 12% of the control group reported symptoms ( p < 0.0001). Patients with migraine exhibited greater Dizziness Handicap Inventory scores than controls ( p < 0.001); and migraine with aura and chronic migraine groups reached greater scores than migraine without aura ( p < 0.01). Presence of migraine is associated with a greater risk of vestibular symptoms (migraine without aura: 5.20, migraine with aura: 6.60, chronic migraine:6.20, p < 0.0003) and with a greater risk of moderate-to-severe handicap (migraine without aura: 20.0, migraine with aura: 40.0, chronic migraine: 40.0, p < 0.0003). The presence of aura and greater migraine frequency adds to the risk of any handicap (migraine with aura: 1.9, chronic migraine: 1.7, p < 0.04) and to the risk of moderate-to-severe handicap (migraine with aura: 2.0, chronic migraine: 2.0, p < 0.0003). Migraine aura, intensity and frequency predict 36% of the dizziness handicap. CONCLUSION: The prevalence of vestibular symptoms is increased in migraine during and between headache attacks, particularly in migraine with aura and chronic migraine along with an increased handicap due to those symptoms. Vestibular symptoms among subgroups of migraine should be considered when evaluating the functional impact of migraine.

Balance Impairments in Different Subgroups of Patients With Migraine.

BACKGROUND: Patients with migraine often experience balance impairments. However, the relationship between clinical features - like aura and chronicity - and the severity of balance impairments is not well established. The objective of this study was to assess balance impairments in different subgroups of migraine patients. METHOD: One hundred five subjects diagnosed according to the ICHD-III were recruited in the study. They were uniformly distributed among three groups: migraine with aura, migraine without aura, and chronic migraine. Thirty-five controls were also recruited in the study. Balance impairments were assessed in all subjects via the modified Sensory Organization test and the Limits of Stability test. The results in the four groups were compared using ANCOVA tests with age, BMI, presence of dizziness, level of physical activity, time of migraine onset, and medication intake as covariates. RESULTS: Subjects in the migraine with aura and the chronic migraine groups showed poorer balance control than control subjects in three of the four conditions tested using the modified Sensory Organization test: FirmCE: CG: 1.5 cm2 , 95%CI 1.3 to 1.7; M: 2.1 cm2 , 95%CI 1.6 to 2.6; MA: 4.5 cm2 , 95%CI 3.2 to 5.8; CM: 4.5 cm2 , 95%CI 3.0 to 6.0; P < .027; FoamOE: CG: 5.1 cm2 , 95%CI 4.6 to 5.6; M: 5.6 cm2 , 95%CI 5.0 to 6.1; MA: 8.8 cm2 , 95%CI 7.3 to 10.2; CM: 8.8 cm2 , 95%CI 7.7 to 10.0; P < .018; FoamCE: CG: 14.8 cm2 , 95%CI 13.7 to 15.9 cm2; M: 17.3 cm2 , 95%CI 15.4 to 19.1; MA: 21.9 cm2 , 95%CI 19.1 to 24.7; CM: 22.4 cm2 , 95%CI 19.9 to 24.9; P < .0001. In the FoamOE and FoamCE conditions, both groups also showed poorer postural control than subjects in the migraine without aura group (P < .01). Differences between control subjects and subjects in all the migraine groups were found in the reaction time, movement velocity, endpoint excursion, and maximal excursion parameters (P < .04) in all the directions tested during the Limits of Stability test. None of the covariates appeared to affect the balance parameters (P > .05). CONCLUSION: There is evidence of balance control impairments in subjects with all subtypes of migraine compared to control subjects. The presence of aura and frequent migraine attacks reflect negatively in the postural control performance and may have a significant clinical impact in patients with migraine that should be addressed with appropriate clinical interventions.

Neck pain disability is related to the frequency of migraine attacks: a cross-sectional study.

BACKGROUND: Migraine and neck pain can be critical causes of disability. The contribution of neck pain for the overall disability of individuals with migraine remains unknown. OBJECTIVE: To contrast the disability experienced by individuals with episodic and chronic migraine with and without neck pain as captured by the Neck Disability Index. METHODS: Disability due to neck pain was assessed using the Neck Disability Index in individuals with episodic or chronic migraine seen at a university-based headache center. Neck disability was defined as mild (score ranging from 5 to 14 points), moderate (15-24 points), severe (25-34 points) or complete (35 points or higher). To compare differences between groups, a chi-square test was applied. Log-binomial logistic regression was used to estimate disability as a function of headache status after adjustments for age, time since migraine onset, and headache intensity. RESULTS: Sample consisted of 169 individuals, 104 with episodic migraine and 65 with chronic migraine. Any disability due to neck pain happened in 69% of those with episodic migraine, relative to 92% in chronic migraine (P < .001). Individuals with chronic migraine were at a significantly increased risk to have mild (RR = 2.5; CI 95% 1.1-6.1), moderate (RR = 3.7; CI 95% 1.5-8.8) and severe (RR = 5.1; CI 95%2.1-11.9) cervical disability relative to those with episodic migraine. Relative risks remained significant after adjustments. Time since episodic or chronic migraine onset significantly influenced the model (P = .035), but age and headache intensity did not (P = .27; P = .46). CONCLUSION: Neck pain significantly adds to the overall disability of individuals with episodic and chronic migraine.

Comparison between neck pain disability and cervical range of motion in patients with episodic and chronic migraine: a cross-sectional study.

OBJECTIVE: The purpose of this study was to evaluate neck pain-related disability and cervical range of motion (CROM) in patients with episodic migraine (EM) and chronic migraine (CM) and to examine the correlation of both outcomes. METHODS: This cross-sectional study consisted of 91 patients with EM and 34 with CM. Cervical range of motion was measured with the CROM device, and pain during the cervical movement was recorded. Self-reported disability related to neck pain was assessed with the Neck Disability Index. RESULTS: Patients with CM showed higher Neck Disability Index scores and more moderate and severe disability (P = .01). Severe disability as a result of neck pain was associated with 7.6-fold risk of developing CM (P = .003). No significant differences in CROM were identified between groups. Moderate negative correlations between CROM and disability were found for 4 motions within the CM group (-0.60

Influence of Role Expectancy on Patient-Reported Outcomes Among Patients With Migraine: A Randomized Clinical Trial.

Importance: It is usually assumed that an individual's classification as a patient or a healthy person is determined by the presence or absence of disease, but little is known about whether the mere awareness of being a patient or a healthy control can play an important role for reporting outcomes. Objective: To investigate whether assignment to the role of a patient or a healthy control has an effect on patient-reported outcomes. Design, Setting, and Participants: This single center, double-blind, 3-group randomized clinical trial included consecutive patients from a tertiary headache clinic based at a single center in Germany who were invited to participate between October 2019 and June 2023. Statistical analysis was performed from January to March 2024. Intervention: Patients with migraine were randomized into 2 groups. The first group was told that this study was centered on migraine symptoms, whereas the second group was told that healthy controls were being sought for a study about patients with vertigo. A third group of age- and sex-matched headache-free participants served as controls. All participants viewed 2 standardized roller coaster videos and provided ratings of their perceived levels of motion sickness and dizziness. Main Outcomes and Measures: The primary outcome was self-reported vestibular symptoms. Secondary outcomes included differences in motion sickness, headache burden, and migraine disability. Outcomes were assessed using standardized questionnaires. Results: The final sample included 366 participants: 122 patients with migraine assigned the role of patient (MP) (migraine as patient): mean [SD] age, 37.56 [12.93] years; 105 [86.1%] female), 122 patients with migraine assigned the role of healthy participant (MH) (migraine as healthy): mean [SD] age, 37.03 [13.10] years; 107 [87.7%] female), and 122 headache-free controls (HC): mean [SD] age, 37.55 [11.56] years; 100 [82.0%] female). The assigned role of the individuals with migraine (MP vs MH) had a significant effect on self-disclosure of (1) estimation that symptoms (dizziness) will occur under specific conditions (self-reported vestibular symptoms: 79 MP [64.8%]; 29 MH [23.8%]; 9 HC [7.4%]; P < .001), (2) the increase of such symptoms (dizziness) after viewing the roller coaster video, and (3) the reported frequency (median [IQR] self-reported monthly headache days for MP: 7 [4-15] days; for MH: 5 [2-10] days; P = .008) and severity (median [IQR] migraine disability assessment score for MP: 35 [20-64] points; for MH: 25 [11-47] points; P = .005) of migraine symptoms. Statistically significant changes were also found for self-reported headache frequency and disability caused by migraine. Conclusions and Relevance: This randomized clinical trial found an effect of expectations regarding the role of a patient with respect to clinical and study outcomes. These findings suggest that role expectations should be taken into account when, for example, invasive treatments are discussed. Trial Registration: ClinicalTrials.gov Identifier: NCT06322550.

Physical Therapist Interventions to Reduce Headache Intensity, Frequency, and Duration in Patients With Cervicogenic Headache: A Systematic Review and Network Meta-Analysis.

OBJECTIVE: The aim of this study was to assess the efficacy of physical therapist interventions on the intensity, frequency, and duration of headaches, as well as on the quality of life of patients with cervicogenic headache. METHODS: The following databases were searched up to October 2022: Physiotherapy Evidence Database, Web of Science, Pubmed, and Cochrane Library. Randomized controlled trials assessing the effect of physical therapist interventions on adults with cervicogenic headache were included. Quality appraisal was conducted using the Cochrane risk of bias 2.0 tool and the Confidence in Network Meta-analysis web app. Synthesis methods were conducted in accordance with the Cochrane Handbook. RESULTS: Of the 28 identified reports, 23 were included in the quantitative synthesis. Manipulation plus dry needling was the highest-ranked intervention to reduce the short-term headache intensity (mean difference [MD] = -4.87; 95% CI = -8.51 to -1.24) and frequency (MD = -3.09; 95% CI = -4.93 to -1.25) when compared to a control intervention. Other high-ranked and clinically effective interventions (when compared to a control intervention) were muscle-energy technique plus exercise (MD = 4.37; 95% CI = -8.01 to -0.74), as well as soft tissue techniques plus exercise (MD = -3.01; 95% CI = -5.1 to -0.92) to reduce short-term headache intensity, and dry needling plus exercise (MD = -2.92; 95% CI = -4.73 to -1.11) to reduce short-term headache frequency. These results were based on a low certainty of evidence. CONCLUSION: The 4 most highly ranked interventions can be considered in clinical practice. However, no conclusive recommendation can be made due to the low certainty of evidence. IMPACT: Combined interventions such as spinal joint manipulation plus dry needling and muscle-energy technique or soft tissue techniques or dry needling plus exercises seem to be the best interventions to reduce short-term cervicogenic headache intensity and/or frequency.

Body Image Measured via the Fremantle Awareness Questionnaire in Individuals With and Without Pain: A Systematic Review and Meta-Analysis.

Research suggests that pain negatively affects body image, and body image may also influence reported pain levels. This review aims to summarize the literature on differences in body image distortion between individuals with pain compared to pain-free individuals. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 statement and an a priori preregistered protocol. The literature was searched using 5 electronic databases. Studies assessing body image with the Fremantle Awareness Questionnaire (FAQ) in individuals with and without pain were eligible for inclusion. Screening and selection of eligible studies were performed by independent reviewers. Methodological quality was assessed with the Joanna Briggs Institute critical appraisal tool. Meta-analyses, meta-correlations, and metamean analyses were performed using random-effect models. The primary outcome was the FAQ score; secondary outcomes were reported pain variables. Data from individuals with pain (n = 2277) and without pain (n = 615) were summarized. Significant body image distortions were found in individuals with pain compared to individuals without pain. Compared to pain-free individuals, the pain group rated significantly higher in the FAQ when experiencing back pain (standardized mean differences=1.33, 95% confidence interval=.88-1.77) or other body parts (standardized mean differences=1.25, 95% confidence interval=.51-1.99). The results of meta-correlation analyses confirmed the positive relationship between body image distortion and pain intensity (r = .31), pain at rest (r = .31), or pain during movement (r = .36), but not for pain duration. A difference in mean FAQ results was observed between individuals with pain in different areas (knee and back). PERSPECTIVE: This review confirms differences in body image distortion between pain and pain-free individuals. Pain intensity was correlated with altered body perception, but not pain duration. A moderate correlation was observed between body image distortion and reported pain variables. Body image was more impaired by knee pain than back pain. REGISTERED PROTOCOL AT PROSPERO: CRD42022309937; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022309937.

Association between myofascial trigger point therapy and conditioned pain modulation.

INTRODUCTION: Myofascial trigger point therapy (MTrP) is a widely used therapeutic approach, although the underlying mechanisms remain unclear. Mechanisms discussed include peripheral involvement of muscles as well as central pain modulating processes such as the conditioned pain modulation (CPM). The aim of this study was to investigate whether the analgesic response of MTrP and the analgesic response of CPM correlate in asymptomatic participants in order to identify shared underlying mechanisms of MTrP and CPM. METHOD: Both, CPM and MTrP protocols consisted of heat-based test stimuli (heat pain thresholds before and after the intervention) and pressure-based (conditioning) stimuli. Asymptomatic participants (n = 94) were randomly assigned to receive either mild, intense or no pressure stimuli (between-group design) to both the fingernail and the MTrP of the infraspinatus muscle (within-group design). Pressure stimuli at both locations (fingernail, MTrP) were applied with a pressure algometer for 120 s and continuously adjusted to maintain a constant pain intensity of mild or intense pain. All thermal stimuli were applied on the lower leg with a thermal stimulator. RESULTS: A significant correlation was shown between the analgesic effect of CPM and MTrP therapy for mild (r = 0.53, p = 0.002) and intensive stimuli (r = 0.73, p < 0.001). 17.3% of the variance of the MTrP effect were explained by CPM after mild stimulation, and 47.1% after intense stimulation. Pain-related characteristics did not explain the variance within the analgesic response using a regression analysis. CONCLUSIONS: Between the analgesic responses following MTrP and CPM paradigms, a moderate to strong correlation was observed, suggesting shared underlying mechanisms.

Assessing the Influence of Nonischemic A-Fiber Conduction Blockade on Offset Analgesia: An Experimental Study.

Offset analgesia (OA) is believed to reflect the efficiency of the endogenous pain modulatory system. However, the underlying mechanisms are still being debated. Previous research suggested both, central and peripheral mechanisms, with the latter involving the influence of specific A-delta-fibers. Therefore, this study aimed to investigate the influence of a nonischemic A-fiber conduction blockade on the OA response in healthy participants. A total of 52 participants were recruited for an A-fiber conduction blockade via compression of the superficial radial nerve. To monitor fiber-specific peripheral nerve conduction capacity, quantitative sensory testing was performed continuously. Before, during, and after the A-fiber block, an individualized OA paradigm was applied to the dorsum of both hands (blocked and control sides were randomized). The pain intensity of each heat stimulus was evaluated by an electronic visual analog scale. A successful A-fiber conduction blockade was achieved in thirty participants. OA has been verified within time (before, during, and after blockade) and condition (blocked and control side) (P < .01, d > .5). Repeated measurements analysis of variance showed no significant interaction effects between OA within condition and time (P = .24, η²p = .05). Hence, no significant effect of A-fiber blockade was detected on OA during noxious heat stimulation. The results suggest that peripheral A-fiber afferents may play a minor role in OA compared with alternative central mechanisms or other fibers. However, further studies are needed to substantiate a central rather than peripheral influence on OA. PERSPECTIVE: This article presents the observation of OA before, during, and after a successful A-fiber conduction blockade in healthy volunteers. A better understanding of the mechanisms of OA and endogenous pain modulation, in general, may help to explain the underlying aspects of pain disorders.