Predictors of Disability in Migraineurs Referred to a Tertiary Clinic: Neck Pain, Headache Characteristics, and Coping Behaviors

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.

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.

Cranial Autonomic Symptoms and Neck Pain in Differential Diagnosis of Migraine

Cranial autonomic symptoms and neck pain have been reported to be highly prevalent in migraine, although they are rarely considered in clinical evaluation. The aim of this review is to focus on the prevalence, pathophysiology, and clinical characteristics of these two symptoms, and their importance in the differential diagnosis between migraines and other headaches. The most common cranial autonomic symptoms are aural fullness, lacrimation, facial/forehead sweating, and conjunctival injection. Migraineurs experiencing cranial autonomic symptoms are more likely to have more severe, frequent, and longer attacks, as well as higher rates of photophobia, phonophobia, osmophobia, and allodynia. Cranial autonomic symptoms occur due to the activation of the trigeminal autonomic reflex, and the differential diagnosis with cluster headaches can be challenging. Neck pain can be part of the migraine prodromal symptoms or act as a trigger for a migraine attack. The prevalence of neck pain correlates with headache frequency and is associated with treatment resistance and greater disability. The convergence between upper cervical and trigeminal nociception via the trigeminal nucleus caudalis is the likely mechanism for neck pain in migraine. The recognition of cranial autonomic symptoms and neck pain as potential migraine features is important because they often contribute to the misdiagnosis of cervicogenic problems, tension-type headache, cluster headache, and rhinosinusitis in migraine patients, delaying appropriate attack and disease management.

Prevalence of neck pain in migraine: A systematic review and meta-analysis

BACKGROUND

Neck pain is a frequent complaint among patients with migraine and seems to be correlated with the headache frequency. Neck pain is more common in patients with chronic migraine compared to episodic migraine. However, prevalence of neck pain in patients with migraine varies among studies.

OBJECTIVE

To estimate the prevalence of neck pain in patients with migraine and non-headache controls in observational studies.

METHODS

A systematic literature search on PubMed and Embase was conducted to identify studies reporting prevalence of neck pain in migraine patients. This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data was extracted by two independent investigators and results were pooled using random-effects meta-analysis. The protocol was registered with PROSPERO (CRD42021264898).

RESULTS

The search identified 2490 citations of which 30 contained relevant original population based and clinic-based data. Among these, 24 studies provided data eligible for the analysis. The meta-analysis for clinic-based studies demonstrated that the pooled relative frequency of neck pain was 77.0% (95% CI: 69.0-86.4) in the migraine group and 23.2% (95% CI:18.6-28.5) in the non-headache control group. Neck pain was more frequent in patients with chronic migraine (87.0%, 95% CI: 77.0-93.0) compared to episodic migraine (77.0%, 95% CI: 69.0-84.0). Neck pain was 12 times more prevalent in migraine patients compared to non-headache controls and two times more prevalent in patients with chronic migraine compared to episodic migraine. The calculated heterogeneity (I² values) ranged from 61.3% to 72.0%.

CONCLUSION

Neck pain is a frequent complaint among patients with migraine. The heterogeneity among the studies emphasize important aspects to consider in future research of neck pain in migraine to improve our understanding of the driving mechanisms of neck pain in a major group of migraine patients.

Cervical musculoskeletal impairments in migraine

Background

Neck pain is common and disabling amongst individuals with migraine. Cervical musculoskeletal interventions are often sought but there is currently no evidence to support such interventions for this population. Improved understanding of how cervical musculoskeletal impairments present in migraine can elucidate neck pain mechanisms and guide clinicians and researchers in the management of patients with migraine and neck pain.

Main body

Migraine hypersensitivity is a major consideration when assessing for cervical impairments as it can aggravate migraine and confound findings. Current evidence of cervical impairments in migraine is limited by disregard for the different underlying causes of neck pain and possible influence of hypersensitivity. Findings of cervical musculoskeletal impairments are mixed within and across studies, indicating that different forms of neck pain are present in migraine. Some migraineurs have neck pain that is part of the migraine symptom complex and therefore exhibit little or no cervical musculoskeletal impairment. Others have a cervical source of neck pain and therefore exhibit a pattern of cervical musculoskeletal impairments akin to that of cervical disorders. The presence of cervical musculoskeletal dysfunction may or may not be related to migraine but knowledge of this is currently lacking which impacts decision making on management. Cervical musculoskeletal interventions may be indicated for migraineurs with identified cervical dysfunction but other factors requiring further clarification include determination of i) patient specific outcomes, ii) impact of co-existing migraine referred neck pain, and iii) potential moderating effects of migraine hypersensitivity on treatment efficacy.

Conclusions

Physiotherapists should seek a combination of cervical impairments through skilful assessment to identify if cervical musculoskeletal dysfunction is present or not in individual patients. The relevance of cervical dysfunction to migraine and influence of co-existing migraine referred neck pain need to be established through detailed evaluation of pain behaviours and further research. Future clinical trials should define expected treatment outcomes and select individuals with cervical musculoskeletal dysfunction when investigating the efficacy of cervical musculoskeletal interventions.

Neck Active Movements Assessment in Women with Episodic and Chronic Migraine

We aimed to compare movement parameters and muscle activity during active cervical spine movements between women with episodic or chronic migraine and asymptomatic control. We also assessed the correlations between cervical movement measures with neck-related disability and kinesiophobia. Women with episodic (n = 27; EM) or chronic (n = 27; CM) migraine and headache-free controls (n = 27; CG) performed active cervical movements. Cervical range of motion, angular velocity, and percentage of muscular activation were calculated in a blinded fashion. Compared to CG, the EM and CM groups presented a reduced total range of motion (p < 0.05). Reduced mean angular velocity of cervical movement was also observed in both EM and CM compared to CG (p < 0.05). Total cervical range of motion and mean angular velocity showed weak correlations with disability (r = −0.25 and −0.30, respectively; p < 0.05) and weak-to-moderate correlations with kinesiophobia (r = −0.30 and −0.40, respectively; p < 0.05). No significant correlation was observed between headache features and total cervical range of motion or mean angular velocity (p > 0.05). No differences in the percentage of activation of both flexors and extensors cervical muscles during active neck movements were seen (p > 0.05). In conclusion, episodic and chronic migraines were associated with less mobility and less velocity of neck movements, without differences within muscle activity. Neck disability and kinesiophobia are negative and weakly associated with cervical movement.

Craniocervical flexion test in patients with migraine: Discriminative validity and accuracy

OBJECTIVES

To evaluate the discriminative validity and provide a clinical cut-off of the craniocervical flexion test (CCFT) in migraineurs stratified by the report of neck pain, headache-related disability and neck disability.

METHODS

Fifty women without headache and 102 women with migraine were recruited by convenience from a local tertiary care setting. Migraine diagnosis followed the International Classification of Headache Disorders. All volunteers underwent the CCFT. Patients with migraine answered the Migraine Disability Assessment (MIDAS) and Neck Disability Index (NDI) questionnaires. Discriminative validity was verified by group comparison, and the clinical cut-off was obtained and classified according to the diagnostic accuracy of the CCFT.

RESULTS

The CCFT presented discriminative validity for comparing control (median = 28, IQR = 6) with migraine (median = 26, IQR = 4, P = .01) and migraine with neck pain (median = 26, IQR = 4, P = .01), but not among the migraine subtypes with disability by migraine or neck pain-related disability on the MIDAS and NDI. The diagnostic accuracies were classified between poor and not discriminating with the area under the receiver operating characteristic curve ranging from 57% to 69% and non-acceptable values of sensitivity, specificity and positive and negative likelihood ratios.

CONCLUSION

The CCFT can discriminate asymptomatic controls from migraine patients with and without neck pain. However, it cannot discriminate patients with migraine according to their pain-related disability. Also, the CCFT does not offer an optimal cut-off value in migraine patients adequate to clinical practice.

Are there gender differences in neck pain and musculoskeletal disorders of the cervical spine associated with migraine?

OBJECTIVE

To evaluate gender differences in clinical characteristics of migraine by examining presence and severity of cutaneous allodynia, migraine-related disability, neck pain and its associated disability, passive mobility of the upper cervical spine, and performance of the deep neck flexor muscles.

DESIGN

cross-sectional study.

SUBJECTS

30 men and 30 women with migraine.

METHODS

Participants responded to the questionnaires Migraine Disability Assessment questionnaire, 12-item Allodynia Symptom Checklist and Neck Disability Index. The mobility of the upper cervical spine was assessed by using the Flexion-Rotation Test. Performance of the deep neck flexor muscles was evaluated by applying the Craniocervical Flexion Test. Comparison of the groups was carried out by using the Student's t-test or the chi-square test. The prevalence ratio was also calculated.

RESULTS

Women showed a higher prevalence of cutaneous allodynia (p = 0.001) and a 4 times greater risk of having severe cutaneous allodynia than to men (p = 0.007). No gender differences were observed in migraine-related disability (p = 0.08). Women showed higher prevalence of self-reported neck pain (p = 0.03) and increased risk of having this symptom in comparison to men (Prevalence Ratio=1.69; p = 0.025). However, there were no gender differences in neck pain-related disability (p = 0.25), mobility of the upper cervical spine (p = 0.92), or performance of the deep neck flexor muscles (p = 0.52).

CONCLUSION

Women with migraine had a higher frequency of self-reported neck pain and higher prevalence and severity of cutaneous allodynia when compared to men. However, the two groups did not differ regarding neck pain-related disability and performance in the physical tests.

Headache Characteristics and Psychological Factors Associated with Functional Impairment in Individuals with Persistent Posttraumatic Headache

OBJECTIVE

Persistent posttraumatic headache (PPTH), one of the most common symptoms following mild traumatic brain injury, is often associated with substantial functional disability. The objective of this study was to assess the contribution of demographics, headache characteristics, and psychological symptoms to disability associated with PPTH.

METHODS

Participants completed the State-Trait Anxiety Inventory (STAI), the Beck Depression Inventory (BDI), the Pain Catastrophizing Scale (PCS), and the Migraine Disability Assessment (MIDAS) questionnaire. Two linear regression models were formulated to interrogate the relationships between 1) demographics and headache characteristics with the MIDAS questionnaire and 2) demographics, headache characteristics, and psychological symptoms with the MIDAS questionnaire. A two-way stepwise regression using the Akaike information criterion was performed to find a parsimonious model describing the relationships between demographics, headache characteristics, and psychological measures with the MIDAS questionnaire.

RESULTS

Participants included 58 patients with PPTH and 39 healthy controls (HCs). The median MIDAS score among those with PPTH was 48.0 (first quartile [1Q] = 20.0, third quartile [3Q] = 92.0), indicative of severe disability. Compared with the HCs, those with PPTH had higher scores on the BDI, STAI, and PCS. Older age predicted lower MIDAS scores (age: B=-0.11, P<0.01), whereas higher headache frequency, greater headache intensity, and higher trait anxiety scores predicted higher MIDAS scores in individuals with PPTH (headache frequency: B=0.07, P<0.001; headache intensity: B=0.51, P=0.04; trait anxiety score: B=1.11, P=0.01).

CONCLUSIONS

Individuals with PPTH had substantial psychological symptoms and headache-related disability. Disability was partially explained by age, headache frequency and intensity, and trait anxiety. Holistic management of patients with PPTH to address headaches and psychological symptoms might reduce headache-associated disability.

Muscle endurance and cervical electromyographic activity during submaximal efforts in women with and without migraine

BACKGROUND

Despite previous reports supporting cervical muscle weakness and altered motor control in migraine, the endurance under standardized submaximal loads has not been investigated. Therefore, this study aimed to assess the endurance and muscle activity of the cervical musculature during submaximal isometric contractions in women with migraine and those without headache.

METHODS

Cervical muscle endurance tests were performed for flexors and extensors at 25%, 50%, and 75% of the output force during maximal isometric contraction using the Multi-Cervical Rehabilitation Unit with customized biofeedback. Initial values and relative rates of changes in root mean square and median frequency were calculated using cervical muscle superficial electromyography.

FINDINGS

Women with chronic migraine presented significantly shorter flexor endurance time in all load tests than controls (25%, P = .001, 50%, P = .005; 75%, P = .013), while episodic migraine only differed from controls at 75% (P = .018). The frequency of neck pain and/or pain referred to the head after the endurance test was up 12% in the control group, 40% in the episodic migraine group and 68% of the chronic migraine group. Few differences between groups were observed in the electromyographic variables and none of them was related to a worse performance in the endurance tests.

INTERPRETATION

Cervical flexor endurance was reduced in women with chronic migraine when independent of the load, whereas it was reduced to 75% of the maximal force in those with episodic migraine. No difference in the electromyographic variables could be related to this reduced flexor endurance. Also, no differences were detected in extensors endurance.

Greater Severity and Functional Impact of Post-traumatic Headache in Veterans With Comorbid Neck Pain Following Traumatic Brain Injury

BACKGROUND

Post-traumatic headache (PTH) is a commonly experienced symptom after mild traumatic brain injury (mTBI). Blast injury- or blunt injury-related mechanisms for mTBI in veterans can also affect musculoskeletal structures in the neck, resulting in comorbid neck pain (NP). However, it is unknown whether the presence of comorbid NP may be associated with a different pattern of headache symptoms, physical functioning, or emotional functioning compared to those without comorbid NP. The purpose of this study is to examine the role of comorbid NP in veterans with mTBI and PTH.

DESIGN AND METHODS

This was a cross-sectional investigation of an existing dataset that included 33 veterans who met inclusion criteria for PTH after mTBI. Standardized measures of headache severity and frequency, insomnia, fatigue, mood disorders, and physical and emotional role function were compared between groups with and without comorbid NP.

RESULTS

The majority of participants with PTH reported comorbid NP (n = 22/33, 67%). Those with comorbid NP experienced more headache symptoms that were severe or incapacitating, as compared to mild or moderate for those without NP (φ = 0.343, P = .049); however, no differences in headache frequency (φ = 0.231, P = .231) or duration (φ = 0.129, P = .712) were observed. Participants with comorbid NP also reported greater insomnia (d = 1.16, P = .003) and fatigue (d = 0.868, P = .040) as well as lower physical functioning (d = 0.802, P = .036) and greater bodily pain (d = 0.762, P = .012). There were no differences in anxiety, depression, mental health, emotional role limitations, vitality, or social functioning between those with and without comorbid NP (d ≤ 0.656, P ≥ .079).

CONCLUSIONS

A majority of veterans with mTBI and PTH in our sample reported comorbid NP that was associated with greater headache symptom severity and physical limitations, but not with mood or emotional limitations. Preliminary findings from this small convenience sample indicate that routine assessment of comorbid NP and associated physical limitations should be considered in veterans with mTBI and PTH.

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.

New Mobile Device to Measure Verticality Perception: Results in Young Subjects with Headaches

The subjective visual vertical (SVV) test has been frequently used to measure vestibular contribution to the perception of verticality. Recently, mobile devices have been used to efficiently perform this measurement. The aim of this study was to analyze the perception of verticality in subjects with migraines and headaches. A cross-sectional study was conducted that included 28 patients with migraine, 74 with tension-type headache (TTH), and 93 healthy subjects. The SVV test was used through a new virtual reality system. The mean absolute error (MAE) of degrees deviation was also measured to qualify subjects as positive when it was greater than 2.5°. No differences in the prevalence of misperception in verticality was found among healthy subjects (31.18%), migraineurs (21.43%), or those with TTH (33.78%) (p = 0.480). The MAE was not significantly different between the three groups (migraine = 1.36°, TTH = 1.61°, and healthy = 1.68°) (F = 1.097, p = 0.336, and η2 = 0.011). The perception of verticality could not be explained by any variable usually related to headaches. No significant differences exist in the vestibular contribution to the perception of verticality between patients with headaches and healthy subjects. New tests measuring visual and somatosensory contribution should be used to analyze the link between the perception of verticality and headaches.

Misperception of Visual Verticality in Patients with Primary Headache Disorders: A Systematic Review with Meta-Analysis

Migraine and tension-type headache (TTH) are the two most prevalent primary headache disorders (PHDs) that may involve visual and vestibular impairments, neck pain, and postural unsteadiness. The perception of visual verticality (VV) has been studied in patients diagnosed with PHD to assess balance disorders showing varying findings. Our study aimed to assess the VV perception in patients diagnosed with PHD in comparison to healthy controls. A systematic review with meta-analysis was carried out in PubMed MEDLINE, Scopus, WOS, CINAHL, and SciELO. The Cohen standardized mean difference (SMD) was used to estimate the differences between exposed and healthy controls. Seven studies with 816 participants were included. The quality of included studies, according to the Newcastle–Ottawa Scale (NOS), was moderate (mean score of 5.2). Patients diagnosed with PHD showed a moderate misperception of VV as assessed with the subjective visual vertical (SVV) test (SMD = 0.530; 95% CI = 0.225, 0.836; p < 0.001). Specifically, a misperception of the SVV was found in patients with migraine (SMD = 0.369; 95% CI = 0.1, 0.638; p = 0.007) and with TTH (SMD = 1.122; 95% CI = 0.540, 1.704; p < 0.001). This review shows a misperception of VV in patients with migraine and TTH when assessed with the SVV test, being higher in patients with TTH, although the THH sample size was low.

Involvement of cervical disability in migraine: a literature review

Background

The trigeminal nerve theory has been proposed as a pathophysiological mechanism of migraine; however, its association with the triggers of migraine remains unclear. Cervical disability such as neck pain and restricted cervical rotation, have been associated with not only cervicogenic headaches but also migraine. The presence of cervical disability could worsen of the migraine, and also the response to pharmacologic treatment may be reduced. The aim in this review is to highlight the involvement of cervical disability in migraine, considering contributing factors.

Findings

In recent years, evidence of neck pain complaints in migraine has been increasing. In addition, there is some recent evidence of cervical musculoskeletal impairments in migraine, as detected by physical assessment. However, the main question of whether neck pain or an associated cervical disability can act as an initial factor leading to migraine attacks still remains. Daily life imposes heavy loads on cervical structures (i.e. muscles, joints and ligaments), for instance, in the forward head position. The repetitive nociceptive stimulation initiating those cervical skeletal muscle positions may amplify the susceptibility to central migraine and contribute to chronicity via the trigeminal cervical complex.

Conclusion

Further studies are needed to explain the association between cervical disability as a source of pain and the development of migraine. However, evidence suggests that cervical disability needs to be considered in the prevention and treatment of migraine.

Neck-specific strengthening exercise compared with sham ultrasound when added to home-stretching exercise in patients with migraine: study protocol of a two-armed, parallel-groups randomized controlled trial

BACKGROUND

Migraine is a highly disabling condition and pharmacological treatment is the gold standard. However, several patients have also positive responses to the application of different manual techniques and therapeutic exercises in terms of reducing the intensity and frequency of migraine attacks. Nevertheless, the effects of a neck-specific exercise program have not yet been evaluated in these patients.

OBJECTIVE

To determine the effectiveness of a neck-specific exercise program in reducing the intensity and frequency of migraine attacks as compared to a sham ultrasound group.

METHODS

A two-armed, parallel-groups randomized controlled trial with 3 months of follow-up will be conducted. 42 individuals, both genders, aged between 18 and 55 years old with a medical diagnosis of migraine will be included. The intervention group will perform a protocol consisting of exercises for strengthening the muscles of the cervical spine. Participants within the sham ultrasound group will receive detuned ultrasound therapy in the upper trapezius muscle. Both groups will receive a weekly session for 8 weeks. The efficacy of each intervention will be measured by the frequency and intensity of migraine at a 3-months follow-up.

TRIAL REGISTRATION

This study was registered under access code RBT-8gfv5j in the Registro Brasileiro de Ensaios Clínicos (ReBEC) in November 28, 2016.

CONCLUSION

This study will aim to determine the efficacy of a neck-specific exercise program in reducing the frequency and intensity of migraine attacks. If the results show that a neck-specific exercise program is effective in reducing the frequency and intensity of migraine attacks, therapists will have a low cost and easily applicable tool to treat migraine.

Is the presence of neck pain associated with more severe clinical presentation in patients with migraine? A cross-sectional study

Objective

To investigate the association between the presence of self-reported neck pain in patients with migraine and clinical features, upper cervical mobility, and neck muscle performance.

Methods

A total of 142 patients with migraine were recruited and stratified by the presence (n = 99) or absence of self-reported neck pain (n = 43). The clinical examination included the Migraine Disability Assessment, the 12-item Allodynia Symptom Checklist, a flexion rotation test, and the Craniocervical Flexion Test.

Results

Migraine-related disability was reported by more than 80% in both groups ( p = 0.82). However, there was a greater prevalence and severity of cutaneous allodynia observed in the group with neck pain ( p < 0.001). Reduced upper cervical mobility was verified in 67% of the patients with neck pain and in 41% of those without neck pain ( p = 0.005). In addition, 67% of the patients with neck pain and 40% without neck pain were not able to maintain the third stage of the Craniocervical Flexion Test without compensation ( p = 0.003).

Conclusions

The presence of self-reported neck pain in patients with migraine was associated with a poor clinical presentation regarding cutaneous allodynia, neck mobility, and muscle function. However, there were no differences in migraine-related disability.

Neck pain in episodic migraine: a cross-sectional study

Purpose: It has been reported that neck pain is more prevalent in episodic migraineurs (EM) than in the general population. Subjects with episodic migraine exhibited widespread hypersensitivity in cranio-cervical region. Our objectives were to explore the potential factors associated with the presence of neck pain for EM, and whether there were differences in pericranial muscle tenderness between EM with and without neck pain.

Patients and methods: Fifty EM with neck pain (34.76±8.04) and 50 age- and sex-matched EM without neck pain (34.26±9.39) were enrolled. The characteristics of headaches and some lifestyle factors were assessed in two groups. The migraine disability score and neck disability index were also recorded. During migraine-free period, cranio-cervical muscle tenderness scores and mechanical pain threshold were assessed for all patients.

Results: There were no significant differences in pain intensity (p=0.44), migraine disability (p=0.71), duration (p=0.44) or frequency (p=0.85) of headache between EM with and without neck pain. The lifestyle factors including smoking, alcohol, coffee, body mass index≧23kg/m², poor sleeping (<8 h/day) and time spent on TV and computers (>2 h/day) were not associated with the presence of neck pain in this study. Compared with EM without neck pain, those with neck pain had higher neck tenderness (p<0.01) and higher cephalic tenderness scores (p<0.01). Neck Disability Index scores were positively correlated with neck and total muscle tenderness scores.

Conclusion: There was a significant difference in cranio-cervical muscle tenderness scores between EM with and without neck pain. For EM, the factors studied in the current research seemed not associated with the onset of neck pain, and further studies including other factors are needed.

Cervical Muscular Endurance Performance in Women With and Without Migraine

BACKGROUND

Despite previous evidence, the association between migraines and cervical muscular performance is unclear.

OBJECTIVE

To compare the differences in neck flexor and extensor muscle endurance between women with and without migraine.

METHODS

In this cross-sectional, controlled laboratory study, 26 women with migraine and 26 age-matched women without migraine or headache were assessed using clinical tests of neck flexor and extensor muscle endurance. Holding times were compared between groups using the Mann-Whitney U test for independent samples.

RESULTS

Patients with migraine exhibited a lower holding time for both neck extensor endurance (P = .001) and neck flexor endurance (P<.001) than did the controls. The median neck flexor holding time was 35.0 seconds for the migraine group and 60.5 seconds for the control group. The migraine group held the neck extensor endurance test position for a median of 166.5 seconds compared to 290.5 seconds held by the control group. Both groups reported a similar level of neck pain during the endurance tests (P>.05); however, only individuals in the migraine group reported pain referred to the head during testing.

CONCLUSION

Women with migraine demonstrated decreased neck flexor and extensor endurance compared to women without migraine, which may indicate an association between migraine and reduced performance of the neck muscles. J Orthop Sports Phys Ther 2019;49(5):330-336. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8816.

Neck pain and migraine: Association or cause?—A narrative review of the literature

This literature review deals with the question whether neck pain (NP) constitutes a symptom or a trigger of migraine. Firstly, a short survey about some techniques for measuring NP in association and relation with migraine is presented. Secondly, the arguments about NP as a symptom or a trigger of migraine are being reviewed and compared. The main questions are the following: Which tests can be used to distinguish NP as a trigger or a symptom of migraine? Is a therapy for NP an adequate method to treat migraine? Finally, the pros and cons of NP as a symptom or as a trigger will be reviewed, and possible treatment options will be suggested. This review found that no reliable and standardized tests exist to classify NP in relation to migraine. However, there is a comparability among these studies due to the common use of migraine definition in the “International Classification of Headache Disorders.” Regarding the quality and methods, different types of studies were analyzed, for example, retrospective, prospective, and cross-sectional studies. Nevertheless, none of these types are specifically suited to show a causality between NP and migraine. In order to do this, the authors would suggest using a randomized controlled study. Another adequate study design might be a population-based case–control crossover study and calculating the population attributable risk. Furthermore, the pathophysiology of NP in migraine patients should be investigated in more detail. Besides their questionable suitability for showing a connection between NP and migraine, some studies were additionally subject to a population and selection bias. To sum up, part of the authors in the reviewed literature generate the hypothesis that NP is more often a symptom than a trigger of migraine. However, due to methodological flaws, more studies are necessary to confirm this hypothesis.

Reduced flexion rotation test in women with chronic and episodic migraine

OBJECTIVE

To compare flexion rotation test and global active cervical mobility in women with chronic migraine, episodic migraine, and headache-free controls. The influence of neck pain-related disability on the flexion rotation test was also analyzed.

METHODS

Women with chronic migraine (n=25), episodic migraine (n=30), and those who were headache-free (n=30) were evaluated. Upper cervical mobility was measured using the flexion rotation test and global active mobility was assessed using the cervical range of motion device. Neck pain related-disability was assessed using the Neck Disability Index. Statistical analyses were performed using a MANOVA test, prevalence ratios, and linear regression.

RESULTS

Chronic (right, MD: -15°; 95%CI: -21° to -11°; left, MD: -13°; 95%CI: -20° to -12°) and episodic (right, MD: -8°; 95%CI: -13° to -4°; left, MD: -8°; 95%CI: -12° to -5°) migraine groups achieved lower flexion rotation test mobility bilaterally than headache-free women. Only chronic migraine was associated with a lower global cervical range of motion compared to that of headache-free women during flexion, (MD: -8°; 95%CI: -15° to -1°), extension (MD: -13°; 95%CI: -20° to -4°), right lateral flexion (MD: -4°; 95%CI: -9° to -0.2°), left lateral flexion (MD: -6°; 95%CI: -10° to -2°), right rotation (MD: -9°; 95%CI: -15° to -4°), and left rotation (MD: -8°; 95%CI: -13° to -2°). Migraine was associated with a 2.85-fold increase in the risk of a positive flexion rotation test. Flexion Rotation Test was influenced by disability-related neck pain (R²=19.1; p=0.001).

CONCLUSION

Women with migraine have a lower upper cervical range of motion than headache-free women. Women with chronic migraine demonstrated reduced global cervical range of motion when compared to headache-free women. Migraine was associated with in increased likelihood of a positive Flexion Rotation Test. Reduction in mobility was influenced by migraine frequency and disability-related neck pain.

The effects of aerobic exercise for persons with migraine and co-existing tension-type headache and neck pain. A randomized, controlled, clinical trial

Aim To evaluate aerobic exercise in migraine and co-existing tension-type headache and neck pain. Methods Consecutively recruited persons with migraine and co-existing tension-type headache and neck pain were randomized into an exercise group or control group. Aerobic exercise consisted of bike/cross-trainer/brisk walking for 45 minutes, three times/week. Controls continued usual daily activities. Pain frequency, intensity, and duration; physical fitness, level of physical activity, well-being and ability to engage in daily activities were assessed at baseline, after treatment and at follow-up. Results Fifty-two persons completed the study. Significant between-group improvements for the exercise group were found for physical fitness, level of physical activity, migraine burden and the ability to engage in physical activity because of reduced impact of tension-type headache and neck pain. Within the exercise group, significant reduction was found for migraine frequency, pain intensity and duration, neck pain intensity, and burden of migraine; an increase in physical fitness and well-being. Conclusions Exercise significantly reduced the burden of migraine and the ability to engage in physical activity because of reduced impact of tension-type headache and neck pain. Exercise also reduced migraine frequency, pain intensity and duration, although this was not significant compared to controls. These results emphasize the importance of regular aerobic exercise for reduction of migraine burden.

The treatment of migraine patients within chiropractic: analysis of a nationally representative survey of 1869 chiropractors

BACKGROUND

While the clinical role of manual therapies in migraine management is unclear, the use of chiropractors for this condition is considerable. The aim of this study is to evaluate the prevalence and characteristics of chiropractors who frequently manage patients with migraine.

METHODS

A national cross-sectional survey of chiropractors collected information on practitioner characteristics, clinical management characteristics and practice settings. A secondary analysis was conducted on 1869 respondents who reported on their migraine caseload to determine the predictors associated with the frequent management of patients with migraine.

RESULTS

A large proportion of chiropractors report having a high migraine caseload (HMC) (n = 990; 53.0%). The strongest factors predicting a chiropractor having a HMC include the frequent treatment of patients with axial neck pain (OR = 2.89; 95%CI: 1.18, 7.07), thoracic pain (referred/radicular) (OR = 2.52; 95%CI: 1.58, 3.21) and non-musculoskeletal disorders (OR = 3.06; 95%CI: 2.13, 4.39).

CONCLUSIONS

Several practice-setting and clinical management characteristics are associated with chiropractors managing a HMC. These findings raise key questions about the therapeutic approach to chiropractic migraine management that deserves further examination. There is a need for more primary research to assess the approach to headache and migraine management provided by chiropractors and to understand the prevalence, burden and comorbidities associated with migraine found within chiropractic patient populations. This information is vital in helping to inform safe, effective and coordinated care for migraine sufferers within the wider health system.

Staying in service with posttraumatic headache

Objective:

To predict the probability of a military outcome (medical discharge/retirement) in patients with mild traumatic brain injury from a clinical analysis of predetermined patient and headache characteristics.

Methods:

This retrospective cohort study sampled all new patients referred for headache evaluation at the Brain Injury Clinic of the Womack Army Medical Center, Ft. Bragg, NC (August 2008–January 2010). Headache characteristics were extracted and analyzed. Multivariable binary logistic regressions were conducted to predict probability of medical discharge/retirement.

Results:

Ninety-five soldiers (age 31.3 ± 7.4 years, male 93.7%) reported 166 headaches. The most common injury cited was a blast (53.7%). Patients with a continuous headache have almost 4 times the odds of a medically related discharge/retirement compared to patients without such a headache (continuous headache regression coefficient estimate: p < 0.042, odds ratio 3.98, 95% Wald confidence interval 1.05–15.07). Results suggest that, compared to service members who did not have a continuous headache, patients with headache histories with severe holocephalic pain who medicate to keep functioning had the highest probability of medical discharge/retirement.

Conclusions:

Certain headache characteristics may be predictive of military outcomes after mild traumatic brain injury, and we propose a profile that may be useful in that prediction. These data could be useful in future attempts to assess and treat patients with posttraumatic headache and to advise longer-term planning for return to duty or discharge.

Migraine Subclassification via a Data-Driven Automated Approach Using Multimodality Factor Mixture Modeling of Brain Structure Measurements

BACKGROUND

The current subclassification of migraine is according to headache frequency and aura status. The variability in migraine symptoms, disease course, and response to treatment suggest the presence of additional heterogeneity or subclasses within migraine.

OBJECTIVE

The study objective was to subclassify migraine via a data-driven approach, identifying latent factors by jointly exploiting multiple sets of brain structural features obtained via magnetic resonance imaging (MRI).

METHODS

Migraineurs (n = 66) and healthy controls (n = 54) had brain MRI measurements of cortical thickness, cortical surface area, and volumes for 68 regions. A multimodality factor mixture model was used to subclassify MRIs and to determine the brain structural factors that most contributed to the subclassification. Clinical characteristics of subjects in each subgroup were compared.

RESULTS

Automated MRI classification divided the subjects into two subgroups. Migraineurs in subgroup #1 had more severe allodynia symptoms during migraines (6.1 ± 5.3 vs. 3.6 ± 3.2, P = .03), more years with migraine (19.2 ± 11.3 years vs 13 ± 8.3 years, P = .01), and higher Migraine Disability Assessment (MIDAS) scores (25 ± 22.9 vs 15.7 ± 12.2, P = .04). There were not differences in headache frequency or migraine aura status between the two subgroups.

CONCLUSIONS

Data-driven subclassification of brain MRIs based upon structural measurements identified two subgroups. Amongst migraineurs, the subgroups differed in allodynia symptom severity, years with migraine, and migraine-related disability. Since allodynia is associated with this imaging-based subclassification of migraine and prior publications suggest that allodynia impacts migraine treatment response and disease prognosis, future migraine diagnostic criteria could consider allodynia when defining migraine subgroups.

Disability, Quality of Life, and Pain Coping in Pediatric Migraine: An Observational Study

OBJECTIVES

The objective was to examine the relationship between disability, health-related quality of life (HrQoL), and pain coping in pediatric migraineurs.

METHOD

Eighty-five patients with migraine were recruited from Pediatric Neurology clinics. Participants completed the Pediatric Migraine Disability Assessment Scale, the Pediatric Quality of Life Inventory, the Pain Coping Questionnaire, and the Pain Catastrophizing Scale. Means were compared to published norms using t-tests. Spearman correlations and logistic regression were used to explore the relationships between the variables.

RESULTS

Mean HrQoL scores were lower than norms for controls and chronically ill pediatric patients ( P < .0001). Patients reported lower mean pain coping scores and higher mean pain catastrophizing scores than norms ( P < .0001). After controlling for age and sex, only the relationship between disability and HrQoL remained significant (OR = 0.91, 95% CI: 0.86-0.95).

CONCLUSION

Pediatric patients with migraine report lower HrQoL, fewer pain coping strategies and more catastrophizing than controls, while disability is inversely associated with HrQoL.

Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain

Background

The prevalence of migraine with co-existing tension-type headache and neck pain is high in the general population. However, there is very little literature on the characteristics of these combined conditions. The aim of this study was to investigate a) the prevalence of migraine with co-existing tension-type headache and neck pain in a clinic-based sample, b) the level of physical activity, psychological well-being, perceived stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain compared to healthy controls, c) the perceived ability of persons with migraine and co-existing tension-type headache and neck pain to perform physical activity, and d) which among the three conditions (migraine, tension-type headache or neck pain) is rated as the most burdensome condition.

Methods

The study was conducted at a tertiary referral specialised headache centre where questionnaires on physical activity, psychological well-being, perceived stress and self-rated health were completed by 148 persons with migraine and 100 healthy controls matched by sex and average age. Semi-structured interviews were conducted to assess characteristics of migraine, tension-type headache and neck pain.

Results

Out of 148 persons with migraine, 100 (67%) suffered from co-existing tension-type headache and neck pain. Only 11% suffered from migraine only. Persons with migraine and co-existing tension-type headache and neck pain had lower level of physical activity and psychological well-being, higher level of perceived stress and poorer self-rated health compared to healthy controls. They reported reduced ability to perform physical activity owing to migraine (high degree), tension-type headache (moderate degree) and neck pain (low degree). The most burdensome condition was migraine, followed by tension-type headache and neck pain.

Conclusions

Migraine with co-existing tension-type headache and neck pain was highly prevalent in a clinic-based sample. Persons with migraine and co-existing tension-type headache and neck pain may require more individually tailored interventions to increase the level of physical activity, and to improve psychological well-being, perceived stress and self-rated health.

Patients with chronic, but not episodic, migraine display altered activity of their neck extensor muscles

The current study aimed to investigate differences in activity of neck flexor and extensor muscles in women with migraine considering the chronicity of their condition. Thirty-one subjects with episodic migraine, 21 with chronic migraine and 31 healthy controls participated. Surface electromyography signals were recorded bilaterally from the sternocleidomastoid, anterior scalene, splenius capitis and upper trapezius muscles as subjects performed 5 stages of cranio-cervical flexion (CCF), representing a progressive increase in range of CCF motion. Comparison of normalized root-mean-square among groups was conducted with 3×5 ANCOVA with task level as the within-subject variable, group as the between-subject variable, and the presence of neck pain and disability as co-variates. The group with chronic migraine exhibited increased activity of their extensor muscles compared to the control and episodic migraine groups (splenius capitis: F=3.149, P=0.045; upper trapezius: F=3.369, P=0.041). No significant between-group differences were found for the superficial neck flexors (sternocleidomastoid: F=1.161, P=0.320; anterior scalene: F=0.135, P=0.874). In conclusion, women with chronic migraine exhibit increased activity of their superficial neck extensor muscles when acting as antagonists during low-load isometric CCF contractions in comparison to non-headache subjects.

The relation of PTSD symptoms to migraine and headache-related disability among substance dependent inpatients

Despite emerging evidence for the comorbidity of posttraumatic stress disorder (PTSD) and migraine, few studies have examined the relation of PTSD and migraine, particularly among clinical populations at-risk for both conditions (e.g., substance-dependent patients). This study examined the role of PTSD symptoms in migraine and headache-related disability within a sample of 153 substance-dependent inpatients (37.25% female, Mean age 36.46). PTSD symptoms predicted both migraine and headache-related disability above and beyond gender, depression and anxiety symptoms, the experience of a Criterion A traumatic event, and current alcohol use disorder. Findings highlight the strong association between migraine and PTSD symptoms in a unique population at risk for both conditions.

Psychological flexibility in migraine: A study of pain acceptance and values-based action

Background

Studies of musculoskeletal pain patients confirm that acceptance of pain and values-based action are strong predictors of pain-related disability and that interventions fostering “psychological flexibility” confer positive outcomes. However, data on these processes in migraine remain limited. This cross-sectional study examined relations between components of psychological flexibility and headache among treatment-seeking migraineurs.

Methods

A total of 103 adults ( M age = 41.5 (11.9) years; 88.2% female) with ICHD-confirmed migraine (71.8% episodic, 28.2% chronic) across three clinics completed measures of psychological flexibility and headache-related disability. Hierarchical regressions quantified relations between acceptance/values-based action and headache variables after first controlling for pain severity and gender.

Results

Acceptance of pain and values-based action accounted for 10% of unique variance in headache severity (Δ R2 p = 0.006) and up to 20% in headache-related disability (Δ R2 ps = 0.02 and < 0.001) but were weakly related to headache frequency. Psychological flexibility was more strongly associated with MIDAS-measured disability than was headache severity or headache frequency. Significant effects were typically of medium-to-large size and driven primarily by values-based action.

Conclusions

Paralleling results from the broader chronic pain literature, pain acceptance and values-based action play significant roles in headache pain and disability. Further study of interventions targeting these processes may enhance existing treatments.

Quality of life in primary headache disorders: A review

BACKGROUND

Health-related quality of life (HRQoL) is emerging as an important element of clinical research in primary headache disorders, allowing a measure of the impact of headache on patients' well-being and daily life. A better understanding of this may contribute to improved resource allocations and treatment approaches.

OBJECTIVE

The objective of this study is to review available data on HRQoL in primary headache disorders and identify any influencing factors.

METHODS

Database searches including MEDLINE, PsycINFO and EMBASE were performed. Studies that investigated HRQoL in patients with primary headache disorders were included and reviewed. Trials that evaluated the efficacy of medications or interventions were excluded.

RESULTS

A total of 80 articles were included in the review. Both physical and emotional/mental aspects of HRQoL were impaired across headache subtypes, although the extent varied depending on headache type. A number of factors influencing HRQoL were also identified.

CONCLUSION

This narrative review suggests that headache, particularly in its chronic form, has a great impact on HRQoL. Clinical practice should not solely focus on pain alleviation but rather adopt routine assessment of HRQoL. Furthermore, identification and management of associated psychological comorbidities, which can significantly influence HRQoL in headache sufferers, are essential for optimal clinical management.

Gender influences headache characteristics with increasing age in migraine patients

Background and aims

Migraine headache is one of the most common primary headache disorders and is three times more prevalent in women than in men, especially during the reproductive ages. The neurobiological basis of the female dominance has been partly established. The present study aimed to investigate the effect of gender on the headache manifestations in migraine patients.

Methods

The study group consisted of 2082 adult patients from five different hospitals’ tertiary care-based headache clinics. The relationship between headache characteristics and gender was evaluated in migraine with aura (MwA) and migraine without aura (MwoA). The duration, severity, frequency of headache and associated symptoms were evaluated in both genders and age-dependent variations and analyzed in two subgroups.

Results

Women with migraine were prone to significantly longer duration and intensity of headache attacks. Nausea, phonophobia and photophobia were more prevalent in women. Median headache duration was also longer in women than in men in MwA ( p = 0.013) and MwoA ( p < 0.001). Median headache intensity was higher in women than in men in MwA ( p = 0.010) and MwoA ( p = 0.009). The frequency of nausea was significantly higher in women than in men in MwA ( p = 0.049). Throbbing headache quality and associated features (nausea, photophobia, and phonophobia) were significantly more frequent in women than in men in MwoA. The gender impact varied across age groups and significant changes were seen in female migraineurs after age 30. No age-dependent variation was observed in male migraineurs.

Conclusion

Gender has an influence on the characteristics of the headache as well as on the associated symptoms in migraine patients, and this impact varies across the age groups, particularly in women.

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.

Prevalence of neck pain in migraine and tension-type headache: a population study

BACKGROUND

We assessed the prevalence of neck pain in the population in relation to headache.

METHODS

In a cross-sectional study, a total of 797 individuals completed a headache interview and provided self-reported data on neck pain. We identified migraine, TTH or both migraine and TTH (M+TTH) groups. Pericranial tenderness was recorded in 496 individuals. A total tenderness score (TTS) was calculated as the sum of local scores with a maximum score of 48.

RESULTS

The one-year prevalence of neck pain was 68.4% and higher in those with vs. without primary headache (85.7% vs. 56.7%; adjusted OR 3.0, 95% CI 2.0-4.4, p<0.001). Adjusting for age, gender, education and poor self-rated health, in comparison with those without headaches, the prevalence of neck pain (56.7%) was significantly higher in those with M+TTH (89.3%), pure TTH (88.4%) and pure migraine (76.2%) (p<0.05 for all three group comparisons). Individuals with neck pain had higher TTS than individuals without neck pain (15.1±10.5 vs. 8.4±8.0, p<0.001).

CONCLUSIONS

Neck pain is highly prevalent in the general population and even more prevalent in individuals with primary headaches. Prevalence is highest in coexistent M+TTH, followed by pure TTH and migraine. Myofascial tenderness is significantly increased in individuals with neck pain.

Is pressure pain sensitivity over the cervical musculature associated with neck disability in individuals with migraine?

The objective was to determine if disability due to neck pain is correlated with pressure pain sensitivity in the cervical muscles in patients with migraine. Thirty-two volunteers with migraine completed the Neck Disability Index (NDI). Pressure pain thresholds (PPT) over the sternocleidomastoid, upper trapezius and suboccipital muscles were also assessed. Data were analyzed using the Spearman correlation coefficient (rs) and linear regression models (α < 0.05). Moderate negative correlations between NDI and PPT were obtained for the sternocleidomastoid (rs = -0.42; p = 0.001), upper trapezius (rs = -0.33; p = 0.001) and suboccipital muscles (rs = -0.41; p = 0.001). The linear regression revealed no association between NDI and PPT of sternocleidomastoid (β = 0.01; R(2) = 0.17), upper trapezius (β = 0.01; R(2) = 0.11) and suboccipital muscles (β = 0.02; R(2) = 0.17). NDI scores and PPT of the cervical muscles correlated moderately and was inversely proportional in patients with migraine, but the association was not linear, so both outcomes should be considered in the assessment of this population.

Dysfunctional coping in headache: avoidance and endurance is not associated with chronic forms of headache

INTRODUCTION

About 4% of the population suffer from daily or near daily headache, which in most cases evolved from an episodic type of headache. The impact of psychological factors on this process is unknown. It seems reasonable to assume, that besides somatic and social conditions psychological factors like pain-related coping and cognition play an important role, as has been shown for other pain conditions.

METHODS

We performed a cross sectional study on pain coping behaviour in 211 patients with migraine and tension type headache. Pain-related cognition and coping was investigated using the Kiel Pain Inventory. Prevalence of depression, medication intake and headache characteristics were analysed in regard to chronicity of headache.

RESULTS

Overall pain intensity was high in the patient sample. The level of depression increased with headache frequency. Dysfunctional coping, characterized by fear and avoidance is frequently used by headache patients. As in low back pain, also endurance is highly prevalent. Other features known to be associated with chronic headache, like depression and medication overuse, could be confirmed.

DISCUSSION

Dysfunctional coping was seen with high prevalence in the entire patient sample (66%). Against our hypothesis, it was not confined to chronic forms of headache. In respect to our data, we discuss the role of avoidance and endurance coping in headache and its possible role in chronicity.

Overattachment and perceived disability in chronic migraineurs

OBJECTIVES

The aim of this cross-sectional study was to assess whether stagnation dimensions and depression were associated with perceived disability in chronic migraineurs.

METHODS

Participants were 69 consecutive adult outpatients admitted to the Regional Referral Headache Centre of the Sant'Andrea Hospital in Rome, Italy. Patients were administered the Center for Epidemiologic Studies Depression Scale, the Stagnation Scale, and the Italian Perceived Disability Scale. They also compiled a headache diary to compute headache frequency.

RESULTS

Patients with higher perceived disability (compared to patients with lower perceived disability) reported higher depression and higher symptoms of stagnation. The effect of Overattachment, a dimension of the Stagnation Scale, on perceived disability was only in part mediated by the severity of depressive symptoms.

CONCLUSION

Our results confirm that many patients with chronic migraine report symptoms of stagnation, and that investigating the presence of the stagnation syndrome may be useful for understanding the psychology of chronic migraineurs.

Insights into the mechanism of onabotulinumtoxinA in chronic migraine

OnabotulinumtoxinA has recently been approved by regulatory agencies in the UK and United States for treatment of chronic migraine based on data generated from the PREEMPT studies. As such, onabotulinumtoxinA is the only prophylactic therapy specifically approved for chronic migraine. Most headache clinicians would agree that acute episodic migraine and chronic migraine differ in their pathophysiology, etiology, diagnosis, and response to pharmacological as well as nonpharmacological therapies. Of the 7 botulinum neurotoxin serotypes, botulinum neurotoxin type A (onabotulinumtoxinA) has been the most thoroughly investigated in preclinical and clinical studies. Based on preclinical studies, onabotulinumtoxinA is known to inhibit the release of excitatory neurotransmitters from both motor and sensory neurons by preventing vesicle fusion to the cell membrane. In addition to the well-documented myorelaxant effects of this neurotoxin, onabotulinumtoxinA can exert a direct analgesic effect that likely involves inhibition of primary and secondary nociceptive neurons. The inhibitory effects of onabotulinumtoxinA are also likely to involve suppressing the activity of myogenic trigger points and decreasing the persistent nociceptive barrage that promotes and maintains central sensitization. This article describes possible mechanisms to explain how onabotulinumtoxinA functions as a therapy for chronic migraine and considers why treatment with the neurotoxin is not effective in some chronic migraineurs.

Headaches in soldiers with mild traumatic brain injury: findings and phenomenologic descriptions

OBJECTIVE

The primary goal of this study was to use headache criteria-based classification for headache types described by service members.

BACKGROUND

Headache is common in soldiers returning from the wars in Afghanistan and Iraq. To date, few papers have provided detailed descriptions of these headaches.

METHODS

The first 25 patients seen by a certified headache specialist at the Traumatic Brain Injury Center at Womack Army Medical Center, Fort Bragg, NC, between August 2008 and December 2009 are reported.

RESULTS

Service members described a total of 55 headaches. Most, but not all, headaches began within 1 week after injury. Migraine type was most common. Aura occurred in 5 soldiers. Continuous headaches were described in 88%. Uncommon headache types including cluster type were diagnosed. Additional symptoms and service outcomes are described.

CONCLUSIONS

We conclude that headaches occurring after various types of head injury, including explosions, can be assigned primary and secondary headache diagnoses using standard classifications not necessarily available to larger survey-based studies.

Neuronal nitric oxide synthase is involved in the induction of nerve growth factor-induced neck muscle nociception

BACKGROUND

Neck muscle nociception mediated by nitric oxide may play a role in the pathophysiology of tension-type headache.

OBJECTIVE

The present study addresses the involvement of neuronal nitric oxide synthase (nNOS) in the facilitation of neck muscle nociception after local application of nerve growth factor (NGF).

METHODS

After administration of NGF into semispinal neck muscles, the impact of neck muscle noxious input on brainstem processing was monitored by the jaw-opening reflex in anesthetized mice. The modulatory effect of preceding and subsequent administration of an inhibitor of neuronal nitric oxide synthase on central facilitation was addressed in a controlled study.

RESULTS

With preceding i.p. application of saline or 0.096 mg/kg of the specific nNOS inhibitor Nω-propyl-L-arginine (NPLA), NGF induced a sustained reflex facilitation within 60 minutes. Preceding injection of 0.96 mg/kg or 1.92 mg/kg NPLA completely prevented the potentially facilitatory effect of NGF. Subsequent administration of 0.96 mg/kg NPLA did not affect established NGF-evoked reflex facilitation. Thus, NPLA prevents facilitation of brainstem processing by noxious myofascial input from neck muscles in a dose-dependent manner.

CONCLUSION

These findings suggest that nNOS is involved in the induction but not the maintenance of NGF-evoked facilitation of nociception in the brainstem. These results from an experimental animal model may support the idea of NOS and nNOS as potential targets for pharmacological treatment of tension-type headache.

Migraine education improves quality of life in a primary care setting

OBJECTIVE

The objective of this study was to evaluate the effectiveness of the Mercy Migraine Management Program (MMMP), an educational program for physicians and patients. The primary outcome was change in headache days from baseline at 3, 6, and 12 months. Secondary outcomes were changes in migraine-related disability and quality of life, worry about headaches, self-efficacy for managing migraines, emergency room (ER) visits for headache, and satisfaction with headache care.

BACKGROUND

Despite progress in the understanding of the pathophysiology of migraine and development of effective therapeutic agents, many practitioners and patients continue to lack the knowledge and skills to effectively manage migraine. Educational efforts have been helpful in improving the quality of care and quality of life for migraine sufferers. However, little work has been performed to evaluate these changes over a longer period of time. Also, there is a paucity of published research evaluating the influence of education about migraine management on cognitive and emotional factors (for example, self-efficacy for managing headaches, worry about headaches).

METHODS

In this open-label, prospective study, 284 individuals with migraine (92% female, mean age = 41.6) participated in the MMMP, an educational and skills-based program. Of the 284 who participated in the program, 228 (80%) provided data about their headache frequency, headache-related disability (as measured by the Headache Impact Test-6 (HIT-6), migraine-specific quality of life (MSQ), worry about headaches, self-efficacy for managing headaches, ER visits for headaches, and satisfaction with care at 4 time points over 12 months (baseline, 3 months, 6 months, 12 months).

RESULTS

Overall, 46% (106) of subjects reported a 50% or greater reduction in headache frequency. Over 12 months, patients reported fewer headaches and improvement on the HIT-6 and MSQ (all P < .001). The improvement in headache impact and quality of life was greater among those who had more worry about their headaches at baseline. There were also significant improvements in "worry about headaches,""self-efficacy for managing headaches," and "satisfaction with headache care."

CONCLUSION

The findings demonstrate that patients participating in the MMMP reported improvements in their headache frequency as well as the cognitive and emotional aspects of headache management. This program was especially helpful among those with high amounts of worry about their headaches at the beginning of the program. The findings from this study are impetus for further research that will more clearly evaluate the effects of education and skill development on headache characteristics and the emotional and cognitive factors that influence headache.

Locus of control moderates the relationship between headache pain and depression

The aim of the current study was to triangulate qualitative and quantitative data in order to examine in greater detail the relationship between self-reported headache pain severity, depression and coping styles. Psychosocial scales, headache characteristic scales and in-depth interviews were administered to 71 adults with the diagnosis of primary headache. Regression analyses with the scales showed that greater self-reported headache pain severity was associated with higher levels of depression. A high internal locus of control weakened the relationship between the headache severity and depression variables. The qualitative data supported the relationship between pain severity and internal locus of control and, in addition, revealed that perceived efficacy of pharmacologic intervention might be a related factor. The results suggested that stronger coping skills might reduce depression among headache sufferers.