Classification and clinical features of headache patients: an outpatient clinic study from China
From: J Headache Pain. 2011 Jul 9. [Epub ahead of print]
This study aimed to analyze and classify the clinical features of headache in neurological outpatients. A cross-sectional study was conducted consecutively from March to May 2010 for headache among general neurological outpatients attending the First Affiliated Hospital of Chongqing Medical University. Personal interviews were carried out and a questionnaire was used to collect medical records.
Diagnosis of headache was according to the International classification of headache disorders, 2nd edition (ICHD-II). Headache patients accounted for 19.5% of the general neurology clinic outpatients. A total of 843 (50.1%) patients were defined as having primary headache, 454 (27%) secondary headache, and 386 (23%) headache not otherwise specified (headache NOS). For primary headache, 401 (23.8%) had migraine, 399 (23.7%) tension type headache, 8 (0.5%) cluster headache and 35 (2.1%) other headache types.
Overall, migraine patients suffered (1) more severe headache intensity, (2) longer than 6 years of headache history and (3) more common analgesic medications use than tension type headache ones. Tension type headache patients had more frequent episodes of headaches than migraine patients, and typically headache frequency exceeded 15 days/month); 22.8% of primary headache patients were defined as chronic daily headache. Almost 20% of outpatient visits to the general neurology department were of headache patients, predominantly primary headache of migraine and tension type headache.
In outpatient headaches, more attention should be given to headache intensity and duration of headache history for migraine patients, while more attention to headache frequency should be given for the tension type headache ones.
Botulinum toxin for subacute/chronic neck pain.
From: Cochrane Database Syst Rev. 2011 Jul 6;7:CD008626
Neck disorders are common, disabling and costly. Botulinum toxin intramuscular injections are often used with the intention of treating neck pain. The authors systematically evaluated the literature on the treatment effectiveness of botulinum toxin for neck pain, disability, global perceived effect and quality of life in adults with neck pain with or without associated cervicogenic headache, but excluding cervical radiculopathy and whiplash associated disorder.
The authors searched randomized and quasi-randomized controlled trials in which botulinum toxin injections were used to treat subacute or chronic neck pain to 20 September 2010. They included nine trials (503 participants). Only botulinum toxin type A was used in these studies. High quality evidence suggests there was little or no difference in pain between botulinum toxin type A and saline injections at four weeks (five trials; 252 participants) and six months for chronic neck pain. Very low quality evidence indicated little or no difference in pain between botulinum toxin type A combined with physiotherapeutic exercise and analgesics and saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants) and six months (one trial; 24 participants). Very low quality evidence from one trial (32 participants) showed little or no difference between botulinum toxin type A and placebo at four weeks and six months for chronic cervicogenic headache. Very low quality evidence from one trial (31 participants), showed a difference in global perceived effect favouring botulinum toxin type A in chronic neck pain at four weeks.
Current evidence fails to confirm either a clinically important or a statistically significant benefit of botulinum toxin type A injection for chronic neck pain associated with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months.
Headache and musculoskeletal complaints among subjects with self reported whiplash injury. The HUNT-2 study.
From: BMC Musculoskelet Disord. 2011 Jun 8;12(1):129. [Epub ahead of print]
Whiplash injury occurs due to an acceleration-deceleration energy transfer to the neck resulting from motor-vehicle collisions, and the term whiplash associated disorders was introduced in order to describe the sign and symptoms associated with the injury.
The prognosis of whiplash injuries show highly variable results and may be due to differences in study populations and definitions of outcome. Usually the prognosis of whiplash is favorable and self-limited. The natural course for those that report symptoms after a whiplash trauma will in most cases be rapid improvement of pain and disability the first three months. Beyond three months there is usually little improvement. It is not clear which patients are at risk of delayed recovery following whiplash injury, but a slow or poor recovery of neck pain seems to be associated with psychological factors, compensation or legal factors and initial self reported symptom severity. The course of recovery in whiplash associated disorders is very similar to the course of neck pain in the general population.
Headache, neck pain and other subjective complaints are common in the general population, and both headache and neck pain are equally frequent in patients with and without a history of whiplash. Headache is commonly reported after a whiplash trauma, but the validity of the acute and chronic whiplash headache included in the ICHD-2 criteria are questionable and represents most likely occurrences of pre-accidental primary headaches like migraine and tension type headache, The prognosis of headache after a whiplash trauma is good and similar to non-traumatized controls.
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Effect of brief daily exercise on headache among adults – secondary analysis of a randomized controlled trial
From: Scand J Work Environ Health. 2011 May 26
This paper investigates secondary outcomes (headache) in a randomized controlled trial with physical exercise among office workers with neck/shoulder pain.
A total of 198 office workers with frequent neck/shoulder pain were randomly allocated to either one of two intervention groups (10 weeks of resistance training with elastic tubing for 2 or 12 minutes per day, 5 times a week) or the control group, which received weekly health information. Secondary outcomes included changes in frequency, intensity, and duration of headache after ten weeks.
Compared with the control group, headache frequency decreased in the 2- and 12-minute intervention groups [0.64 days/week and 0.79, corresponding to a 43% and 56% decrease from baseline, respectively]. Intensity and duration of the remaining headaches were unaffected.
Two minutes of daily resistance training for ten weeks reduces headache frequency among office workers with neck/shoulder pain. The vast number of adult workers suffering from one or two days of weekly headaches and who could potentially comply with and benefit from brief exercise programs stresses the applicability of these findings.
Presence of neck pain may delay migraine treatment.
From: Postgrad Med. 2011 Mar;123(2):163-8.
To determine whether the presence of neck pain is associated with a delay in migraine treatment. The authors have previously shown that 1) neck pain is exceedingly common in migraine; 2) its presence on the day preceding migraine is associated with impaired treatment response; and 3) neck pain is predictive of migraine related disability independent of headache frequency and severity.
This was a prospective, observational, cross-sectional study of 113 patients with migraine, ranging in attack frequency from episodic to chronic migraine. Subjects were examined by headache specialists to confirm the diagnosis of migraine and exclude both cervicogenic headache and fibromyalgia. Details of all headaches were recorded over the course of at least 1 month and until 6 qualifying migraines had been treated. Subjects were permitted to treat at the stage they customarily treated. A chi-square test of independence was performed to examine the relationship between the presence of neck pain and treatment within 30 minutes of headache onset. Analysis of variance was used to test the relationship of neck pain intensity with headache intensity at the time of migraine treatment.
Subjects recorded 2411 headache days, 786 of which were migraines, the majority of which were treated in the moderate pain stage. Presence of neck pain in the hour preceding initial migraine treatment was associated with delay in treatment beyond 30 minutes of headache onset and initiation of treatment at a greater headache pain intensity. When neck pain accompanied migraine, those with moderate or severe neck pain were more likely to treat within 30 minutes of headache onset than those with mild neck pain.
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Are pre-season reports of neck pain, dizziness and/or headaches risk factors for concussion in male youth ice hockey players?
From: Br J Sports Med. 2011 Apr;45(4):319-20.
Concussion is a commonly encountered injury associated with potential long-term sequelae. No previous studies have evaluated dizziness, neck pain and headache as potential risk factors for concussion. The objective of this study is to determine the risk of concussion in male youth hockey players with preseason reports of neck pain, headaches and dizziness.
This study is a secondary data analysis of a prospective cohort study examining the risk of injury associated with body checking among paediatric ice hockey players. Setting Youth ice hockey in Alberta and Quebec, Canada. Participants A total of 3902 11-14 year old males from 282 teams participated. Assessment of risk factors Each participant completed a pre-season baseline demographic and injury history questionnaire. Preseason reports of neck pain, headache or dizziness were documented on the Sport Concussion Assessment Tool. Main outcome measurements Diagnosed concussions were recorded during the season of play via a previously validated, prospective injury surveillance system.
A total of 178 concussions occurred during the studies, with 11 players sustaining two concussions. Incidence rate ratios were calculated using Poisson regression, adjusted for exposure hours, cluster by team and potential covariates. Dizziness was not a significant predictor of concussion. Individuals reporting a headache or neck pain at the start of the season were 1.48 and 1.69 times more likely to suffer a concussion during the season than those not reporting these symptoms. Individuals reporting any two of dizziness, headache and neck pain were 1.99 times more likely to sustain a concussion.
Male youth athletes reporting headache or neck pain at baseline were at an increased risk of concussion during the season. From an injury prevention perspective, baseline testing may aid in identifying individuals at a higher risk for concussion.
Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: a single-blind, randomized controlled study
From: Cranio. 2011 Jan;29(1):43-56.
The present study was comprised of 43 patients (16 men) with cervicogenic headaches for over three months, diagnosed according to the International Classification of Diagnostic Criteria of Headaches (ICDH-II). The patients were randomly assigned to receive either manual therapy for the cervical region (usual care group) or additional manual therapy techniques to the temporomandibular region to additionally influence temporomandibular disorders. All patients were assessed prior to treatment, after six sessions of treatment, and at a six-month follow-up. The outcome criteria were: intensity of headaches measured on a colored analog scale, the Neck Disability Index (Dutch version), the Conti Anamnestic Questionnaire, noise registration at the mandibular joint using a stethoscope, the Graded Chronic Pain Status (Dutch version), mandibular deviation, range of mouth opening, and pressure/pain threshold of the masticatory muscles.
The results indicate in the studied sample of cervicogenic headache patients, 44.1% had temporomandibular disorders. The group that received additional temporomandibular manual therapy techniques showed significantly decreased headache intensities and increased neck function after the treatment period. These improvements persisted during the treatment-free period (follow-up) and were not observed in the usual care group. This trend was also reflected on the questionnaires and the clinical temporomandibular signs. Based on these observations, we strongly believe that treatment of the temporomandibular region has beneficial effects for patients with cervicogenic headaches, even in the long-term.
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Effectiveness of an educational and physical program in reducing accompanying symptoms in subjects with head and neck pain: a workplace controlled trial
From: J Headache Pain. 2011 Jan 20. [Epub ahead of print]
The objective of this study is to evaluate the effectiveness of an educational and physical program in reducing behavioral or somatic symptoms along with headache, neck and shoulder pain in a working community. A controlled, non-randomized trial was carried out in a working community and 384 employees were enrolled and divided into a study group (Group 1) and a control group (Group 2). The Group 1 received a physical and educational intervention, consisting of relaxation and posture exercises and the use of visual feedback. After 6 months, the intervention was administered to the Group 2. Both groups were then followed for an additional 6 months until the end of the trial. The presence of accompanying symptoms was investigated with a semi-structured interview using a checklist of 20 items, along with headache, neck, and shoulder pain parameters and the prevalence of generalized anxiety disorder and depression, in three clinical examinations at baseline, after 6 months and after 12 months. For each symptom, as well as the presence of any type of symptom, the differences between groups in the prevalence at the clinical examinations following the baseline were evaluated by applying logistic models.
After 6 months, the probability of the presence of any type of symptom was significantly lower in the Group 1 with respect to the Group 2. After 12 months, the pooled estimation did not show any significant difference of symptom prevalence between groups. In conclusion, this is the first longitudinal study relative to accompanying symptoms. Its results suggest the effectiveness of this cognitive program in reducing the burden of physical and psychiatric complaints in a large, working population.
Treating tension-type headache – an expert opinion
From: Expert Opin Pharmacother. 2011 Jan 20. [Epub ahead of print]
Tension type headache is a highly prevalent disorder with enormous costs for the individual and the society. Nonpharmacological and pharmacological treatments are reviewed. Electromyographic (EMG) biofeedback has a documented effect in tension type headache, while cognitive-behavioral therapy and relaxation training are most likely to be effective. Physical therapy and acupuncture may be valuable options for patients with frequent tension type headache. Simple analgesics and nonsteroidal anti-inflammatory drugs are recommended for treatment of episodic tension type headache. Combination analgesics containing caffeine are drugs of second choice. Triptans, muscle relaxants and opioids should not be used. It is crucial to avoid frequent and excessive use of analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is the drug of first choice for the prophylactic treatment of chronic tension type headache. Mirtazapine and venlafaxine are second-choice drugs.
There is an urgent need for more research in nonpharmacological as well as pharmacological treatment possibilities of tension type headache. Future studies should examine the relative efficacy of the various treatment modalities and clarify how treatment programs can be optimized and combined to best suit the individual patient. Frequent tension type headache may be difficult to treat, but an acceptable result can usually be obtained by a combination of nonpharmacological and pharmacological treatments.
Synovial folds – A pain in the neck?
From: Man Ther. 2011 Jan 7. [Epub ahead of print]
The synovial folds of the cervical spine are regarded as a potential source of neck pain and headache, especially following whiplash injury. Damage to the synovial folds following motor vehicle trauma has been well documented in post-mortem studies. However, methods of identifying injury to the synovial folds in the survivors of motor vehicle trauma have proven elusive to date. Recently, it has been made possible to image the synovial folds in vivo using magnetic resonance imaging. This now makes it feasible to investigate the potential involvement of synovial folds in the generation of neck pain and headache and its relief using spinal manipulation. This paper reviews critically the morphology of the synovial folds of the cervical spine that underpins the hypotheses proposed to explain their functional and clinical significance and a new system of naming and classifying the synovial folds is presented. Although there is some evidence to support the contribution of the synovial folds to neck pain, several theories have little or no support and require investigation and further evaluation. These findings have implications for understanding the anatomical basis of neck pain and headache and the rationale for the use of spinal manipulation in their management.
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