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.

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.

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.

The construct validity of the whiplash syndrome is questionable, and several studies report an association between whiplash injury and a wide variety of symptoms and pain in other areas not restricted to the head and neck region. Two studies have specifically evaluated the risk factors associated with the occurrence of wide spread bodily pain after motor vehicle collision, but these studies included insurance claimants and it is therefore not known whether there is an increased prevalence of musculoskeletal complaints among subject with self reported whiplash injury in the general population. Thus the main purpose of the present study was to study the relationship between self reported whiplash injury and chronic musculoskeletal complaints and headache in a large unselected adult population.

In this large population-based, cross-sectional study, self-reported whiplash injury was associated with increased prevalence of headache and chronic musculoskeletal complaints, which was evident for all anatomical sites. Individuals with a combination of headache and chronic musculoskeletal complaints were five times more likely to report whiplash injury than those without any complaints.

The life-time prevalence of having sustained a whiplash trauma in our study was 2.9% and is much lower than the 15.9% reported in a population-based cross-sectional study among the Saskatchewan population. Published reports from the Confederation of Norwegian Enterprise comprising all the Norwegian government insurance companies indicate that the most common cause of whiplash, a rear end collision, in year 2000 involved 54000 vehicles and half of these were hit from behind, i.e. 27000 people. Over a 10 year period one can calculate that approximately 270 000, i.e. 6% of the population, will be involved in such collision. In addition comes all other traffic and sport accidents. This means that the percentage who have sustained on an accident with whiplash mechanism within a relevant time period is probably much higher than the 2.9% who self report a whiplash accident. It is therefore very likely that whiplash traumas were grossly under-reported in the present study, and that selective reporting, e.g. among those with complaints may be present.

The present results are in accordance with previous cross-sectional studies, reporting a wide variety of health complaints among persons with self-reported whiplash injury and a Swedish cohort study showed that persons with chronic pain after a whiplash injury had an increased risk for pain from different anatomical sites. There are some that argue that these symptoms might reflect central sensitization but there is also a strong association between whiplash injury and psychiatric disorders, which might reflect a reversed causality, that is, increased risk of future self-reported whiplash injury in individuals who already have anxiety and depression. Thus, the strong relationship between whiplash injury and the combination of headache and chronic musculoskeletal complaints in the present study may, at least in part, reflect personality traits rather than biological mechanisms.

It should be emphasized that in studies dealing with subjective complaints like headache, musculoskeletal pain and psychiatric symptoms, the results may be influenced by a tendency to answer in a similar way all questions regarding complaints (reporting bias). The results from the present cross-sectional study must be evaluated with caution. It cannot be determined whether whiplash injury causes neither musculoskeletal complaints nor headache, or whether other risk factors or a shared susceptibility causes these associations. Secondly, since both headache, chronic musculoskeletal complaints and whiplash injury are based on self-report, individuals with neck pain and other pain are more likely to remember and report a previous neck trauma than those without complaints, i.e. differential information (recall bias).

Even though the use of validated questionnaires reduces the risk for misclassification, the questionnaire-based diagnoses are not optimal when compared to interview diagnoses. There is a possibility of non-differential misclassification of diagnosis that might weaken real associations, but the authors think this is a minor problem as the prevalence of headache and musculoskeletal complaints in the current population is consistent with data from other population-based studies in the Western countries.

In addition the large and unselected population and the high participating rate, reduces the risk of selection bias. Selective participation was unlikely, since neither headache, neck distortion nor chronic musculoskeletal complaints were the main objectives. The impact of non-participants has been discussed in more detail previously, but the large sample size decreased the risk of chance findings and the wide range of data made it possible to adjust for potential confounding variables.

Subjects with self reported whiplash injury had significantly more headache and musculoskeletal complaints than those without, and may in part be due to selective reporting. The causal mechanism remains unclear and cannot be addressed in the present study design.

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.

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.

Presence of neck pain was associated with delayed treatment of migraine, as indicated not only by higher pain burden at time of treatment but also by delay beyond 30 minutes.

In The prevalence of neck pain in migraine. Headache. 2010 Sep;50(8):1273-7. Epub 2010 Jan 18, a study was done to determine the prevalence of neck pain at the time of migraine treatment relative to the prevalence of nausea, a defining associated symptom of migraine.

It was concluded, neck pain was more commonly associated with migraine than was nausea, a defining characteristic of the disorder. Awareness of neck pain as a common associated feature of migraine may improve diagnostic accuracy and have a beneficial impact on time to treatment.

Neck pain is often not recognized as a significant symptom associated with migraine. The article shows that neck pain is more common than nausea in migraine patients. It also emphasizes that this symptom is not mentioned by patients, and doctors do not often ask about it. Neck pain may serve as a warning for impending migraine and may be a better standard by which to gauge severity of migraine and measure treatment.

Related Source: Advances in Migraine Treatment

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.

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.

In The effects of manual therapy and exercise directed at the cervical spine on pain and pressure pain sensitivity in patients with myofascial temporomandibular disorders. J Oral Rehabil. 2009 Sep;36(9):644-52. Epub 2009 Jul 14.

Treatments were directed at the cervical spine in patients with temporomandibular disorders. Our aim was to investigate the effects of joint mobilization and exercise directed at the cervical spine on pain intensity and pressure pain sensitivity in the muscles of mastication in patients with temporomandibular disorders.

It was concluded, The application of treatment directed at the cervical spine may be beneficial in decreasing pain intensity, increasing pain pressure thresholds over the masticatory muscles and an increasing pain-free mouth opening in patients with myofascial temporomandibular disorders.

In, Cervicogenic headaches: a critical review. Spine J. 2001 Jan-Feb;1(1):31-46. The review indicated: Hilton described the concept of headaches originating from the cervical spine in 1860. In 1983 Sjaastad introduced the term “cervicogenic headache”. Diagnostic criteria have been established by several expert groups, with agreement that these headaches start in the neck or occipital region and are associated with tenderness of cervical paraspinal tissues. Prevalence estimates range from 0.4% to 2.5% of the general population to 15% to 20% of patients with chronic headaches. cervicogenic headache affects patients with a mean age of 42.9 years, has a 4:1 female disposition, and tends to be chronic. Almost any pathology affecting the cervical spine has been implicated in the genesis of cervicogenic headache as a result of convergence of sensory input from the cervical structures within the spinal nucleus of the trigeminal nerve.

The main differential diagnoses are tension type headache and migraine headache, with considerable overlap in symptoms and findings between these conditions. No specific pathology has been noted on imaging or diagnostic studies which correlates with cervicogenic headache. cervicogenic headache seems unresponsive to common headache medication. Small, noncontrolled case series have reported moderate success with surgery and injections. A few randomized controlled trials and a number of case series support the use of cervical manipulation, transcutaneous electrical nerve stimulation, and botulinum toxin injection.

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.

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.

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.

Intra-articular synovial folds are formed by folds of synovial membrane (synovium) that project into the joint cavity and are found in synovial articulations throughout the vertebral column. The earliest description of synovial folds in the vertebral column is attributed to Henle in 1855 (Dörr, 1958). Since then the gross morphology, histology, innervation and pathology of the synovial folds of the human cervical spine have been studied predominantly in cadavers or surgically removed tissue. Recently, advances in magnetic resonance (MR) imaging have made it possible to study the cervical synovial folds in vivo with greater resolution and reduced acquisition times than previous attempts using cadavers. The optimal plane for imaging the synovial folds is the sagittal plane from which measurements have been made and 3D models created to quantify the normal morphology of the synovial folds. To date these MR methods have not been employed in a clinical setting.

Correlation of synovial fold injury to clinical presentations of neck pain, whose pathological basis remains elusive to date and where radiological investigations have proven to be insufficiently sensitive to elucidate the source of pain and disability, has been attempted by many authors. Hypotheses proposed to explain these clinical presentations include synovial fold ENtrapment, synovial fold EXtrapment, intra-articular adhesions and synovial fold impingement following whiplash. Most of these theories depend upon the existence of sensory nerve elements within the synovial folds that may become irritated by deformation and/or inflammation and are closely related to theories concerning the mechanism of spinal manipulation and mobilisation for the treatment of spinal pain and disability. The major limitation of these theories is that to date they have been solely based on the post-mortem morphology of the synovial folds.

Until recently, investigations of the morphology of the cervical synovial folds have been limited to cadaveric studies. The ability to visualise the synovial folds of the cervical spine in vivo using MR imaging and quantify their morphology now provides an opportunity to investigate and identify possible synovial fold injury in patients with neck pain. Currently the hypotheses concerning the clinical significance of the synovial folds are speculations only and it is hoped that MR imaging will enable potential mechanisms of synovial fold injury to be determined. Furthermore MR imaging provides the prospect of investigating whether manual therapy has a mechanical effect upon injured synovial folds in patients with neck pain. A method for diagnosing some types of neck pain, especially those that result from whiplash, would improve our understanding of the pathoanatomical basis of neck pain and enable appropriate treatment and management options to be developed.

Reference: Synovial folds – A pain in the neck?