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Headache disorders recently have been reclassified, and new operational diagnostic criteria assist in making the correct diagnosis. These diagnostic criteria have been accepted worldwide.
Head, neck, and facial pain disorders possess characteristic features that, in some ways, distinguish them from other painful disorders. Generally speaking, the headache disorders can be reconciled within the same model of assessment as that of other painful conditions.
The classification and diagnostic criteria of the primary headaches--migraine, tension-type headache, and cluster headache--have been reviewed. Additional features of these conditions may enhance diagnostic accuracy. Modification of the classification and diagnostic criteria will take place as epidemiologic and pathophysiologic data continue to develop.
Recent studies indicate that aerobic activities might reduce severity and/or frequency of migraine attacks. The present study was intended to investigate whether physical activities and fitness (aerobic endurance, flexibility, and muscle strength endurance) as well as body composition are different in patients with headache disorders and healthy control subjects. The study included 56 patients (aged 17-64 years) with headache disorders (migraine, tension-type, cluster, analgetics abuse, and other types of headache) and 145 age-matched volunteers without history of recurrent or chronic headache. A standardized questionnaire revealed similar self-esteem of physical activities in both groups. Objective physical fitness testing in a representative sample of 22 patients and 36 control subjects showed significantly reduced aerobic endurance in female and male patients as well as reduced flexibility in female patients as compared to control subjects, whereas muscle strength endurance was not significantly different between both groups. Female patients presented with a significantly higher total body fat as compared to control subjects. In conclusion, headache patients turned out to be less physically fit than control subjects. There was a discrepancy between self-esteem and objective test results regarding physical activity and fitness in patients with headache disorders.
For 20 years botulinum toxin A has been used for the treatment of a variety of disorders characterised by pathologically increased muscle contraction. Recently, treatment of tension headache, migraine, cluster headache, and myofascial pain syndromes of neck, shoulder girdle, and back with botulinum toxin A has become a rapidly expanding new field of research. Several modes of action are discussed for these indications. The blockade of cholinergic innervation reduces muscular hyperactivity for 3 to 6 months. Degenerative changes in the musculoskeletal system of the head and neck are prevented. Nociceptive afferences and blood vessels of the pericranial muscles are decompressed and muscular trigger points and tender points are resolved. The normalisation of muscle spindle activity leads to a normalisation of muscle tone and central control mechanisms of muscle activity. Oromandibular dysfunction is eliminated and muscular stress removed. However, the effect of botulinum toxin A cannot be explained by muscular actions only. Its retrograde uptake into the central nervous system modulates the expression of substance P and enkephalins in the spinal cord and nucleus raphe. Recent findings suggest an inhibition of sterile inflammation which may lead to a blockade of the neurogenic inflammation believed to be the pathophysiological substrate of primary headache disorders. The efficacy of botulinum toxin A in the treatment of pain disorders is being investigated in several studies at the moment. The results and experiences obtained so far present new alternatives in the treatment of chronic pain disorders. The practical use of botulinum toxin A is demonstrated.
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The main purpose of this study was to assess neck mobility (by Cybex equipment) in different headache disorders and, in particular, cervicogenic headache, and to compare these findings with those in controls. A total of 51 control subjects and 90 headache patients were investigated, where of 28 patients suffered from common migraine (migraine without aura), 34 from tension-type headache (9 episodic and 25 chronic), and 28 patients from cervicogenic headache. One-way ANOVA and post hoc Bonferroni analysis showed significant differences between those with cervicogenic headache and the other groups for rotation (P < 0.001) and flexion/extension (P < 0.001), but not for lateral neck movement (P = NS). There were no significant differences between migraine patients, tension-type headache patients, and controls. In all four groups, there was a significant positive correlation between active and passive neck movement for rotation (P < 0.001), flexion/extension (P < 0.001), and lateral neck movement (P < 0.001). Repeated measures analysis of variance (ANOVA) showed no significant day-to-day differences in 10 control subjects. In the control group (n = 51), there was a significant negative correlation between age and neck movement. For rotation, Pearson's correlation coefficient was; r = -0.71 (P < 0.001), for flexion/extension r = -0.71 (P < 0.001), and for lateral neck movement r = -0.67 (P < 0.001). No significant sex difference was found as for any of the neck movements. Pain at the time of investigation did not seem to influence neck mobility. Cervicogenic headache has been recognized as a pain syndrome by the International Association for the Study of Pain (IASP). Since reduced neck mobility is one of the major criteria for this diagnosis, it emphasizes the need for systematic, objective neck mobility measurements in the individual patient to substantiate the diagnosis. The technique is simple and proved reliable.
Clinical features and pathophysiological mechanisms of primary (idiopathic) headaches are revisited in the light of the new classification of headache, recently proposed by the Ad Hoc Committee of the International Headache Society. This computer-based classification is hierarchically constructed and offers operational diagnostic criteria for all headache disorders. However, further investigations are required in some cases (e.g. in case of tension-type headache) to better define the clinical form.
The long-term effects of relaxation training for pediatric headache disorders was determined for 17 of 20 original participants from a prospective control-group experimental design study with random assignment to autogenic relaxation, progressive relaxation, autogenic plus progressive relaxation, or waiting list control groups. Long-term follow-up data were obtained at an average of 51 months post-treatment. All participants reported some increases in headache activity. Participants in the three relaxation treatment groups, however, had significantly more headache-free days and less severe headaches compared to the control group. There were no significant effects of treatment for headache duration, medication intake and rest time due to headache. Twelve of the 13 treated participants indicated relaxation training was effective in relieving headaches, with 7 reporting they practiced relaxation exercises within the past month. The results generally support the long-term benefits of relaxation in reducing headaches originating in childhood.
A literature review concerning the relationships between motor vehicle accidents and temporomandibular disorders, whiplash, headache, neck pain, and litigation was undertaken. The review shows that many patients recover or resume work prior to settlement, but most unsuccessfully treated patients do not generally recover following the settlement of legal claims; the postinjury problems are not strictly psychologic. Litigating patients and nonlitigating patients are often not dramatically different in most important regards (including pain and return to work), with litigating patients deserving the same treatment as other patients with chronic pain. It was found that postinjury neck symptoms and headaches can be persistent. Employment appears to be a better predictor of long-term outcome than compensation and litigation. In addition, limited consensus is available concerning prognostic factors. Patients with postinjury temporomandibular disorders tend to respond less well to treatment than do noninjury patients with temporomandibular disorders, as do litigating compared to nonlitigating temporomandibular disorders patients, but a cause and effect relationship is not known. The incidence of temporomandibular disorders following motor vehicle accidents may not be as high as has been claimed in whiplash cases. More research is required in the area of temporomandibular disorders, motor vehicle accidents, and litigation.
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This article presents a selective summarization and critique of research on the psychological treatment of headache, with the primary focus on research appearing since 1980. Suggestions for future research directions and methodological improvements are included.
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This is the first in a series of three articles addressing nonpharmacologic therapies for management of recurrent migraine and tension-type headache. It provides an overview of the commonly employed nonpharmacologic therapies for recurrent headache, reviews scientific evidence of their efficacy, and identifies the psychosocial interventions that have the greatest potential to enhance the management of recurrent migraine and tension-type headache in primary care settings internationally. In the second article, the authors offer practical guidelines for the administration of recommended nonpharmacologic interventions. The third article explores healthcare policy implications involved in a decision to incorporate psychosocial interventions into primary care practice.
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