Possible mechanisms of action of nitric oxide synthase inhibitors in chronic tension-type headache.
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It has been demonstrated recently that nitric oxide synthase (NOS) inhibition has an analgesic effect in patients with chronic tension-type headache. The aim of the present study was to investigate the influence of the NOS inhibitor, L-N(G) methyl arginine hydrochloride (L-NMMA), on two of the most prominent features of chronic tension-type headache, i.e. increased muscle hardness and increased myofascial tenderness. In a double blind, crossover designed trial, 16 patients with chronic tension-type headache were randomized to receive intravenous infusion of 6 mg/kg L-NMMA or placebo on 2 days separated by at least 1 week. Muscle hardness of the trapezius muscle was measured with a hardness meter. Myofascial tenderness in the pericranial region was evaluated by manual palpation with standardized and validated methodology. All parameters were recorded at baseline and at 60 and 120 min after start of infusion. Compared with baseline, muscle hardness, 107 +/- 17 kPa/cm and tenderness, 18 +/- 11 were significantly reduced at 60 and 120 min to: hardness, 101 +/- 17 kPa/cm and 101 +/- 17 kPa/cm, respectively; tenderness, 15 +/- 11 and 14 +/- 11, respectively, after treatment with L-NMMA (P < 0.05 and P < 0.01, respectively), while there was no significant reduction at any time after treatment with the placebo. Compared with the placebo, the summary score of muscle hardness was significantly reduced (P = 0.04), while tenderness showed a non-significant reduction (P = 0.11) following treatment with L-NMMA. Since increased muscle hardness in patients with chronic tension-type headache may reflect sensitization of second order neurons due to prolonged nociceptive input from myofascial tissues, we suggest that the decrease in muscle hardness following treatment with L-NMMA may be caused by reduction of central sensitization. (+info)
Headaches and other pain symptoms among patients with psychogenic non-epileptic seizures.
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Studies of patients with psychogenic non-epileptic seizures (NES) typically focus upon the phenomenology and outcome of NES episodes. Little is known, however, about the frequency and nature of other somatic symptoms such as pain, in this population. To assess the frequency, location and severity of symptoms of pain among NES patients, we administered structured interviews to 56 patients, 6 or more months following the diagnosis of psychogenic non-epileptic seizures (NES). Patients were recruited from a tertiary hospital-based epilepsy monitoring unit. Seventy-seven percent of patients suffered from moderate to severe pain, most commonly headache (61%), while neck pain and backache were also common. Twenty-six of 27 patients with persistent NES vs. 17 of 29 patients whose NES resolved experienced moderate to severe pain (P < 0.001). Pain is an under-recognized problem that occurs frequently and with significant severity among NES patients. Pain symptoms are more common among patients with persistent NES than those whose NES resolve. (+info)
Psychosocial correlates and impact of chronic tension-type headaches.
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OBJECTIVES: To examine the psychosocial correlates of chronic tension-type headache and the impact of chronic tension-type headache on work, social functioning, and well-being. METHODS: Two hundred forty-five patients (mean age = 37.0 years) with chronic tension-type headache as a primary presenting problem completed an assessment protocol as part of a larger treatment outcome study. The assessment included a structured diagnostic interview, the Medical Outcomes Study Short Form, Disability Days/Impairment Ratings, Recurrent Illness Impact Profile, Beck Depression Inventory, State-Trait Anxiety Inventory-Trait Form, Primary Care Evaluation for Mental Disorders, and the Hassles Scale Short Form. Comparisons were made with matched controls (N = 89) and, secondarily, with Medical Outcomes Study data for the general population, arthritis, and back problem samples. RESULTS: About two thirds of those with chronic tension-type headache recorded daily or near daily (> or =25 days per month) headaches with few (12%) recording headaches on less than 20 days per month. Despite the fact that patients reported that their headaches had occurred at approximately the present frequency for an average of 7 years, chronic tension-type headache sufferers were largely lapsed consulters (54% of subjects) or current consulters in primary care (81% of consulters). Significant impairments in functioning and well-being were evident in chronic tension-type headache and were captured by each of the assessment devices. Although headache-related disability days were reported by 74% of patients (mean = 7 days in previous 6 months), work or social functioning was severely impaired in only a small minority of patients. Sleep, energy level, and emotional well-being were frequently impaired with about one third of patients recording impairments in these areas on 10 or more days per month. Most patients with chronic tension-type headache continued to carry out daily life responsibilities when in pain, although role performance at times was clearly impaired by headaches and well-being was frequently impaired. Chronic tension-type headache sufferers were 3 to 15 times more likely than matched controls to receive a diagnosis of an anxiety or mood disorder with almost half of the patients exhibiting clinically significant levels of anxiety or depression. Affective distress and severity of headaches (Headache Index) were important determinants of headache impact/impairment. CONCLUSIONS: Chronic tension-type headache has a greater impact on individuals' lives than has generally been realized, with affective distress being an important correlate of impairment. If treatment is to remedy impairment in functioning, affective distress, as well as pain, thus needs to be addressed. (+info)
Nitric oxide-induced headache in patients with chronic tension-type headache.
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An experimental model of headache offers unique possibilities to study the mechanisms responsible for head pain. Using the glyceryl trinitrate [GTN; nitric oxide (NO) donor] model of experimental headache, we studied the intensity, quality and time profile of headache after infusion of GTN in 16 patients with chronic tension-type headache and in 16 healthy controls. Subjects were randomized to receive intravenous infusion of GTN (0.5 microg/kg per minute for 20 min) or placebo on two headache-free days separated by at least 1 week. Headache intensity was measured on a 10-point verbal rating scale during 2 h of observation and for the next 10 h after discharge from hospital. The primary endpoints were the difference between the area under the curve (AUC-intensities x duration) for headache recorded on the day of GTN treatment and on the day of placebo treatment in patients, and in patients and controls on the days of GTN treatment. In patients, the AUC on a GTN day [2221 (1572-3704); median with quartiles in parentheses], was significantly greater than on a placebo day [730 (60-1678), P: = 0. 008]. On the GTN day, the AUC in patients [2221 (1572-3704)] was significantly higher than in controls [43 (0-972), P: = 0.0001]. In patients, peak pain intensity occurred 8 h after infusion of GTN, whereas in controls it occurred 20 min after the start of infusion. The present study demonstrates that an NO-induced biphasic response with an immediate and a delayed headache is common to chronic tension-type headache and migraine. Furthermore, the NO-induced delayed headache has the characteristics of the primary headache disorder. This suggests that NO contributes to the mechanisms of several types of primary headaches and that NO-related central sensitization may be an important common denominator in the pain mechanisms of primary headaches. (+info)
Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial.
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CONTEXT: Chronic tension-type headaches are characterized by near-daily headaches and often are difficult to manage in primary practice. Behavioral and pharmacological therapies each appear modestly effective, but data are lacking on their separate and combined effects. OBJECTIVE: To evaluate the clinical efficacy of behavioral and pharmacological therapies, singly and combined, for chronic tension-type headaches. DESIGN AND SETTING: Randomized placebo-controlled trial conducted from August 1995 to January 1998 at 2 outpatient sites in Ohio. PARTICIPANTS: Two hundred three adults (mean age, 37 years; 76% women) with diagnosis of chronic tension-type headaches (mean, 26 headache d/mo). INTERVENTIONS: Participants were randomly assigned to receive tricyclic antidepressant (amitriptyline hydrochloride, up to 100 mg/d, or nortriptyline hydrochloride, up to 75 mg/d) medication (n = 53), placebo (n = 48), stress management (eg, relaxation, cognitive coping) therapy (3 sessions and 2 telephone contacts) plus placebo (n = 49), or stress management therapy plus antidepressant medication (n = 53). MAIN OUTCOME MEASURES: Monthly headache index scores calculated as the mean of pain ratings (0-10 scale) recorded by participants in a daily diary 4 times per day; number of days per month with at least moderate pain (pain rating >/=5), analgesic medication use, and Headache Disability Inventory scores, compared by intervention group. RESULTS: Tricyclic antidepressant medication and stress management therapy each produced larger reductions in headache activity, analgesic medication use, and headache-related disability than placebo, but antidepressant medication yielded more rapid improvements in headache activity. Combined therapy was more likely to produce clinically significant (>/=50%) reductions in headache index scores (64% of participants) than antidepressant medication (38% of participants; P =.006), stress management therapy (35%; P =.003), or placebo (29%; P =.001). On other measures the combined therapy and its 2 component therapies produced similar outcomes. CONCLUSIONS: Our results indicate that antidepressant medication and stress management therapy are each modestly effective in treating chronic tension-type headaches. Combined therapy may improve outcome relative to monotherapy. (+info)
Temporomandibular disorders in adults with repaired cleft lip and palate: a comparison with controls.
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The purpose of this study was to investigate the prevalence of temporomandibular disorders (TMD), and assess psycho-social distress in adult subjects with repaired complete cleft lip and palate (CLP). Sixty-three adults (42 males and 21 females, mean age 24.2 years, range 19.5-29.2) with repaired CLP (CLP group) were compared with a group of 66 adults without cleft (non-cleft group, 49 males and 17 females, mean age 25.5 years, range 20.2-29.9). All subjects underwent a clinical TMD examination, which followed the guidelines in the Research Diagnostic Criteria for TMD (RDC/TMD). Jaw function was assessed by evaluating answers to the mandibular function impairment questionnaire (MFIQ). Tension-type headache was diagnosed according to the International Headache Society (IHS) classification. Psychological status was assessed using the depression score and the non-specific physical symptom score with subscales of the Revised Symptom Checklist-90 (SCL-90-R). The prevalence of reported pain in the face, jaws and/or TMJs was 14 and 9 per cent for the CLP and non-cleft group, respectively, and did not differ significantly between the groups. The CLP group exhibited a significantly reduced jaw-opening pattern (P < 0.001) and a higher frequency of crossbites (P < 0.05) compared with the non-cleft group. Whilst jaw function was similar in both groups, a few items, e.g. speech and drinking, were significantly more impaired (P < 0.01) in the CLP group than in the non-cleft group. There were no significant differences between the two groups concerning tension-type headache or psycho-social distress. The study found that overall TMD pain or psycho-social distress was not more common in this CLP group than in a non-cleft group. (+info)
Management of primary headache: serendipity and science.
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Most patients find some relief with current agents, even though a poor understanding of the causes of chronic primary headache limits prophylaxis and treatment. The author reviews current preventive and treatment strategies for migraine, chronic tension headache, cluster headache, and substance withdrawal headache. (+info)
Physical and psychological correlates of primary headache in young adulthood: a 26 year longitudinal study.
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OBJECTIVES: To determine if physical and/or psychological risk factors could differentiate between subtypes of primary headache (migraine, tension-type headache (TTH), and coexisting migraine and TTH (combined)) among members of a longitudinal birth cohort study. METHODS: At age 26, the headache status of members of the Dunedin Multidisciplinary Health and Development Study (DMHDS) was determined using International Headache Society criteria. Headache history and potential physical and psychological correlates of headache were assessed. These factors included perinatal problems and injuries sustained to age 26; and behavioural, personality, and psychiatric disorders assessed between ages 5 to 21. RESULTS: The 1 year prevalences for migraine, TTH, and combined headache at the age of 26 were 7.2%, 11.1%, and 4.3%, respectively. Migraine was related to maternal headache, anxiety symptoms in childhood, anxiety disorders during adolescence and young adulthood, and the stress reactivity personality trait at the age of 18. TTH was significantly associated with neck or back injury in childhood (before the age of 13). Combined headache was related to maternal headache and anxiety disorder at 18 and 21 only among women with a childhood history of headache. Headache status at the age of 26 was unrelated to a history of perinatal complication, neurological disorder, or mild traumatic head injury. CONCLUSIONS: Migraine and TTH seem to be distinct disorders with different developmental characteristics. Combined headache may also have a distinct aetiology. (+info)