Neurological Sciences

, Volume 36, Issue 10, pp 1771–1775 | Cite as

Serum oxidant and antioxidant status of patients with chronic tension-type headache: possible effects of medical treatment

  • Burcu Gökçe ÇokalEmail author
  • Bilal Aytaç
  • Zahide Esra Durak
  • Hafize Nalan Güneş
  • Bahadır Öztürk
  • Selda Keskin Güler
  • İlker Durak
  • Tahir Kurtuluş Yoldaş
Original Article


Tension-type headache (TTH) is one of the most common and costly primary types of headache in clinical practice, with an unknown etiology. This study assessed to investigate oxidative and antioxidative status in patients with chronic tension-type headache (CTTH), and to evaluate possible effect of medical treatment. The study included 41 CTTH patients and 19 age- and sex-matched healthy subjects without headache as controls. The CTTH group comprised 20 patients receiving treatment and 21 untreated patients. We evaluated oxidant/antioxidant status by measuring serum malondialdehyde (MDA) levels and activities of antioxidant enzymes, namely glutathione peroxidase (GSH-Px) and catalase (CAT). Comparison of oxidative parameters in the patient and control groups revealed significantly lower CAT activities and higher MDA level and GSH-Px activities in the patient group. In the CTTH group, serum CAT activities were found to be significantly decreased in patient groups, while serum MDA levels and GSH-Px activities were found to be higher in the untreated CTTH patients. These findings suggest that oxidative stress is increased in the patients with CTTH, and medical treatment abolishes the stress in part. It has been concluded that antioxidant support might be helpful for the patients with CTTH to prevent oxidant stress and peroxidation damages further.


Tension-type headache Treatment Oxidative stress Malondialdehyde Catalase Glutathione peroxidase 


Tension-type headache (TTH) is one of the most common and costly primary types of headache in clinical practice [1]. Tension headaches affect 16–30 % of people worldwide, and are more common in females than in males. The prevalence peaks between the age of 30 and 39, and decreases slightly thereafter with age in both sexes [2]. The term TTH was adopted by the International Classification Headache Disorders I (ICHD-I) [3] in 1988 and remained unchanged in the ICHD-II [4] in 2004.

TTH is a complex disorder, and heterogeneous mechanisms are thought to play a role [5]. Both peripheral mechanisms (e.g., tenderness of pericranial myofascial tissues) and central mechanisms (e.g., sensitization of the central nervous system [CNS]) have been demonstrated in patients with TTH. Peripheral mechanisms are thought to play a greater role in episodic TTH, whereas central mechanisms are likely more important in the occurrence of chronic TTH (CTTH) [6]. Despite numerous clinical and neurophysiological studies, the pathophysiology of TTH is not clear.

The activities of both oxidant and antioxidant enzymes have been investigated in various types of diseases and in TTH; however, the effects of treatments against oxidants and antioxidants in serum of patients with CTTH have not been investigated. Therefore, we investigated the oxidative and antioxidative status of patients with CTTH, and evaluated the possible effects of medical treatment.

Materials and methods


Analytical grade chemicals were purchased from Sigma (St. Louis, MO, USA) for use in the biochemical analyses.

Experimental design

We recruited patients from the Outpatient Headache Unit in the Department of Neurology, Ankara Education and Research Hospital. This study was approved by the hospital ethics committee. Written informed consent was obtained from all patients and controls. The CTTH group was composed of 41 patients [32 females (78 %), 9 males (22.0 %); mean age, 37.65 ± 10.97 years], and the control group included 19 sex-matched healthy subjects without headache [15 females (78.9 %), 4 (21.1 %) males; mean age, 36.74 ± 6.86 years]. There were 20 treated CTTH patients (mean age, 39.70 ± 11.56 years) and 21 untreated patients (mean age, 35.60 ± 10.23 years). CTTH was diagnosed by a neurologist according to the International Headache Society criteria [4]. Routine laboratory tests were performed, such as whole blood count, routine biochemistry, and thyroid function tests, and the levels were within the normal ranges. Further, vitamin B-12, folate, and ferritin levels as well as prothrombin time were within the normal ranges. Computed tomography (CT) or magnetic resonance imaging (MRI) was also performed when deemed necessary to exclude secondary headache.

The treated patients were chosen among CTTH patients who were taking antidepressant drugs for prophylaxis at least 4 weeks prior to study. Untreated patients were chosen among CTTH patients who did not take any prophylactic or acute attack treatments within the 4 weeks prior to the study.

All subjects underwent a thorough clinical examination to detect signs or symptoms of neurological, psychiatric, chronic, or infectious diseases. The exclusion criteria were: hypertension, any renal function disorder, endocrinological or rheumatological diseases, an active infection, cigarette smoking, alcohol consumption, and taking any other kind of medicine for at least 4 weeks prior to the study.

Biochemical analysis

Fasting blood samples were collected at the same time in the morning while the patients were seated. The patients were headache-free on the day that the blood samples were acquired. The samples were collected from a cubital vein into blood tubes, which were shaken gently a few times and immediately centrifuged at 2000 rpm for 5 min. After centrifugation, samples were directly transferred to Eppendorf tubes and stored at −80 °C until assayed.

Malondialdehyde (MDA; nmol/mL) levels and catalase (CAT; IU/mL) and glutathione peroxidase (GSH-Px; mIU/mL) activities were determined. The MDA level was measured using the thiobarbituric acid-reactive substances (TBARS) method [7]. CAT activity was determined by measuring the decrease in hydrogen peroxide (H2O2) absorbance at 240 nm, as described previously [8]. GSH-Px activity was measured by following the changes in nicotinamide adenine dinucleotide phosphate (NADPH) absorbance at 340 nm, as described previously [9]. In the activity calculations, the extinction coefficients of H2O2 and NADPH were used for CAT and GSH-Px, respectively.

Statistical analysis

All statistical tests were performed using the Statistical Package for the Social Sciences software (SPSS ver. 20; SPSS, Chicago, IL, USA). Quantitative variables are expressed as the mean ± standard deviation (SD), whereas qualitative variables are expressed as numbers and percentages. The patient and control groups were compared using unpaired t tests, Pearson’s Chi-squared analysis, and Fisher’s exact test. The distribution was examined using the Kolmogorov–Smirnov test. Because the variables were not normally distributed, nonparametric tests were used in subsequent analyses. The Mann–Whitney U test was used to detect significant differences between the TTH patients and healthy controls for each variable. A one-way variance analysis (ANOVA) was used for a three-way comparison of oxidative and antioxidative parameters in the treated and untreated CTTH patients and controls. The Lease Significant Difference (LSD) method was used for two-way comparisons. Values of p < 0.05 were considered to be significantly significant.


No significant differences were observed in age or gender between the patient and control groups, and between the treated and untreated TTH groups. Comparison of the oxidative stress and antioxidative defense parameters in the patient and control groups revealed significantly lower CAT activities as well as higher MDA levels and GSH-Px activities in the patient group (p = 0.0004, p = 0.006, and p = 0.0001, respectively; Table 1). The GSH-Px and CAT activities as well as the MDA levels were significantly different when the CTTH group and controls were compared (p = 0.0001, p = 0.007, and p = 0.003, respectively; Table 2).
Table 1

Demographic data and mean ± standard deviation of the malondialdehyde, glutathione peroxidase, and catalase levels in the serum of chronic tension-type headache (CTTH) patients and controls









Age (years)

37.65 ± 10.97

36.74 ± 6.86


Gender (female/male)




Glutathione peroxidase(IU/mL)

214.15 ± 128.39

132.38 ± 53.36


Catalase (IU/mL)

18.82 ± 26.83

38.22 ± 28.34


Malondialdehyde (nmol/mL)

2.11 ± 1.40

1.08 ± 0.17


* Mann–Whitney U test

** Chi-squared test

Table 2

Demographic data and mean ± standard deviation of the malondialdehyde, glutathione peroxidase, and catalase levels in the serum of treated and untreated chronic tension-type headache (CTTH) patients and controls


Treated CTTH

Untreated CTTH








Age (years)

39.70 ± 11.56

35.60 ± 10.23

36.74 ± 6.86


Gender (female/male)





Glutathione peroxidase (IU/mL)

163.00 ± 103.11

262.86 ± 133.27

132.38 ± 53.36


Catalase (IU/mL)

17.57 ± 28.03

20.01 ± 26.29

38.22 ± 28.34


Malondialdehyde (nmol/mL)

1.82 ± 1.04

2.39 ± 1.65

1.08 ± 0.17


* Analysis of variance (ANOVA)

** Chi-squared test

When comparing GSH-Px, CAT, and MDA in the treated and untreated CTTH groups and controls, we found lower CAT activities in both patient groups compared to the controls (p = 0.01 and p = 0.02, respectively). CAT activities did not significantly differ between the treated and untreated TTH groups (p = 0.954). MDA level was higher in the untreated TTH patients than in controls (p = 0.002), did not significantly differ between the treated and untreated TTH groups (p = 0.259), and did not significantly differ between the treated TTH and control groups (p = 0.123). GSH-Px activity was higher in the untreated TTH patients than in the treated patients and in controls (p = 0.001 and p = 0.008, respectively).


TTH is one of the most common and most socioeconomically costly of all headaches [10]. The ICHD-II [4] divides TTH into infrequent and frequent episodic (ETTH) and chronic (CTTH) subtypes. The chronic form is defined as 15 or more headache days per month for at least 3 months per year.

Despite recent studies on pain mechanisms, our knowledge of the pathophysiological mechanism of TTH is limited. Although the pain in TTH is thought to be caused by peripheral activation or sensitization of the myofascial nociceptors [6, 11] both peripheral and central mechanisms are believed to be involved. Peripheral mechanisms are most likely of major importance in episodic TTH. Prolonged peripheral nociceptive inputs from the pericranial myofascial tissues sensitize the CNS, which results in the conversion of episodic to chronic TTH [12].

TTH patients are treated with acute symptomatic treatment or pharmacological prophylaxis. Analgesics are used to treat acute symptoms. For most patients with CTTH, a combination of drug and non-drug therapies (e.g., physical therapy, acupuncture, relaxation, and cognitive-behavioral therapy) is recommended. Amitriptyline is the first drug of choice for the prophylactic treatment of CTTH. Mirtazapine and venlafaxine can be used as second choices [13]. Sertraline and citalopram are also used for the treatment of CTHH, but are less efficacious than tricyclic antidepressants [14].

This study investigated the oxidant and antioxidant status in patients with CTTH, and evaluated the possible effects of medical treatment. For this purpose, we compared treated CTTH patients with an untreated group and healthy controls. Oxidative stress is generated as a result of an imbalance between reactive oxygen species (ROS) and the antioxidant defense system. A disruption of this balance is hypothesized to play a role in the development and prognosis of many chronic or late-onset diseases, such as diabetes, asthma, cancer, Alzheimer’s disease, Parkinson’s disease, schizophrenia, depression, ischemia, epilepsy, and migraine [15, 16, 17].

MDA is one of the final products of the peroxidation of unsaturated fatty acids in phospholipids and it is used as a marker of oxidative stress [18]. GSH-Px and CAT are important antioxidant enzymes in the human antioxidant system [19], and play important roles in the clearance of free radicals in tissue defects caused by these radicals. We evaluated oxidative status using MDA, and determined the activities of the antioxidant enzymes GSH-Px and CAT in the serum of CTTH patients and controls. We found that CAT activities were significantly lower in the CTTH patient group than in controls; GSH-Px activities and MDA levels were higher in the CTTH patients than in healthy controls. Low CAT activity might lead to oxidative stress; GSH-Px might increase as a compensatory mechanism, but is likely unable to overcome the oxidative stress. Consequently, oxidative stress continues and causes lipid peroxidation, resulting in high MDA levels. These results suggest that it is feasible to consider antioxidant supplementation to prevent oxidative stress in patients with CTTH.

The subgroup analysis revealed that CAT activities were decreased in both CTTH patient groups compared to the controls. Further, the MDA levels were significantly higher in the untreated group than in controls. The GSH-Px activities were higher in the untreated group than in both the control and treated groups. Based on these data, it seemed that low CAT activity did not improve with treatment, but MDA levels were significantly reduced. We did not observe excessive oxidative stress in treated patients, and therefore GSH-Px did not increase much. This suggests that treatment affects the levels of MDA and GSH-Px activities.

A few studies exist in the literature in which oxidant status was evaluated TTH [20, 21, 22, 23]. The results of some of these studies contradict our findings. However, the demographic and clinical features of the patients in these studies and the enzymes measured were different than those in our study. Gupta et al. compared migraine, TTH, and healthy subjects. Both episodic and chronic TTH patients as well as TTH patients were chosen who had not taken a prophylactic drug for more than 3 weeks preceding the study. They found no significant differences in MDA levels between the TTH and control groups [20]. Bolayir et al. evaluated intraerythrocyte antioxidant enzyme activities in migraine and TTH patients. They found no differences in CAT or GSH-Px activities between the TTH and control groups. Their TTH patients had not taken any medication within 2 weeks prior to the study, with the exception of simple analgesics. All the patients were women [22].

To the best of our knowledge, this is the first study to evaluate the oxidant and antioxidant status of patients with CTTH and the effects of medical treatment. We believe that these enzyme levels are an important finding in CTTH. We conclude that drugs affect oxidant status and antioxidant supplementation can be administered to CTTH patients to eliminate oxidant stress. Further investigation is needed.



The authors had no funding sources for this study.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed on human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer-Verlag Italia 2015

Authors and Affiliations

  • Burcu Gökçe Çokal
    • 1
    Email author
  • Bilal Aytaç
    • 2
  • Zahide Esra Durak
    • 3
  • Hafize Nalan Güneş
    • 1
  • Bahadır Öztürk
    • 4
  • Selda Keskin Güler
    • 1
  • İlker Durak
    • 5
  • Tahir Kurtuluş Yoldaş
    • 1
  1. 1.Department of NeurologyAnkara Education and Research HospitalAnkaraTurkey
  2. 2.Ministry of Health, Directorate of Health ServicesAnkaraTurkey
  3. 3.Biochemistry LaboratoryPublic Health Institute of TurkeyAnkaraTurkey
  4. 4.Department of BiochemistrySelçuk University Faculty of MedicineKonyaTurkey
  5. 5.Department of BiochemistryAnkara University Faculty of Medicine AnkaraTurkey

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