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Pathophysiology of tension-type headache

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Abstract

Tension-type headache is one of the most common primary headache disorders. Advances in basic pain and clinical research have improved our understanding of pathophysiologic mechanisms of tension-type headache. Increased excitability of the central nervous system generated by repetitive and sustained pericranial myofascial input may be responsible for the transformation of episodic tension-type headache into the chronic form. Studies of nitric oxide (NO) mechanisms suggest that NO may play a key role in the pathophysiology of tension-type headache and that the antinociceptive effect of nitric oxide synthase inhibitors may become a novel principle in the future treatment of chronic headache. Future studies should focus on investigation of the source of peripheral nociception, the role of descending pain modulation, and the development of an animal model of tension-type headache to support the pathophysiologic importance of central sensitization in tension-type headache.

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References and Recommended Reading

  1. Rasmussen BK, Jensen R, Schroll M, et al.: Epidemiology of headache in a general population: a prevalence study. J Clin Epidemiol 1991, 44:1147–1157.

    Article  PubMed  CAS  Google Scholar 

  2. Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders, edn 2. Cephalalgia 2004, 24(suppl 1):9–160.

    Google Scholar 

  3. Ashina S, Ashina M: Current and potential future drug therapies for tension-type headache. Curr Pain Headache Rep 2003, 7:466–474.

    PubMed  Google Scholar 

  4. Ashina M: Neurobiology of chronic tension-type headache. Cephalalgia 2004, 24:161–172. A review on the role of NO and neuropeptides in CTTH.

    Article  PubMed  CAS  Google Scholar 

  5. Bendtsen L: Central sensitization in tension-type headache: possible pathophysiological mechanisms. Cephalalgia 2000, 20:486–508. An important and comprehensive review on the role of central sensitization in the pathophysiology of CTTH.

    Article  PubMed  CAS  Google Scholar 

  6. Schoenen J: Depression in tension-type headache sufferers: bystander or villain? Pain 2004, 111:225.

    Article  PubMed  CAS  Google Scholar 

  7. Spierings EL, Ranke AH, Honkoop PC: Precipitating and aggravating factors of migraine versus tension-type headache. Headache 2001, 41:554–558.

    Article  PubMed  CAS  Google Scholar 

  8. Rasmussen BK: Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 1993, 53:65–72.

    Article  PubMed  CAS  Google Scholar 

  9. Clark GT, Sakai S, Merrill R, et al.: Cross-correlation between stress, pain, physical activity, and temporalis muscle EMG in tension-type headache. Cephalalgia 1995, 15:511–518.

    Article  PubMed  CAS  Google Scholar 

  10. Gannon LR, Haynes SN, Cuevas J, et al.: Psychophysiological correlates of induced headaches. J Behav Med 1987, 10:411–423.

    Article  PubMed  CAS  Google Scholar 

  11. Holroyd KA: Behavioral and psychologic aspects of the pathophysiology and management of tension-type headache. Curr Pain Headache Rep 2002, 6:401–407. A review on the importance of behavioral and psychologic factors in pathophysiology and treatment of TTH.

    PubMed  Google Scholar 

  12. Janke EA, Holroyd KA, Romanek K: Depression increases onset of tension-type headache following laboratory stress. Pain 2004, 111:230–238.

    Article  PubMed  Google Scholar 

  13. Lipchik GL, Holroyd KA, O’Donnell FJ, et al.: Exteroceptive suppression periods and pericranial muscle tenderness in chronic tension-type headache: effects of psychopathology, chronicity and disability. Cephalalgia 2000, 20:638–646.

    Article  PubMed  CAS  Google Scholar 

  14. Ulrich V, Gervil M, Olesen J: The relative influence of environment and genes in episodic tension-type headache. Neurology 2004, 62:2065–2069.

    PubMed  Google Scholar 

  15. Ostergaard S, Russell MB, Bendtsen L, et al.: Comparison of first degree relatives and spouses of people with chronic tension headache. BMJ 1997, 314:1092–1093.

    PubMed  CAS  Google Scholar 

  16. Russell MB, Ostergaard S, Bendtsen L, et al.: Familial occurrence of chronic tension-type headache. Cephalalgia 1999, 19:207–210.

    Article  PubMed  CAS  Google Scholar 

  17. Russell MB, Iselius L, Ostergaard S, et al.: Inheritance of chronic tension-type headache investigated by complex segregation analysis. Hum Genet 1998, 102:138–140.

    Article  PubMed  CAS  Google Scholar 

  18. Bendtsen L, Jensen R, Olesen J: Decreased pain detection and tolerance thresholds in chronic tension-type headache. Arch Neurol 1996, 53:373–376.

    PubMed  CAS  Google Scholar 

  19. Jensen R, Rasmussen BK, Pedersen B, et al.: Muscle tenderness and pressure pain thresholds in headache: a population study. Pain 1993, 52:193–199.

    Article  PubMed  CAS  Google Scholar 

  20. Jensen R, Bendtsen L, Olesen J: Muscular factors are of importance in tension-type headache. Headache 1998, 38:10–17.

    Article  PubMed  CAS  Google Scholar 

  21. Langemark M, Olesen J: Pericranial tenderness in tension headache: a blind, controlled study. Cephalalgia 1987, 7:249–255.

    Article  PubMed  CAS  Google Scholar 

  22. Lipchik GL, Holroyd KA, Talbot F, et al.: Pericranial muscle tenderness and exteroceptive suppression of temporalis muscle activity: a blind study of chronic tension-type headache. Headache 1997, 37:368–376.

    Article  PubMed  CAS  Google Scholar 

  23. Pikoff H: Is the muscular model of headache still viable? A review of conflicting data. Headache 1984, 24:186–198.

    Article  PubMed  CAS  Google Scholar 

  24. Jensen R: Pathophysiological mechanisms of tension-type headache: a review of epidemiological and experimental studies. Cephalalgia 1999, 19:602–621.

    Article  PubMed  CAS  Google Scholar 

  25. Ashina M, Bendtsen L, Jensen R, et al.: Muscle hardness in patients with chronic tension-type headache: relation to actual headache state. Pain 1999, 79:201–205.

    Article  PubMed  CAS  Google Scholar 

  26. Sakai F, Ebihara S, Akiyama M, et al.: Pericranial muscle hardness in tension-type headache: a non-invasive measurement method and its clinical application. Brain 1995, 118:523–531.

    Article  PubMed  Google Scholar 

  27. Mense S: The pathogenesis of muscle pain. Curr Pain Headache Rep 2003, 7:419–425.

    PubMed  Google Scholar 

  28. Jensen R, Olesen J: Initiating mechanisms of experimentally induced tension-type headache. Cephalalgia 1996, 16:175–182.

    Article  PubMed  CAS  Google Scholar 

  29. Christensen MB, Bendtsen L, Ashina M, et al.: Experimental induction of muscle tenderness and headache in tensiontype headache patients. Cephalalgia 2005, in press.

  30. Gobel H, Weigle L, Kropp P, et al.: Pain sensitivity and pain reactivity of pericranial muscles in migraine and tensiontype headache. Cephalalgia 1992, 12:142–151.

    Article  PubMed  CAS  Google Scholar 

  31. Hatch JP, Moore PJ, Cyr-Provost M, et al.: The use of electromyography and muscle palpation in the diagnosis of tension-type headache with and without pericranial muscle involvement. Pain 1992, 49:175–178.

    Article  PubMed  CAS  Google Scholar 

  32. Sandrini G, Antonaci F, Pucci E, et al.: Comparative study with EMG, pressure algometry, and manual palpation in tensiontype headache and migraine. Cephalalgia 1994, 14:451–457.

    Article  PubMed  CAS  Google Scholar 

  33. Hubbard DR, Berkoff GM: Myofascial trigger points show spontaneous needle EMG activity. Spine 1993, 18:1803–1807.

    Article  PubMed  CAS  Google Scholar 

  34. Karnath HO: Subjective body orientation in neglect and the interactive contribution of neck muscle proprioception and vestibular stimulation. Brain 1994, 117:1001–1012.

    Article  PubMed  Google Scholar 

  35. Karlberg M, Persson L, Magnusson M: Impaired postural control in patients with cervico-brachial pain. Acta Otolaryngol Suppl 1995, 520:440–442.

    PubMed  Google Scholar 

  36. Giacomini PG, Alessandrini M, Evangelista M, et al.: Impaired postural control in patients affected by tension-type headache. Eur J Pain 2004, 8:579–583.

    Article  PubMed  CAS  Google Scholar 

  37. Henriksson K, Lindman R: Morphologic, physiologic, and biochemical changes in tender and painful muscle. In Tension-type Headache: Classification, Mechanisms, and Treatment, vol 3. Edited by Olesen J, Schoenen J. New York: Raven Press; 1993:97–107.

    Google Scholar 

  38. Langemark M, Jensen K, Olesen J: Temporal muscle blood flow in chronic tension-type headache. Arch Neurol 1990, 47:654–658.

    PubMed  CAS  Google Scholar 

  39. Ashina M, Stallknecht B, Bendtsen L, et al.: In vivo evidence of altered skeletal muscle blood flow in chronic tension-type headache. Brain 2002, 125:320–326.

    Article  PubMed  CAS  Google Scholar 

  40. Mork H, Ashina M, Bendtsen L, et al.: Possible mechanisms of pain perception in patients with episodic tension-type headache: a new experimental model of myofascial pain. Cephalalgia 2004, 24:466–475.

    Article  PubMed  CAS  Google Scholar 

  41. Mork H, Ashina M, Bendtsen L, et al.: Induction of prolonged tenderness in patients with tension-type headache by means of a new experimental model of myofascial pain. Eur J Neurol 2003, 10:249–256.

    Article  PubMed  CAS  Google Scholar 

  42. Ashina M, Stallknecht B, Bendtsen L, et al.: Tender points are not sites of ongoing inflammation: in vivo evidence in patients with chronic tension-type headache. Cephalalgia 2003, 23:109–116.

    Article  PubMed  CAS  Google Scholar 

  43. Ashina S, Babenko L, Jensen R, et al.: Increased muscular and cutaneous pain sensitivity in cephalic region in patients with chronic tension-type headache. Eur J Neurol 2005, 12:543–549.

    Article  PubMed  CAS  Google Scholar 

  44. Langemark M, Jensen K, Jensen TS, et al.: Pressure pain thresholds and thermal nociceptive thresholds in chronic tensiontype headache. Pain 1989, 38:203–210.

    Article  PubMed  CAS  Google Scholar 

  45. Schoenen J, Bottin D, Hardy F, et al.: Cephalic and extracephalic pressure pain thresholds in chronic tension-type headache. Pain 1991, 47:145–149.

    Article  PubMed  CAS  Google Scholar 

  46. de TommasoM, Libro G, Guido M, et al.: Heat pain thresholds and cerebral event-related potentials following painful CO2 laser stimulation in chronic tension-type headache. Pain 2003, 104:111–119.

    Article  PubMed  Google Scholar 

  47. Jensen K, Andersen HO, Olesen J, et al.: Pressure-pain threshold in human temporal region: evaluation of a new pressure algometer. Pain 1986, 25:313–323.

    Article  PubMed  CAS  Google Scholar 

  48. Bendtsen L, Jensen R, Olesen J: Qualitatively altered nociception in chronic myofascial pain. Pain 1996, 65:259–264.

    Article  PubMed  CAS  Google Scholar 

  49. Ashina S, Bendtsen L, Ashina M, et al.: Evidence for generalized muscular and cutaneous hyperalgesia in patients with chronic tension-type headache. Abstract presented at the 14th International Headache Research Seminar. Copenhagen: March 11–13, 2005.

  50. Willer JC, De Broucker T, Le Bars D: Encoding of nociceptive thermal stimuli by diffuse noxious inhibitory controls in humans. J Neurophysiol 1989, 62:1028–1038.

    PubMed  CAS  Google Scholar 

  51. Le Bars D: The whole body receptive field of dorsal horn multireceptive neurones. Brain Res Brain Res Rev 2002, 40:29–44.

    Article  PubMed  Google Scholar 

  52. Langemark M, Bach FW, Jensen TS, et al.: Decreased nociceptive flexion reflex threshold in chronic tension-type headache. Arch Neurol 1993, 50:1061–1064.

    PubMed  CAS  Google Scholar 

  53. Sawynok J, Reid A: Interactions of descending serotonergic systems with other neurotransmitters in the modulation of nociception. Behav Brain Res 1996, 73:63–68.

    Article  PubMed  CAS  Google Scholar 

  54. Bendtsen L, Jensen R, Hindberg I, et al.: Serotonin metabolism in chronic tension-type headache. Cephalalgia 1997, 17:843–848.

    Article  PubMed  CAS  Google Scholar 

  55. Edvinsson L, Goadsby PJ: Neuropeptides in migraine and cluster headache. Cephalalgia 1994, 14:320–327.

    Article  PubMed  CAS  Google Scholar 

  56. Ashina M, Bendtsen L, Jensen R, et al.: Plasma levels of substance P, neuropeptide Y, and vasoactive intestinal polypeptide in patients with chronic tension-type headache. Pain 1999, 83:541–547.

    Article  PubMed  CAS  Google Scholar 

  57. Bach FW, Langemark M, Ekman R, et al.: Effect of sulpiride or paroxetine on cerebrospinal fluid neuropeptide concentrations in patients with chronic tension-type headache. Neuropeptides 1994, 27:129–136.

    Article  PubMed  CAS  Google Scholar 

  58. Ashina M, Bendtsen L, Jensen R, et al.: Plasma levels of calcitonin gene-related peptide in chronic tension-type headache. Neurology 2000, 55:1335–1340.

    PubMed  CAS  Google Scholar 

  59. Alam Z, Coombes N, Waring RH, et al.: Plasma levels of neuroexcitatory amino acids in patients with migraine or tension headache. J Neurol Sci 1998, 156:102–106.

    Article  PubMed  CAS  Google Scholar 

  60. Sarchielli P, Alberti A, Floridi A, et al.: L-Arginine/nitric oxide pathway in chronic tension-type headache: relation with serotonin content and secretion and glutamate content. J Neurol Sci 2002, 198:9–15.

    Article  PubMed  CAS  Google Scholar 

  61. Langemark M, Bach FW, Ekman R, et al.: Increased cerebrospinal fluid Met-enkephalin immunoreactivity in patients with chronic tension-type headache. Pain 1995, 63:103–107.

    Article  PubMed  CAS  Google Scholar 

  62. Mazzotta G, Sarchielli P, Gaggioli A, et al.: Study of pressure pain and cellular concentration of neurotransmitters related to nociception in episodic tension-type headache patients. Headache 1997, 37:565–571.

    Article  PubMed  CAS  Google Scholar 

  63. Bendtsen L, Jensen R, Olesen J: A non-selective (amitriptyline), but not a selective (citalopram), serotonin reuptake inhibitor is effective in the prophylactic treatment of chronic tensiontype headache. J Neurol Neurosurg Psychiatry 1996, 61:285–290.

    Article  PubMed  CAS  Google Scholar 

  64. Ashina S, Bendtsen L, Jensen R: Analgesic effect of amitriptyline in chronic tension-type headache is not directly related to serotonin reuptake inhibition. Pain 2004, 108:108–114.

    Article  PubMed  CAS  Google Scholar 

  65. Bendtsen L, Jensen R, Olesen J: Amitriptyline, a combined serotonin and noradrenaline re-uptake inhibitor, reduces exteroceptive suppression of temporal muscle activity in patients with chronic tension-type headache. Electroencephalogr Clin Neurophysiol 1996, 101:418–422.

    PubMed  CAS  Google Scholar 

  66. Sawynok J, Esser MJ, Reid AR: Antidepressants as analgesics: an overview of central and peripheral mechanisms of action. J Psychiatry Neurosci 2001, 26:21–29.

    PubMed  CAS  Google Scholar 

  67. Watanabe Y, Saito H, Abe K: Tricyclic antidepressants block NMDA receptor-mediated synaptic responses and induction of long-term potentiation in rat hippocampal slices. Neuropharmacology 1993, 32:479–486.

    Article  PubMed  CAS  Google Scholar 

  68. Ji RR, Kohno T, Moore KA, et al.: Central sensitization and LTP: Do pain and memory share similar mechanisms? Trends Neurosci 2003, 26:696–705.

    Article  PubMed  CAS  Google Scholar 

  69. Blier P, Abbott FV: Putative mechanisms of action of antidepressant drugs in affective and anxiety disorders and pain. J Psychiatry Neurosci 2001, 26:37–43.

    PubMed  CAS  Google Scholar 

  70. Bendtsen L, Jensen R: Amitriptyline reduces myofascial tenderness in patients with chronic tension-type headache. Cephalalgia 2000, 20:603–610.

    Article  PubMed  CAS  Google Scholar 

  71. Bendtsen L, Jensen R: Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Neurology 2004, 62:1706–1711.

    PubMed  CAS  Google Scholar 

  72. Ashina M, Lassen LH, Bendtsen L, et al.: Effect of inhibition of nitric oxide synthase on chronic tension-type headache: a randomized, crossover trial. Lancet 1999, 353:287–289. An important study demonstrating the antinociceptive effect of NOS inhibitor that counteracts central sensitization in CTTH.

    Article  PubMed  CAS  Google Scholar 

  73. Ashina M, Bendtsen L, Jensen R, et al.: Possible mechanisms of action of nitric oxide synthase inhibitors in chronic tensiontype headache. Brain 1999, 122:1629–1635.

    Article  PubMed  Google Scholar 

  74. Ashina M, Bendtsen L, Jensen R, et al.: Nitric oxide-induced headache in patients with chronic tension-type headache. Brain 2000, 123:1830–1837.

    Article  PubMed  Google Scholar 

  75. Makowska A, Panfil C, Ellrich J: Long-term potentiation of orofacial sensorimotor processing by noxious input from the semispinal neck muscle in mice. Cephalalgia 2005, 25:109–116.

    Article  PubMed  CAS  Google Scholar 

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  1. Danish Headache Center and Department of Neurology, Glostrup Hospital, University of Copenhagen, DK-2600 Glostrup, Copenhagen, Denmark

    Messoud Ashina MD, PhD

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  1. Sait Ashina MD
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  2. Lars Bendtsen MD, PhD
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  3. Messoud Ashina MD, PhD
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Ashina, S., Bendtsen, L. & Ashina, M. Pathophysiology of tension-type headache. Current Science Inc 9, 415–422 (2005). https://doi.org/10.1007/s11916-005-0021-8

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