César Fernández-de-las-Peñas, Daniel M. Fernández-Mayoralas, Ricardo Ortega-Santiago, Silvia Ambite-Quesada, Domingo Palacios-Ceña and Juan A. Pareja
Department of Physical Therapy,
Rehabilitation and Physical Medicine,
Facultad de Ciencias de la Salud,
Universidad Rey Juan Carlos,
Avenida de Atenas s/n,
28922 Alcorcón, Madrid
Our aim was to describe the referred pain pattern and areas from trigger points (TrPs) in head, neck, and shoulder muscles in children with chronic tension type headache (CTTH). Fifty children (14 boys, 36 girls, mean age: 8 ± 2) with CTTH and 50 age- and sex- matched children participated. Bilateral temporalis, masseter, superior oblique, upper trapezius, sternocleidomastoid, suboccipital, and levator scapula muscles were examined for TrPs by an assessor blinded to the children’s condition. TrPs were identified with palpation and considered active when local and referred pains reproduce headache pain attacks. The referred pain areas were drawn on anatomical maps, digitalized, and also measured.
The total number of TrPs was significantly greater in children with CTTH as compared to healthy children (P < 0.001). Active TrPs were only present in children with CTTH (P < 0.001). Within children with CTTH, a significant positive association between the number of active TrPs and headache duration (r (s) = 0.315; P = 0.026) was observed: the greater the number of active TrPs, the longer the duration of headache attack. Significant differences in referred pain areas between groups (P < 0.001) and muscles (P < 0.001) were found: the referred pain areas were larger in CTTH children (P < 0.001), and the referred pain area elicited by suboccipital TrPs was larger than the referred pain from the remaining TrPs (P < 0.001). Significant positive correlations between some headache clinical parameters and the size of the referred pain area were found. Our results showed that the local and referred pains elicited from active TrPs in head, neck and shoulder shared similar pain pattern as spontaneous CTTH in children, supporting a relevant role of active TrPs in CTTH in children.
Sait Ashina, Lars Bendtsen, Ann C Lyngberg, Richard B Lipton, Nazrin Hajiyeva and Rigmor Jensen
Department of Pain Medicine and Palliative Care,
Mount Sinai Beth Israel,
Icahn School of Medicine at Mount Sinai, NY, USA
BACKGROUND: We assessed the prevalence of neck pain in the population in relation to headache.
METHODS: In a cross-sectional study, a total of 797 individuals completed a headache interview and provided self-reported data on neck pain. We identified migraine, TTH or both migraine and TTH (M+TTH) groups. Pericranial tenderness was recorded in 496 individuals. A total tenderness score (TTS) was calculated as the sum of local scores with a maximum score of 48.
RESULTS: The one-year prevalence of neck pain was 68.4% and higher in those with vs. without primary headache (85.7% vs. 56.7%; adjusted OR 3.0, 95% CI 2.0–4.4, p<0.001). Adjusting for age, gender, education and poor self-rated health, in comparison with those without headaches, the prevalence of neck pain (56.7%) was significantly higher in those with M+TTH (89.3%), pure TTH (88.4%) and pure migraine (76.2%) (p<0.05 for all three group comparisons). Individuals with neck pain had higher TTS than individuals without neck pain (15.1±10.5 vs. 8.4±8.0, p<0.001).
CONCLUSIONS: Neck pain is highly prevalent in the general population and even more prevalent in individuals with primary headaches. Prevalence is highest in coexistent M+TTH, followed by pure TTH and migraine. Myofascial tenderness is significantly increased in individuals with neck pain.
Neck pain and primary headaches are highly prevalent in the population. [1, 2] Estimated global one-year period prevalence is about 10% for migraine and about 38% for tension-type headache (TTH). [3, 4] One-year prevalence of neck pain ranges from 4.8% to 79.5% in population-based studies.  Variation in epidemiological studies of neck pain is attributable, at least in part, to differences in sample selection, ascertainment of symptoms and case definitions.  Neck pain can arise from many local structures, including muscles, ligaments, facet joints and visceral structures of the neck, through direct compression of upper cervical roots or it can be referred.  Thus, the differential diagnosis for neck pain includes various conditions such as spinal disease, whiplash-associated disorder, fibromyalgia, myofascial pain, rheumatic disease, direct trauma and neoplasms.
Neck pain is common in people with primary headaches, both in population-based studies and in the clinic. [6–10] Neck pain may occur as a premonitory manifestation or during the headache phase.  A better understanding of neck pain in primary headache is important. First, it will help facilitate more accurate diagnosis. Second, neck pain may influence the treatment response and result in increased disability in headache suffers.  Finally, neck pain may play a role in the pathophysiology of both migraine and TTH. [13, 14] It may arise because of convergent input from the first division of the trigeminal nerve and the upper cervical roots to the trigeminal cervical complex. 
The aim of our study was to assess the prevalence of self-reported neck pain in individuals with common primary headaches including migraine, TTH and coexistent migraine and TTH in a general population sample using the clear diagnostic criteria of the International Classification of Headache Disorders (ICHD).
Faculty of Kinesiology,
University of Calgary,
Calgary, AB T2N 1N4, Canada.
Biomechanics is the science that deals with the external and internal forces acting on biological systems and the effects produced by these forces. Here, we describe the forces exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the spine and the physiological responses produced by the treatments. The external forces were found to vary greatly among clinicians and locations of treatment on the spine. Spinal manipulative treatments produced reflex responses far from the treatment site, caused movements of vertebral bodies in the “para-physiological” zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.
Chiropractic spinal manipulations are mechanical events. Clinicians exert a force of specific magnitudein a controlled direction to a target site,typically on the spine. High-velocity, low-amplitude (HVLA) manipulations are more frequently used by chiropractors than other treatment modalities, and they are of special interest, as force magnitudes and the rates of force application are high. HVLA treatments cause deformations of the spine and surrounding soft tissues and often elicit a cracking sound that has been identified as cavitation of spinal facet joints (Cascioli et al.,2003; Conway et al.,1993; Haas,1990; Herzog et al.,1993c; Mealand Scott,1986; Miereau et al., 1988; Reggars,1996). Despite the acknowledged nature of mechanical force application as a treatment modality (Triano,2000), and the accepted idea that HVLA treat ments produce mechanical effects (e.g., Triano and Schultz, 1997) at the treatment site, little is known about the biomechanics of spinal manipulation.
Paul S. Nolet, DC, MS, MPHa, Pierre Cote, DC, PhD, Vicki L. Kristman, PhD, Mana Rezai, DC, MHS, Linda J. Carroll, PhD, J. David Cassidy, DC, PhD, DrMedSc
Department of Graduate Education and Research,
Canadian Memorial Chiropractic College,
6100 Leslie Street,
North York, Ontario, Canada. M2H 3J1.
BACKGROUND CONTEXT: Current evidence suggests that neck pain is negatively associated with health-related quality of life (HRQoL). However, these studies are cross-sectional and do not inform the association between neck pain and future HRQoL.
PURPOSE: The purpose of this study was to investigate the association between increasing grades of neck pain severity and HRQoL 6 months later. In addition, this longitudinal study examines the crude association between the course of neck pain and HRQoL.
STUDY DESIGN: This is a population-based cohort study.
PATIENT SAMPLE: Eleven hundred randomly sampled Saskatchewan adults were included.
OUTCOME MEASURES: Outcome measures were the mental component summary (MCS) and physical component summary (PCS) of the Short-Form-36 (SF-36) questionnaire.
METHODS: We formed a cohort of 1,100 randomly sampled Saskatchewan adults in September 1995. We used the Chronic Pain Questionnaire to measure neck pain and its related disability. The SF-36 questionnaire was used to measure physical and mental HRQoL 6 months later. Multivariable linear regression was used to measure the association between graded neck pain and HRQoL while controlling for confounding. Analysis of variance and t tests were used to measure the crude association among four possible courses of neck pain and HRQoL at 6 months. The neck pain trajectories over 6 months were no or mild neck pain, improving neck pain, worsening neck pain, and persistent neck pain. Finally, analysis of variance was used to examine changes in baseline to 6-month PCS and MCS scores among the four neck pain trajectory groups.
RESULTS: The 6-month follow-up rate was 74.9%. We found an exposure-response relationship between neck pain and physical HRQoL after adjusting for age, education, arthritis, low back pain, and depressive symptomatology. Compared with participants without neck pain at baseline, those with mild (β=–1.53, 95% confidence interval [CI]=–2.83, –0.24), intense (β=–3.60, 95% CI=–5.76, –1.44), or disabling (β=–8.55, 95% CI=–11.68, –5.42) neck pain had worse physical HRQoL 6 months later. We did not find an association between neck pain and mental HRQoL. A worsening course of neck pain and persistent neck pain were associated with worse physical HRQoL.
Ron D. Hays, Ph.D., Karen L. Spritzer, B.S., Cathy D. Sherbourne, Ph.D., Gery W. Ryan, Ph.D., Ian D. Coulter, Ph.D.
Division of General Internal Medicine & Health Services Research
UCLA Department of Medicine
911 Broxton Avenue
Los Angeles, CA
STUDY DESIGN: Prospective observational study.
OBJECTIVE: To evaluate group-level and individual-level change in health-related quality of life among persons with chronic low back pain or neck pain receiving chiropractic care in the United States.
SUMMARY OF BACKGROUND DATA: Chiropractors treat chronic low back and neck pain, but there is limited evidence of the effectiveness of their treatment
METHODS: A 3–month longitudinal study of 2,024 patients with chronic low back pain or neck pain receiving care from 125 chiropractic clinics at 6 locations throughout the United States was conducted. Ninety-one percent of the sample completed the baseline and 3–month follow-up survey (n = 1,835). Average age was 49, 74% females, and most of the sample had a college degree, were non-Hispanic White, worked full-time, and had an annual income of $60,000 or more. Group-level (within group t-tests) and individual-level (coefficient of repeatability) changes on the Patient-Reported Outcomes Measurement Information System (PROMIS) v2.0 profile measure was evaluated: 6 multi-item scales (physical functioning, pain, fatigue, sleep disturbance, social health, emotional distress) and physical and mental health summary scores.
RESULTS: Within group t-tests indicated significant group-level change (p < 0.05) for all scores except for emotional distress, and these changes represented small improvements in health (absolute value of effect sizes ranged from 0.08 for physical functioning to 0.20 for pain). From 13% (physical functioning) to 30% (PROMIS-29 Mental Health Summary Score) got better from baseline to 3 months later according to the coefficient of repeatability.