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1.  Does sleep aggravate tension-type headache?: An investigation using computerized ecological momentary assessment and actigraphy 
Background
Both insufficient sleep and oversleeping have been reported as precipitating and aggravating factors of tension-type headache (TTH). However, previous studies relied on recalled self-reports, and the relationship has not been confirmed prospectively and objectively in a daily life situation. Recently, ecological momentary assessment (EMA) using electronic diaries, i.e., computerized EMA, is used to record subjective symptoms with the advantages of avoiding recall bias and faked compliance in daily settings. In addition, actigraphy has become an established method to assess sleep outside laboratories. Therefore, the aim of this study was to investigate the within-individual effect of sleep on the following momentary headache intensity in TTH patients during their daily lives utilizing EMA and actigraphy.
Methods
Twenty-seven patients with TTH wore watch-type computers as electronic diaries for seven consecutive days and recorded their momentary headache intensity using a visual analog scale of 0-100 approximately every six hours, on waking up, when going to bed, and at the time of headache exacerbations. They also recorded their self-report of sleep quality, hours of sleep and number of awakenings with the computers when they woke up. Physical activity was continuously recorded by an actigraph inside the watch-type computers. Activity data were analyzed by Cole's algorithm to obtain total sleep time, sleep efficiency, sleep latency, wake time after sleep onset and number of awakenings for each night. Multilevel modeling was used to test the effect of each subjective and objective sleep-related variable on momentary headache intensity on the following day.
Results
Objectively measured total sleep time was significantly positively associated with momentary headache intensity on the following day, while self-reported sleep quality was significantly negatively associated with momentary headache intensity on the following day.
Conclusions
Using computerized EMA and actigraphy, longer sleep and worse sleep quality were shown to be related to more intense headache intensity on within-individual basis and they may be precipitating or aggravating factors of TTH.
doi:10.1186/1751-0759-5-10
PMCID: PMC3163177  PMID: 21835045
2.  Multidisciplinary integrated headache care: a prospective 12-month follow-up observational study 
The Journal of Headache and Pain  2012;13(7):521-529.
This prospective study investigated the effectiveness of a three-tier modularized out- and inpatient multidisciplinary integrated headache care program. N = 204 patients with frequent headaches (63 migraine, 11 tension-type headache, 59 migraine + tension-type headache, 68 medication-overuse headache and 3 with other primary headaches) were enrolled. Outcome measures at baseline, 6- and 12-month follow-ups included headache frequency, Migraine Disability Assessment (MIDAS), Hospital Anxiety and Depression Scale (HADS), standardized headache diary and a medication survey. Mean reduction in headache frequency was 5.5 ± 8.5 days/month, p < 0.001 at 6 months’ follow-up and 6.9 ± 8.3 days/month, p < 0.001 after 1 year. MIDAS decreased from 53.0 ± 60.8 to 37.0 ± 52.4 points, p < 0.001 after 6 months and 34.4 ± 53.2 points, p < 0.001 at 1 year. 44.0 % patients demonstrated at baseline an increased HAD-score for anxiety and 16.7 % of patients revealed a HAD-score indicating a depression. At the end of treatment statistically significant changes could be observed for anxiety (p < 0.001) and depression (p < 0.006). The intake frequency of attack-aborting medication decreased from 10.3 ± 7.3 days/month at admission to 4.7 ± 4.1 days/month, p < 0.001 after 6 months and reached 3.8 ± 3.5 days/month, p < 0.001 after 1 year. At baseline 37.9 % of patients had experience with non-pharmacological treatments and 87.0 % at 12-month follow-up. In conclusion, an integrated headache care program was successfully established. Positive health-related outcomes could be obtained with a multidisciplinary out- and inpatient headache treatment program.
doi:10.1007/s10194-012-0469-y
PMCID: PMC3444539  PMID: 22790281
Integrated; Care; Multidisciplinary treatment program; Outcome study; Headache-related disability; Headache-related quality of life; Chronic headache
3.  Co-Variation of Depressive Mood and Locomotor Dynamics Evaluated by Ecological Momentary Assessment in Healthy Humans 
PLoS ONE  2013;8(9):e74979.
Computerized ecological momentary assessment (EMA) is widely accepted as a “gold standard” method for capturing momentary symptoms repeatedly experienced in daily life. Although many studies have addressed the within-individual temporal variations in momentary symptoms compared with simultaneously measured external criteria, their concurrent associations, specifically with continuous physiological measures, have not been rigorously examined. Therefore, in the present study, we first examined the variations in momentary symptoms by validating the associations among self-reported symptoms measured simultaneously (depressive mood, anxious mood, and fatigue) and then investigated covariant properties between the symptoms (especially, depressive mood) and local statistics of locomotor activity as the external objective criteria obtained continuously. Healthy subjects (N = 85) from three different populations (adolescents, undergraduates, and office workers) wore a watch-type computer device equipped with EMA software for recording the momentary symptoms experienced by the subjects. Locomotor activity data were also continuously obtained by using an actigraph built into the device. Multilevel modeling analysis confirmed convergent associations by showing positive correlations among momentary symptoms. The increased intermittency of locomotor activity, characterized by a combination of reduced activity with occasional bursts, appeared concurrently with the worsening of depressive mood. Further, this association remained statistically unchanged across groups regardless of group differences in age, lifestyle, and occupation. These results indicate that the temporal variations in the momentary symptoms are not random but reflect the underlying changes in psychophysiological variables in daily life. In addition, our findings on the concurrent changes in depressive mood and locomotor activity may contribute to the continuous estimation of changes in depressive mood and early detection of depressive disorders.
doi:10.1371/journal.pone.0074979
PMCID: PMC3773004  PMID: 24058642
4.  Diagnosis and management of the primary headache disorders in the emergency department setting 
Headache continues to be a frequent cause of emergency department (ED) use, accounting for 2% of all visits. The majority of these headaches prove to be benign but painful exacerbations of chronic headache disorders, such as migraine, tension-type, and cluster. The goal of ED management is to provide rapid and quick relief of benign headache, without causing undue side effects, as well as recognizing headaches with malignant course. Though these headaches have distinct epidemiologies and clinical phenotypes, there is overlapping response to therapy: non-steroidals, triptans, dihydroergotamine, and the anti-emetic dopamine-antagonists may play a therapeutic role for each of these acute headaches. Because these headaches often recur over the days and months following ED discharge, the responsibility of the emergency physician includes identifying as yet unmet treatment needs and ensuring successful transition of care of these patients to an outpatient healthcare provider. Herein, we review the diagnostic criteria and management strategies for the primary headache disorders.
doi:10.1016/j.emc.2008.09.005
PMCID: PMC2676687  PMID: 19218020
headache; migraine; emergency department
5.  Stress and Sleep Duration Predict Headache Severity in Chronic Headache Sufferers 
Pain  2012;153(12):2432-2440.
The objective of this study was to evaluate the time-series relationships between stress, sleep duration, and headache pain among patients with chronic headaches. Sleep and stress have long been recognized as potential triggers of episodic headache (< 15 headache days/month), though prospective evidence is inconsistent and absent in patients diagnosed with chronic headaches (≥ 15 days/month). We reanalyzed data from a 28-day observational study of chronic migraine (n = 33) and chronic tension-type headache (n = 22) sufferers. Patients completed the Daily Stress Inventory and recorded headache and sleep variables using a daily sleep/headache diary. Stress ratings, duration of previous nights' sleep, and headache severity were modeled using a series of linear mixed models with random effects to account for individual differences in observed associations. Models were displayed using contour plots. Two consecutive days of either high stress or low sleep were strongly predictive of headache, whereas two days of low stress or adequate sleep were protective. When patterns of stress or sleep were divergent across days, headache risk was increased only when the earlier day was characterized by high stress or poor sleep. As predicted, headache activity in the combined model was highest when high stress and low sleep occurred concurrently during the prior 2 days denoting an additive effect. Future research is needed to expand on current findings among chronic headache patients and to develop individualized models that account for multiple simultaneous influences of headache trigger factors.
doi:10.1016/j.pain.2012.08.014
PMCID: PMC3626265  PMID: 23073072
Stress; Sleep; Headache; Time-series; Headache trigger factors; Headache precipitants
6.  Validity of the Hangover Symptoms Scale: Evidence from an Electronic Diary Study 
Background
The Hangover Symptoms Scale (HSS) assesses the frequency of 13 symptoms experienced after drinking in the past year. Cross-sectional analyses in college drinkers showed preliminary evidence for the validity of the HSS (Slutske et al., 2003). The current investigation extended this work by examining the construct validity of the HSS in an ecological momentary assessment investigation.
Methods
Frequent drinkers (N = 404) carried electronic diaries to track their daily experiences over three weeks. Each morning, the diary assessed prior-night drinking behaviors, the presence of current hangover, and intensity of current headache and nausea.
Results
Adjusting for sex and body mass, the HSS significantly predicted diary endorsement of hangover (OR = 2.11, 95% CI = 1.78–2.49, p <.001). Participants who endorsed the HSS headache and nausea items were especially likely to report elevations of corresponding symptoms in diary records made the morning after drinking. HSS scores incrementally predicted hangover when the number of drinks consumed in the episode was covaried but did not moderate the relationship between the number of drinks and diary hangover reports.
Conclusions
The HSS appears to be a valid tool for hangover research. Higher HSS scores identify individuals who complain of “real world” hangovers and who may be especially likely to display particular symptoms after a night of drinking. Past hangovers predicted future hangovers, suggesting hangovers do not necessarily discourage or inhibit future drinking, at least across the several-week time interval studied here. There is a need to develop and evaluate complementary measures that can more directly index individual differences in hangover susceptibility in survey designs.
doi:10.1111/j.1530-0277.2011.01592.x
PMCID: PMC3197866  PMID: 21762183
hangover; symptoms; questionnaire; Hangover Symptoms Scale; ecological momentary assessment
7.  Tension–type headache in 40–year-olds: a Danish population–based sample of 4000 
The Journal of Headache and Pain  2005;6(6):441-447.
The aim of this study was to evaluate the one–year prevalence of tension–type headache in the general population. Three thousand men and one thousand women aged 40 years from the Danish population were included. They received a mailed questionnaire and the response rate was 87%. The selfreported one–year prevalence of tension– type headache was 84.7%. The one–year prevalence of infrequent episodic, frequent episodic and chronic tension–type headache was 48.2%, 33.8% and 2.3%, respectively. No tension–type headache and infrequent episodic tension–type headache was significantly more frequent in men than women (p<0.0005 and p=0.004), while frequent and chronic tension–type headache was significantly more frequent in women than men (p<0.0005 and p<0.0005). No tension– type headache and infrequent tension–type headache was significantly more frequent among those without than with self–reported migraine (no headache, men, p<0.0005 and women, p=0.002 and infrequent, men, p<0.0005 and women, p<0.0005), while episodic frequent and chronic tension–type headache was significantly more frequent among those with than those without self–reported migraine, with the exception of chronic tension–type in women (frequent episodic, men, p<0.0005 and women, p<0.0005 and chronic, men, p<0.0005 and women, p=0.08). Women are more prone to tensiontype headache than men and they have it more frequently than men. Self–reported migraine increases the risk for frequent episodic and chronic tension–type headache.
doi:10.1007/s10194-005-0253-3
PMCID: PMC3452303  PMID: 16388338
Tension–type headache; Epidemiology; Prevalence
8.  Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study 
Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its efficacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45-minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereafter. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7±0.7 episodes per week during baseline to 3.7±0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2±1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0±1.3 to 2.8±0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.
PMCID: PMC2565109  PMID: 19119396
Complementary and Alternative Medicine; Headache Disability Index; Manual Therapy; Myofasical Pain; Myofascial Trigger Points
9.  Tricyclic antidepressants and headaches: systematic review and meta-analysis 
Objective To evaluate the efficacy and relative adverse effects of tricyclic antidepressants in the treatment of migraine, tension-type, and mixed headaches.
Design Meta-analysis.
Data sources Medline, Embase, the Cochrane Trials Registry, and PsycLIT.
Studies reviewed Randomised trials of adults receiving tricyclics as only treatment for a minimum of four weeks.
Data extraction Frequency of headaches (number of headache attacks for migraine and number of days with headache for tension-type headaches), intensity of headache, and headache index.
Results 37 studies met the inclusion criteria. Tricyclics significantly reduced the number of days with tension-type headache and number of headache attacks from migraine than placebo (average standardised mean difference −1.29, 95% confidence interval −2.18 to −0.39 and −0.70, −0.93 to −0.48) but not compared with selective serotonin reuptake inhibitors (−0.80, −2.63 to 0.02 and −0.20, −0.60 to 0.19). The effect of tricyclics increased with longer duration of treatment (β=−0.11, 95% confidence interval −0.63 to −0.15; P<0.0005). Tricyclics were also more likely to reduce the intensity of headaches by at least 50% than either placebo (tension-type: relative risk 1.41, 95% confidence interval 1.02 to 1.89; migraine: 1.80, 1.24 to 2.62) or selective serotonin reuptake inhibitors (1.73, 1.34 to 2.22 and 1.72, 1.15 to 2.55). Tricyclics were more likely to cause adverse effects than placebo (1.53, 95% confidence interval 1.11 to 2.12) and selective serotonin reuptake inhibitors (2.22, 1.52 to 3.32), including dry mouth (P<0.0005 for both), drowsiness (P<0.0005 for both), and weight gain (P<0.001 for both), but did not increase dropout rates (placebo: 1.22, 0.83 to 1.80, selective serotonin reuptake inhibitors: 1.16, 0.81 to 2.97).
Conclusions Tricyclic antidepressants are effective in preventing migraine and tension-type headaches and are more effective than selective serotonin reuptake inhibitors, although with greater adverse effects. The effectiveness of tricyclics seems to increase over time.
doi:10.1136/bmj.c5222
PMCID: PMC2958257  PMID: 20961988
10.  The treatment of migraines and tension-type headaches with intravenous and oral niacin (nicotinic acid): systematic review of the literature 
Nutrition Journal  2005;4:3.
Background
Migraine and tension-type headaches impose a tremendous economic drain upon the healthcare system. Intravenous and oral niacin has been employed in the treatment of acute and chronic migraine and tension-type headaches, but its use has not become part of contemporary medicine, nor have there been randomized controlled trials further assessing this novel treatment. We aimed to systematically review the evidence of using intravenous and/or oral niacin as a treatment for migraine headaches, tension-type headaches, and for headaches of other etiologic types.
Methods
We searched English and non-English language articles in the following databases: MEDLINE (1966–February 2004), AMED (1995–February 2004) and Alt HealthWatch (1990–February 2004).
Results
Nine articles were found to meet the inclusion criteria and were included in this systematic review. Hypothetical reasons for niacin's effectiveness include its vasodilatory properties, and its ability to improve mitochondrial energy metabolism. Important side effects of niacin include flushing, nausea and fainting.
Conclusion
Although niacin's mechanisms of action have not been substantiated from controlled clinical trials, this agent may have beneficial effects upon migraine and tension-type headaches. Adequately designed randomized trials are required to determine its clinical implications.
doi:10.1186/1475-2891-4-3
PMCID: PMC548511  PMID: 15673472
11.  Ecological Momentary Assessment of Affect, Stress, and Binge-Purge Behaviors: Day of Week and Time of Day Effects in the Natural Environment 
Objective
The present study examined ecological momentary assessments of binge/vomit behavior, mood, and type and severity of stressors in a sample of 133 women with bulimia nervosa.
Method
Participants completed an ecological momentary assessment protocol for a period of 2 weeks.
Results
Mixed-effects and multilevel logistic models revealed significant variation across time of day and day of the week in the occurrence of binging, vomiting, positive and negative affect, and the severity and types of stressful events.
Discussion
These findings explicate how momentary and daily experiences vary in the natural environments of women with bulimia nervosa, and document critical time periods for intervention.
doi:10.1002/eat.20623
PMCID: PMC2996234  PMID: 19115371
EMA; bulimia nervosa; diurnal cycle; time of day; day of week
12.  Headache, anxiety and depressive disorders: the HADAS study 
The Journal of Headache and Pain  2010;11(2):141-150.
The objective of this paper was to assess prevalence and characteristics of anxiety and depression in migraine without aura and tension-type headache, either isolated or in combination. Although the association between headache and psychiatric disorders is undisputed, patients with migraine and/or tension-type headache have been frequently investigated in different settings and using different tests, which prevents meaningful comparisons. Psychiatric comorbidity was tested through structured interview and the MINI inventory in 158 adults with migraine without aura and in 216 persons with tension-type headache or migraine plus tension-type headache. 49 patients reported psychiatric disorders: migraine 10.9%, tension-type headache 12.8%, and migraine plus tension-type headache 21.4%. The MINI detected a depressive episode in 59.9, 67.0, and 69.6% of cases. Values were 18.4, 19.3, and 18.4% for anxiety, 12.7, 5.5, and 14.2%, for panic disorder and 2.3, 1.1 and 9.4% (p = 0.009) for obsessive–compulsive disorder. Multivariate analysis showed panic disorder prevailing in migraine compared with the other groups (OR 2.9; 95% CI 1.2–7.0). The association was higher (OR 6.3; 95% CI 1.4–28.5) when migraine (with or without tension-type headache) was compared to pure tension-type headache. This also applied to obsessive–compulsive disorder (OR 4.8; 95% CI 1.1–20.9) in migraine plus tension-type headache. Psychopathology of primary headache can reflect shared risk factors, pathophysiologic mechanisms, and disease burden.
doi:10.1007/s10194-010-0187-2
PMCID: PMC3452290  PMID: 20108021
Migraine; Tension-type headache; Depression; Anxiety; Prevalence
13.  Chronic daily headaches 
Annals of Indian Academy of Neurology  2012;15(Suppl 1):S40-S50.
Chronic Daily Headache is a descriptive term that includes disorders with headaches on more days than not and affects 4% of the general population. The condition has a debilitating effect on individuals and society through direct cost to healthcare and indirectly to the economy in general. To successfully manage chronic daily headache syndromes it is important to exclude secondary causes with comprehensive history and relevant investigations; identify risk factors that predict its development and recognise its sub-types to appropriately manage the condition. Chronic migraine, chronic tension-type headache, new daily persistent headache and medication overuse headache accounts for the vast majority of chronic daily headaches. The scope of this article is to review the primary headache disorders. Secondary headaches are not discussed except medication overuse headache that often accompanies primary headache disorders. The article critically reviews the literature on the current understanding of daily headache disorders focusing in particular on recent developments in the treatment of frequent headaches.
doi:10.4103/0972-2327.100002
PMCID: PMC3444216  PMID: 23024563
Chronic daily headache; chronic migraine; chronic tension type headache; hemicrania continua; new daily persistent headache
14.  Clinical features of headache patients with fibromyalgia comorbidity 
The Journal of Headache and Pain  2011;12(6):629-638.
Our previous study assessed the prevalence of fibromyalgia (FM) syndrome in migraine and tension-type headache. We aimed to update our previous results, considering a larger cohort of primary headache patients who came for the first time at our tertiary headache ambulatory. A consecutive sample of 1,123 patients was screened. Frequency of FM in the main groups and types of primary headaches; discriminating factor for FM comorbidity derived from headache frequency and duration, age, anxiety, depression, headache disability, allodynia, pericranial tenderness, fatigue, quality of life and sleep, and probability of FM membership in groups; and types of primary headaches were assessed. FM was present in 174 among a total of 889 included patients. It prevailed in the tension-type headache main group (35%, p < 0.0001) and chronic tension-type headache subtype (44.3%, p < 0.0001). Headache frequency, anxiety, pericranial tenderness, poor sleep quality, and physical disability were the best discriminating variables for FM comorbidity, with 81.2% sensitivity. Patients presenting with chronic migraine and chronic tension-type headache had a higher probability of sharing the FM profile (Bonferroni test, p < 0.01). A phenotypic profile where headache frequency concurs with anxiety, sleep disturbance, and pericranial tenderness should be individuated to detect the development of diffuse pain in headache patients.
doi:10.1007/s10194-011-0377-6
PMCID: PMC3208047  PMID: 21847547
Primary headache; Fibromyalgia; Comorbidity
15.  Clinical features of headache patients with fibromyalgia comorbidity 
The Journal of Headache and Pain  2011;12(6):629-638.
Our previous study assessed the prevalence of fibromyalgia (FM) syndrome in migraine and tension-type headache. We aimed to update our previous results, considering a larger cohort of primary headache patients who came for the first time at our tertiary headache ambulatory. A consecutive sample of 1,123 patients was screened. Frequency of FM in the main groups and types of primary headaches; discriminating factor for FM comorbidity derived from headache frequency and duration, age, anxiety, depression, headache disability, allodynia, pericranial tenderness, fatigue, quality of life and sleep, and probability of FM membership in groups; and types of primary headaches were assessed. FM was present in 174 among a total of 889 included patients. It prevailed in the tension-type headache main group (35%, p < 0.0001) and chronic tension-type headache subtype (44.3%, p < 0.0001). Headache frequency, anxiety, pericranial tenderness, poor sleep quality, and physical disability were the best discriminating variables for FM comorbidity, with 81.2% sensitivity. Patients presenting with chronic migraine and chronic tension-type headache had a higher probability of sharing the FM profile (Bonferroni test, p < 0.01). A phenotypic profile where headache frequency concurs with anxiety, sleep disturbance, and pericranial tenderness should be individuated to detect the development of diffuse pain in headache patients.
doi:10.1007/s10194-011-0377-6
PMCID: PMC3208047  PMID: 21847547
Primary headache; Fibromyalgia; Comorbidity
16.  New daily persistent headache 
Annals of Indian Academy of Neurology  2012;15(Suppl 1):S62-S65.
New daily persistent headache (NDPH) is a chronic headache developing in a person who does not have a past history of headaches. The headache begins acutely and reaches its peak within 3 days. It is important to exclude secondary causes, particularly headaches due to alterations in cerebrospinal fluid (CSF) pressure and volume. A significant proportion of NDPH sufferers may have intractable headaches that are refractory to treatment. The condition is best viewed as a syndrome rather than a diagnosis. The headache can mimic chronic migraine and chronic tension-type headache, and it is also important to exclude secondary causes, particularly headaches due to alterations in CSF pressure and volume. A large proportion of NDPH sufferers have migrainous features to their headache and should be managed with treatments used for treating migraine. A small group of NDPH sufferers may have intractable headaches that are refractory to treatment.
doi:10.4103/0972-2327.100011
PMCID: PMC3444222  PMID: 23024565
Chronic daily headache; new daily persistent headache; intractable headache
17.  Acupuncture in patients with tension-type headache: randomised controlled trial 
BMJ : British Medical Journal  2005;331(7513):376-382.
Objective To investigate the effectiveness of acupuncture compared with minimal acupuncture and with no acupuncture in patients with tension-type headache.
Design Three armed randomised controlled multicentre trial.
Setting 28 outpatient centres in Germany.
Participants 270 patients (74% women, mean age 43 (SD 13) years) with episodic or chronic tension-type headache.
Interventions Acupuncture, minimal acupuncture (superficial needling at non-acupuncture points), or waiting list control. Acupuncture and minimal acupuncture were administered by specialised physicians and consisted of 12 sessions per patient over eight weeks.
Main outcome measure Difference in numbers of days with headache between the four weeks before randomisation and weeks 9-12 after randomisation, as recorded by participants in headache diaries.
Results The number of days with headache decreased by 7.2 (SD 6.5) days in the acupuncture group compared with 6.6 (SD 6.0) days in the minimal acupuncture group and 1.5 (SD 3.7) days in the waiting list group (difference: acupuncture v minimal acupuncture, 0.6 days, 95% confidence interval -1.5 to 2.6 days, P = 0.58; acupuncture v waiting list, 5.7 days, 3.9 to 7.5 days, P < 0.001). The proportion of responders (at least 50% reduction in days with headache) was 46% in the acupuncture group, 35% in the minimal acupuncture group, and 4% in the waiting list group.
Conclusions The acupuncture intervention investigated in this trial was more effective than no treatment but not significantly more effective than minimal acupuncture for the treatment of tension-type headache.
Trial registration number ISRCTN9737659.
doi:10.1136/bmj.38512.405440.8F
PMCID: PMC1184247  PMID: 16055451
18.  Association between lifestyle factors and headache 
The Journal of Headache and Pain  2011;12(2):147-155.
Modification of lifestyle habits is a key preventive strategy for many diseases. The role of lifestyle for the onset of headache in general and for specific headache types, such as migraine and tension-type headache (TTH), has been discussed for many years. Most results, however, were inconsistent and data on the association between lifestyle factors and probable headache forms are completely lacking. We evaluated the cross-sectional association between different lifestyle factors and headache subtypes using data from three different German cohorts. Information was assessed by standardized face-to-face interviews. Lifestyle factors included alcohol consumption, smoking status, physical activity and body mass index. According to the 2004 diagnostic criteria, we distinguished the following headache types: migraine, TTH and their probable forms. Regional variations of lifestyle factors were observed. In the age- and gender-adjusted logistic regression models, none of the lifestyle factors was statistically significant associated with migraine, TTH, and their probable headache forms. In addition, we found no association between headache subtypes and the health index representing the sum of individual lifestyle factors. The lifestyle factors such as alcohol consumption, smoking, physical activity and overweight seem to be unrelated to migraine and TTH prevalence. For a judgement on their role in the onset of new or first attacks of migraine or TTH (incident cases), prospective cohort studies are required.
Electronic supplementary material
The online version of this article (doi:10.1007/s10194-010-0286-0) contains supplementary material, which is available to authorized users.
doi:10.1007/s10194-010-0286-0
PMCID: PMC3072498  PMID: 21222138
Migraine; Tension-type headache; Alcohol consumption; Body mass index; Physical activity; Smoking
19.  Association between lifestyle factors and headache 
The Journal of Headache and Pain  2011;12(2):147-155.
Modification of lifestyle habits is a key preventive strategy for many diseases. The role of lifestyle for the onset of headache in general and for specific headache types, such as migraine and tension-type headache (TTH), has been discussed for many years. Most results, however, were inconsistent and data on the association between lifestyle factors and probable headache forms are completely lacking. We evaluated the cross-sectional association between different lifestyle factors and headache subtypes using data from three different German cohorts. Information was assessed by standardized face-to-face interviews. Lifestyle factors included alcohol consumption, smoking status, physical activity and body mass index. According to the 2004 diagnostic criteria, we distinguished the following headache types: migraine, TTH and their probable forms. Regional variations of lifestyle factors were observed. In the age- and gender-adjusted logistic regression models, none of the lifestyle factors was statistically significant associated with migraine, TTH, and their probable headache forms. In addition, we found no association between headache subtypes and the health index representing the sum of individual lifestyle factors. The lifestyle factors such as alcohol consumption, smoking, physical activity and overweight seem to be unrelated to migraine and TTH prevalence. For a judgement on their role in the onset of new or first attacks of migraine or TTH (incident cases), prospective cohort studies are required.
Electronic supplementary material
The online version of this article (doi:10.1007/s10194-010-0286-0) contains supplementary material, which is available to authorized users.
doi:10.1007/s10194-010-0286-0
PMCID: PMC3072498  PMID: 21222138
Migraine; Tension-type headache; Alcohol consumption; Body mass index; Physical activity; Smoking
20.  A real-time assessment of the effect of exercise in chronic fatigue syndrome 
Physiology & behavior  2007;92(5):963-968.
Patients with chronic fatigue syndrome (CFS) report substantial symptom worsening after exercise. However, the time course over which this develops has not been explored. Therefore, the objective of this study was to investigate the influence of exercise on subjective symptoms and on cognitive function in CFS patients in natural settings using a computerized ecological momentary assessment method, which allowed us to track the effects of exercise within and across days. Subjects were 9 female patients with CFS and 9 healthy women. A watch-type computer was used to collect real time data on physical and psychological symptoms and cognitive function for one week before and two weeks after a maximal exercise test. For each variable, we investigated temporal changes after exercise using multilevel modeling. Following exercise, physical symptoms did get worse but not until a five-day delay in CFS patients. Despite this, there was no difference in the temporal pattern of changes in psychological symptoms or in cognitive function after exercise between CFS patients and controls. In conclusion, physical symptoms worsened after a several day delay in patients with CFS following exercise while psychological symptoms or cognitive function did not change after exercise.
doi:10.1016/j.physbeh.2007.07.001
PMCID: PMC2170105  PMID: 17655887
chronic fatigue syndrome; ecological momentary assessment; multilevel modeling
21.  Genetics of tension-type headache 
Abstract
The objective of this study was to investigate the importance of genetics in tension-type headache. A MEDLINE search from 1966 to December 2006 was performed for “tension-type headache and prevalence” and “tension-type headache and genetics” The prevalence of tensiontype headache varies from 11 to 93%, with a slight female preponderance. Co-occurrence of migraine increases the frequency of tension-type headache. A family study of chronic tension-type headache suggests that genetic factors are important. A twin study analysing tension-type headache in migraineurs found that genetic factors play a minor role in episodic tension-type headache. Another twin study analysing twin pairs without co-occurrence of migraine showed a significantly higher concordance rate among monozygotic than same-gender dizygotic twin pairs with no or frequent episodic tension-type headache, while the difference was minor in twin pairs with infrequent episodic tensiontype headache. Frequent episodic and chronic tension-type headache is caused by a combination of genetic and environmental factors, while infrequent episodic tensiontype headache is caused primarily by environmental factors.
doi:10.1007/s10194-007-0366-y
PMCID: PMC2795154  PMID: 17497260
Genetics; Twins; Families; Tension-type headache; Migraine
22.  Genetics of tension-type headache 
The objective of this study was to investigate the importance of genetics in tension-type headache. A MEDLINE search from 1966 to December 2006 was performed for “tension-type headache and prevalence” and “tension-type headache and genetics” The prevalence of tensiontype headache varies from 11 to 93%, with a slight female preponderance. Co-occurrence of migraine increases the frequency of tension-type headache. A family study of chronic tension-type headache suggests that genetic factors are important. A twin study analysing tension-type headache in migraineurs found that genetic factors play a minor role in episodic tension-type headache. Another twin study analysing twin pairs without co-occurrence of migraine showed a significantly higher concordance rate among monozygotic than same-gender dizygotic twin pairs with no or frequent episodic tension-type headache, while the difference was minor in twin pairs with infrequent episodic tensiontype headache. Frequent episodic and chronic tension-type headache is caused by a combination of genetic and environmental factors, while infrequent episodic tensiontype headache is caused primarily by environmental factors.
doi:10.1007/s10194-007-0366-y
PMCID: PMC2795154  PMID: 17497260
Genetics; Twins; Families; Tension-type headache; Migraine
23.  Sertraline versus amitriptyline in the prophylactic therapy of non-depressed chronic tension-type headache patients 
Patients with chronic tension- type headache (CTTH) are the most difficult to treat. Tricyclic antidepressants are the first-line therapeutic agents, but their anticholinergic side effects limit their usage. Selective serotonin reuptake inhibitors (SSRI) with fewer side effects than tricyclic antidepressants have also been used in treatment of CTTH, but the results are conflicting. In this study, prophylactic action of sertraline in treatment of nondepressed patients with CTTH was investigated and compared with amitriptyline in a prospective, randomized, open label, parallel-group study. A 4-week baseline period was followed by a 12-week treatment period with either 50 mg sertraline (n=41 patients) or 25 mg amitriptyline (n=44 patients). Efficacies of treatments were determined by using a headache diary, in which patients recorded the occurrence, number, intensity and duration of headaches in days, analgesic drug consumption and any adverse events. Both drugs reduced headache symptoms and analgesic drug consumption at the first, second and third months of treatment compared to baseline values. There was significant superiority of amitriptyline in the headache symptoms and drug consumption reductions versus sertraline at the second and third months of treatment. Side effects were more favorable in the sertraline-treated patients, but dropouts were similar in both groups. These results suggest that both drugs were effective in the treatment of non-depressed patients with CTTH, but in comparison between groups, amitriptyline was more effective than sertraline.
doi:10.1007/s10194-003-0034-9
PMCID: PMC3452139
Chronic tension-type headache; Prophylaxis; Sertraline; Amitriptyline
24.  The differential diagnosis of chronic daily headaches: an algorithm-based approach 
The Journal of Headache and Pain  2007;8(5):263-272.
Chronic daily headaches (CDHs) refers to primary headaches that happen on at least 15 days per month, for 4 or more hours per day, for at least three consecutive months. The differential diagnosis of CDHs is challenging and should proceed in an orderly fashion. The approach begins with a search for “red flags” that suggest the possibility of a secondary headache. If secondary headaches that mimic CDHs are excluded, either on clinical grounds or through investigation, the next step is to classify the headaches based on the duration of attacks. If the attacks last less than 4 hours per day, a trigeminal autonomic cephalalgia (TAC) is likely. TACs include episodic and chronic cluster headache, episodic and chronic paroxysmal hemicrania, SUNCT, and hypnic headache. If the duration is ≥4 h, a CDH is likely and the differential diagnosis encompasses chronic migraine, chronic tension-type headache, new daily persistent headache and hemicrania continua. The clinical approach to diagnosing CDH is the scope of this review.
doi:10.1007/s10194-007-0418-3
PMCID: PMC2793374  PMID: 17955166
Chronic daily headache; Differential diagnosis; Strategy
25.  The differential diagnosis of chronic daily headaches: an algorithm-based approach 
The Journal of Headache and Pain  2007;8(5):263-272.
Chronic daily headaches (CDHs) refers to primary headaches that happen on at least 15 days per month, for 4 or more hours per day, for at least three consecutive months. The differential diagnosis of CDHs is challenging and should proceed in an orderly fashion. The approach begins with a search for “red flags” that suggest the possibility of a secondary headache. If secondary headaches that mimic CDHs are excluded, either on clinical grounds or through investigation, the next step is to classify the headaches based on the duration of attacks. If the attacks last less than 4 hours per day, a trigeminal autonomic cephalalgia (TAC) is likely. TACs include episodic and chronic cluster headache, episodic and chronic paroxysmal hemicrania, SUNCT, and hypnic headache. If the duration is ≥4 h, a CDH is likely and the differential diagnosis encompasses chronic migraine, chronic tension-type headache, new daily persistent headache and hemicrania continua. The clinical approach to diagnosing CDH is the scope of this review.
doi:10.1007/s10194-007-0418-3
PMCID: PMC2793374  PMID: 17955166
Chronic daily headache; Differential diagnosis; Strategy

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