Pain Medicine 2015; 16: 1629–1634 Wiley Periodicals, Inc.
HEADACHE & FACIAL PAIN SECTION Original Research Article Generalized Pressure Pain Hypersensitivity in the Cervical Muscles in Women with Migraine
*Department of Biomechanics, Medicine and Locomotor Apparatus Rehabilitation; †Department of Neurosciences and Behavioral Sciences, Faculty of ~o Preto, University of Sa ~o Paulo, Medicine of Ribeira ~o Preto-SP, Brazil; ‡Department of Physical Ribeira Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, n, Spain Alcorco Reprint requests to: Lidiane Lima Florencio, MD, Avenida Bandeirantes, 3900 – Monte Alegre CEP ~o Preto/SP A/C Fisioterapia. 14049-900, Ribeira Tel.: 1551198579-1787; Fax: 155 16 3315-4413; E-mail: [email protected]. Conflict of interest: The authors state that there is no conflict of interest. Funding sources: This study received financial sup~o Paulo Research Foundation (FAPESP). port from Sa
Methods. Pressure pain thresholds (PPT) were bilaterally assessed over upper trapezius, sternocleidomastoid, suboccipital, levator scapulae, and anterior scalene muscles in a blinded design. Mean values of both sides were pooled for statistical analysis. Comparison between groups was performed by unpaired Student t-test and correlation with headache features with Spearman’s correlation test. Results. Migraine patients exhibited lower PPT in all muscles compared with controls: upper trapezius (P 5 0.046); suboccipital (P < 0.001); sternocleidomastoid (P < 0.001); anterior scalene (P < 0.001), and levator scapulae (P < 0001). No associations were observed between the frequency and the intensity of migraine or years with the disease and PPT. Conclusion. This study showed generalized pressure pain hypersensitivity in the cervical musculature in women with migraine. Our findings provide support for the physical therapy treatment and evaluation of musculoskeletal cervical spine disorders in individuals with migraine and reinforce that all cervical muscles should be evaluated. Key Words. Pressure Pain Threshold; Cervical Spine; Muscles; Migraine
Introduction Abstract Objective. To investigate the differences in pressure sensitivity in the cervical musculature including the upper trapezius, sternocleidomastoid, suboccipital, levator scapulae, and anterior scalene muscles between women with migraine and healthy controls. Design. Cross-sectional study. Subjects. Thirty women with migraine and 30 healthy women participated.
Migraine is a chronic pain disease with recurrent episodes affecting between 5% and 12% of the general population [1–3]. Accordingly to the diagnostic criteria suggested by the International Headache Society, migraine headache attacks are mainly characterized by headaches lasting from 4 to 72 hours, throbbing and pulsating quality, of moderate to severe intensity, which can be exacerbated by routine physical activity and is associated with nausea, vomiting, photophobia, and/or phonophobia [4]. However, other clinical features have been also highlighted as being important in predicting the prognosis of migraine pain, such as the presence of neck pain [5].
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Downloaded from http://painmedicine.oxfordjournals.org/ by guest on March 8, 2016
Lidiane Lima Florencio, MD,* Maria Carolina Merli Giantomassi,* Gabriela Ferreira Carvalho, MD,* udia Gonc¸alves, PhD,* Maria Cla Fabıola Dach, PhD,† sar Ferna ndez-de-las-Pen ~ as, PhD,‡ Ce bora Bevilaqua-Grossi, PhD* and De
Florencio et al. The prevalence of neck pain in patients with migraine is almost 76% [6], and it may appear in the premonitory phase or accompany the headache phase [7]. Neck pain is more prevalent than nausea during migraine attacks [8] and is an important predictor of disability in migraine patients [5–7], capable of delaying the therapeutic effect of abortive drug treatment [9].
Pressure pain hypersensitivity, expressed as decreased PPT, is generally regarded as a common clinical manifestation of sensitization of nociceptive pain pathways. Previous studies investigating PPT on migraine patients reported conflicting results as some studies have observed lower values in patients when compared with controls [16–19]; whereas others reported no differences in PPT between migraine, tension-type headache, and healthy subjects [20,21]. These previous studies only investigated pressure pain sensitivity in the temporalis or upper trapezius muscle, but mechanical sensitivity of other cervical muscles in individuals with migraine has not been determined yet. To determine the presence of pressure hypersensitivity in other cervical muscles can contribute to deeper understanding of the clinical features in patients with migraine and to more integrative clinical evaluation of this population. The aim of this study was to investigate differences in pressure pain sensitivity in the neck musculature including the upper trapezius, sternocleidomastoid, suboccipital, levator scapulae, and anterior scalene muscles between migraine patients and controls subjects. Our hypothesis was that migraineurs exhibit lower PPT compared with individuals without migraine in all the muscles evaluated. Methods Participants Patients with headache from a university-based headache center were screened for eligibility criteria. Migraine patients were diagnosed following the International Headache Society criteria by an experienced neurologist 1630
Pressure Pain Thresholds PPT was assessed using a digital manual dynamometer (DDK-10 Kratos) adapted for algometry evaluation. The device’s calibration ranges from 0 to 29 kg with an accuracy of 0.001 kg. A 1-cm2 rubber disk was adapted to the device’s metal point to avoid any harm. PPT was bilaterally assessed at the following five muscles in a random sequence for two consecutive series: (X1) sternocleidomastoid (fibers below the mastoid process); (X2) levator scapulae (central point between the proximal portion of the sternocleidomastoid and upper trapezius insertion); (X3) suboccipital (below the occipital bone, lateral to upper trapezius insertion); (X4) upper trapezius (midpoint between the C7 spinous process and the acromion); and (X5) anterior scalene (middle portion between the transverse processes of the cervical vertebrae and the first rib) (Figure 1). The examiner was blinded to the subject’s condition. The examiner was previously trained to apply a constant pressure of about 1 kg/cm2/s with optimal positioning of the device perpendicular to the evaluated anatomical surfaces. A digital metronome with a frequency of 1 Hz was used in all evaluations for providing an audio feedback and standardization of the pressure application speed to the examiner. The order of point assessment was randomized between participants. Participants were informed that the evaluation was to determine the pain threshold and not pain tolerance; therefore, they were asked for signaling as soon as they first felt pain. All participants were firstly trained with a first assessment on the thenar region of the right hand. The evaluation was held when all migraine patients were headache-free, and when at least 1 week had elapsed since the last migraine attack to avoid migraine-related allodynia. All patients were being taken prophylactic drugs, but none of them was taking any migraine abortive drug at the time of the study. No other medication inferring in pressure sensitivity, such as muscle relaxants or antipsychotics, was permitted.
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on March 8, 2016
Several musculoskeletal impairments of the cervical spine are usually seen in patients with migraine including restricted cervical range of motion, presence of myofascial trigger points, increased muscle hypersensitivity, forward head posture, and reduced pressure pain thresholds (PPT); [10–12]. The relationship between neck pain and migraine can be explained by the trigeminocervical nucleus caudalis, which is the anatomical region where the nociceptive afferences from the upper cervical and trigeminal nerves converge. Therefore, cervical spine stimulation can cause pain in any area innervated of the trigeminal nerve [13]. The cervical spine can be considered as a hidden irritative thorn where a continuous bombardment of nociceptive stimuli may lead to the hyperexcitability of the central nervous system seen in patients with migraine [14,15].
[4]. In all participants, headache features including time of disease, frequency and intensity of migraine attacks, family history, and medications were assessed from the clinical history. Patients were excluded if presented other primary headaches; medication overuse headache; pregnancy; systemic degenerative diseases such as rheumatoid arthritis, lupus erythematous, or other medical diseases affecting sensitivity, for example, such fibromyalgia or previous neck trauma (whiplash). A careful examination of each participant was conducted to determine inclusion and exclusion criteria. Control group without migraine history were selected at the same hospital and matched by age to migraine group. The study was approved by the local Ethics Committee (process 2013/08836-0). All participants in the study signed the informed consent form.
Neck Muscles PPT in Migraine
Figure 1 Anatomical sites of PPT assessment: (X1) Sternocleidomastoid; (X2) Levator Scapulae; (X3) Suboccipital; (X4) Upper Trapezius; and (X5) Anterior Scalene.
from 0.3 to 0.7 moderate correlation; and >0.7 strong correlation [23]. The analysis was conducted at 95% confidence level. A P value less than 0.05 was considered statistically significant.
The sample size determination was performed with an C, ~o de la Muestra, 1.1V appropriate software (Taman Spain). The calculations were based on detecting, at least, significant clinically differences of 20% on PPT between groups [22] with an alpha level of 0.05, a power of 80%, and an estimated interindividual coefficient of variation for PPT measures of 20%. This generated a sample size of at least 16 participants per group.
Results From January 2014 to June 2014, 418 potentially eligible subjects were screened. Three hundred and fiftythree (n 5 353, 87%) were excluded due to the following reasons: another type of primary headache (n 5 180), age (n 5 73), associated medical diseases that may interfere the sensibility such as fibromyalgia (n 5 82), refute to participate (n 5 18) and male gender (n 5 5). Were analyzed 30 women, aged from 18 to 55 years (mean: 37 years), with migraine and 30 healthy women, aged from 18 to 50 years (mean: 32 years). All participants were taking amitriptyline as a prophylactic medication on their regular basis. No significant differences were found in age and body mass index between both groups (Table 1).
Statistical Analysis Data were analyzed with Statistical Package for Social C ). Scientist package version 18.0 (SPPS Inc, ChicagoV Means, standard deviations or 95% confidence intervals were calculated. As no side-to-side differences were observed, mean of both sides were used in the main analysis for between-groups comparisons. The unpaired Student t-test was used to investigate differences in PPT between patients with migraine and healthy controls. The Spearman’s rho (rs) test was used to analyze the association between the intensity and frequency of migraine and history (years) with the disease with PPT over each muscle within the migraine group. For linear associations, values
HEADACHE & FACIAL PAIN SECTION Original Research Article Generalized Pressure Pain Hypersensitivity in the Cervical Muscles in Women with Migraine
*Department of Biomechanics, Medicine and Locomotor Apparatus Rehabilitation; †Department of Neurosciences and Behavioral Sciences, Faculty of ~o Preto, University of Sa ~o Paulo, Medicine of Ribeira ~o Preto-SP, Brazil; ‡Department of Physical Ribeira Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, n, Spain Alcorco Reprint requests to: Lidiane Lima Florencio, MD, Avenida Bandeirantes, 3900 – Monte Alegre CEP ~o Preto/SP A/C Fisioterapia. 14049-900, Ribeira Tel.: 1551198579-1787; Fax: 155 16 3315-4413; E-mail: [email protected]. Conflict of interest: The authors state that there is no conflict of interest. Funding sources: This study received financial sup~o Paulo Research Foundation (FAPESP). port from Sa
Methods. Pressure pain thresholds (PPT) were bilaterally assessed over upper trapezius, sternocleidomastoid, suboccipital, levator scapulae, and anterior scalene muscles in a blinded design. Mean values of both sides were pooled for statistical analysis. Comparison between groups was performed by unpaired Student t-test and correlation with headache features with Spearman’s correlation test. Results. Migraine patients exhibited lower PPT in all muscles compared with controls: upper trapezius (P 5 0.046); suboccipital (P < 0.001); sternocleidomastoid (P < 0.001); anterior scalene (P < 0.001), and levator scapulae (P < 0001). No associations were observed between the frequency and the intensity of migraine or years with the disease and PPT. Conclusion. This study showed generalized pressure pain hypersensitivity in the cervical musculature in women with migraine. Our findings provide support for the physical therapy treatment and evaluation of musculoskeletal cervical spine disorders in individuals with migraine and reinforce that all cervical muscles should be evaluated. Key Words. Pressure Pain Threshold; Cervical Spine; Muscles; Migraine
Introduction Abstract Objective. To investigate the differences in pressure sensitivity in the cervical musculature including the upper trapezius, sternocleidomastoid, suboccipital, levator scapulae, and anterior scalene muscles between women with migraine and healthy controls. Design. Cross-sectional study. Subjects. Thirty women with migraine and 30 healthy women participated.
Migraine is a chronic pain disease with recurrent episodes affecting between 5% and 12% of the general population [1–3]. Accordingly to the diagnostic criteria suggested by the International Headache Society, migraine headache attacks are mainly characterized by headaches lasting from 4 to 72 hours, throbbing and pulsating quality, of moderate to severe intensity, which can be exacerbated by routine physical activity and is associated with nausea, vomiting, photophobia, and/or phonophobia [4]. However, other clinical features have been also highlighted as being important in predicting the prognosis of migraine pain, such as the presence of neck pain [5].
1629
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on March 8, 2016
Lidiane Lima Florencio, MD,* Maria Carolina Merli Giantomassi,* Gabriela Ferreira Carvalho, MD,* udia Gonc¸alves, PhD,* Maria Cla Fabıola Dach, PhD,† sar Ferna ndez-de-las-Pen ~ as, PhD,‡ Ce bora Bevilaqua-Grossi, PhD* and De
Florencio et al. The prevalence of neck pain in patients with migraine is almost 76% [6], and it may appear in the premonitory phase or accompany the headache phase [7]. Neck pain is more prevalent than nausea during migraine attacks [8] and is an important predictor of disability in migraine patients [5–7], capable of delaying the therapeutic effect of abortive drug treatment [9].
Pressure pain hypersensitivity, expressed as decreased PPT, is generally regarded as a common clinical manifestation of sensitization of nociceptive pain pathways. Previous studies investigating PPT on migraine patients reported conflicting results as some studies have observed lower values in patients when compared with controls [16–19]; whereas others reported no differences in PPT between migraine, tension-type headache, and healthy subjects [20,21]. These previous studies only investigated pressure pain sensitivity in the temporalis or upper trapezius muscle, but mechanical sensitivity of other cervical muscles in individuals with migraine has not been determined yet. To determine the presence of pressure hypersensitivity in other cervical muscles can contribute to deeper understanding of the clinical features in patients with migraine and to more integrative clinical evaluation of this population. The aim of this study was to investigate differences in pressure pain sensitivity in the neck musculature including the upper trapezius, sternocleidomastoid, suboccipital, levator scapulae, and anterior scalene muscles between migraine patients and controls subjects. Our hypothesis was that migraineurs exhibit lower PPT compared with individuals without migraine in all the muscles evaluated. Methods Participants Patients with headache from a university-based headache center were screened for eligibility criteria. Migraine patients were diagnosed following the International Headache Society criteria by an experienced neurologist 1630
Pressure Pain Thresholds PPT was assessed using a digital manual dynamometer (DDK-10 Kratos) adapted for algometry evaluation. The device’s calibration ranges from 0 to 29 kg with an accuracy of 0.001 kg. A 1-cm2 rubber disk was adapted to the device’s metal point to avoid any harm. PPT was bilaterally assessed at the following five muscles in a random sequence for two consecutive series: (X1) sternocleidomastoid (fibers below the mastoid process); (X2) levator scapulae (central point between the proximal portion of the sternocleidomastoid and upper trapezius insertion); (X3) suboccipital (below the occipital bone, lateral to upper trapezius insertion); (X4) upper trapezius (midpoint between the C7 spinous process and the acromion); and (X5) anterior scalene (middle portion between the transverse processes of the cervical vertebrae and the first rib) (Figure 1). The examiner was blinded to the subject’s condition. The examiner was previously trained to apply a constant pressure of about 1 kg/cm2/s with optimal positioning of the device perpendicular to the evaluated anatomical surfaces. A digital metronome with a frequency of 1 Hz was used in all evaluations for providing an audio feedback and standardization of the pressure application speed to the examiner. The order of point assessment was randomized between participants. Participants were informed that the evaluation was to determine the pain threshold and not pain tolerance; therefore, they were asked for signaling as soon as they first felt pain. All participants were firstly trained with a first assessment on the thenar region of the right hand. The evaluation was held when all migraine patients were headache-free, and when at least 1 week had elapsed since the last migraine attack to avoid migraine-related allodynia. All patients were being taken prophylactic drugs, but none of them was taking any migraine abortive drug at the time of the study. No other medication inferring in pressure sensitivity, such as muscle relaxants or antipsychotics, was permitted.
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on March 8, 2016
Several musculoskeletal impairments of the cervical spine are usually seen in patients with migraine including restricted cervical range of motion, presence of myofascial trigger points, increased muscle hypersensitivity, forward head posture, and reduced pressure pain thresholds (PPT); [10–12]. The relationship between neck pain and migraine can be explained by the trigeminocervical nucleus caudalis, which is the anatomical region where the nociceptive afferences from the upper cervical and trigeminal nerves converge. Therefore, cervical spine stimulation can cause pain in any area innervated of the trigeminal nerve [13]. The cervical spine can be considered as a hidden irritative thorn where a continuous bombardment of nociceptive stimuli may lead to the hyperexcitability of the central nervous system seen in patients with migraine [14,15].
[4]. In all participants, headache features including time of disease, frequency and intensity of migraine attacks, family history, and medications were assessed from the clinical history. Patients were excluded if presented other primary headaches; medication overuse headache; pregnancy; systemic degenerative diseases such as rheumatoid arthritis, lupus erythematous, or other medical diseases affecting sensitivity, for example, such fibromyalgia or previous neck trauma (whiplash). A careful examination of each participant was conducted to determine inclusion and exclusion criteria. Control group without migraine history were selected at the same hospital and matched by age to migraine group. The study was approved by the local Ethics Committee (process 2013/08836-0). All participants in the study signed the informed consent form.
Neck Muscles PPT in Migraine
Figure 1 Anatomical sites of PPT assessment: (X1) Sternocleidomastoid; (X2) Levator Scapulae; (X3) Suboccipital; (X4) Upper Trapezius; and (X5) Anterior Scalene.
from 0.3 to 0.7 moderate correlation; and >0.7 strong correlation [23]. The analysis was conducted at 95% confidence level. A P value less than 0.05 was considered statistically significant.
The sample size determination was performed with an C, ~o de la Muestra, 1.1V appropriate software (Taman Spain). The calculations were based on detecting, at least, significant clinically differences of 20% on PPT between groups [22] with an alpha level of 0.05, a power of 80%, and an estimated interindividual coefficient of variation for PPT measures of 20%. This generated a sample size of at least 16 participants per group.
Results From January 2014 to June 2014, 418 potentially eligible subjects were screened. Three hundred and fiftythree (n 5 353, 87%) were excluded due to the following reasons: another type of primary headache (n 5 180), age (n 5 73), associated medical diseases that may interfere the sensibility such as fibromyalgia (n 5 82), refute to participate (n 5 18) and male gender (n 5 5). Were analyzed 30 women, aged from 18 to 55 years (mean: 37 years), with migraine and 30 healthy women, aged from 18 to 50 years (mean: 32 years). All participants were taking amitriptyline as a prophylactic medication on their regular basis. No significant differences were found in age and body mass index between both groups (Table 1).
Statistical Analysis Data were analyzed with Statistical Package for Social C ). Scientist package version 18.0 (SPPS Inc, ChicagoV Means, standard deviations or 95% confidence intervals were calculated. As no side-to-side differences were observed, mean of both sides were used in the main analysis for between-groups comparisons. The unpaired Student t-test was used to investigate differences in PPT between patients with migraine and healthy controls. The Spearman’s rho (rs) test was used to analyze the association between the intensity and frequency of migraine and history (years) with the disease with PPT over each muscle within the migraine group. For linear associations, values
