Pericranial tenderness in tension headache

A blind, controlled study

Michael Langemark, Jes Olesen

CEPHALALGIA

Langemark M, Olesen J. Pericranial tenderness in tension headache. A blind, controlled study. Cephalalgia
1987;7:249-255. Oslo. ISSN 0333-1024

Forty patients with tension headache and 40 healthy comparable control persons were palpated by the same
"blinded" observer. Tenderness in 10 pericranial muscles on each side was rated on a four-point scale. A
Total Tenderness Score was calculated for each individual by adding the scores from all palpated areas.
Headache patients had significantly higher scores than controls and also significantly higher tenderness in
each point separately. Median normal values and confidence limits for tenderness are given. Among 23
patients with daily headache a correlation was found between headache intensity and Total Tenderness
Score. It is likely that the pathologic tenderness in patients with tension headache is the source of nociception,
but pain mechanisms are more complex, as evidenced by discrepancy between tenderness and pain in some
patients. Pathologic tenderness should be a contributing criterion to the diagnosis of tension headache
(muscle conctraction headache). † Endogenous pain inhibition, headache, myofascial pain syndromes,
palpation, temporomandibular joint syndrome

Michael Langemark, Jes Olesen, Department of Neurology, Gentofte University Hospital, DK-2900 Hellerup,
Denmark; Correspondence to Jes Olesen; Accepted 14 June 1987
The definition of headache disorders given by the Ad Hoc Committee of the U.S. National Institute of Health has been
generally used and accepted. Muscle contraction headache is listed as synonymous with tension headache and defined
as follows: "Ache or sensations of tightness, pressure, or constriction, widely varied in intensity, frequency, and
duration, sometimes long-lasting, and commonly sub-occipital. It is associated with sustained contraction of skeletal
muscles in the absence of permanent structural change, usually as part of the individual's reaction during life stress.
The ambiguous and unsatisfactory terms "tension", "psychogenic", and "nervous" headache refer largely to this group"
(1).

Sustained contraction of muscles is mentioned as a cardinal feature, but no guidelines are given for the verification
of sustained muscular contraction in the individual patient.

A simple and obvious approach to the evaluation of myofascial pathology seems to be palpation of the chewing and
neck muscles, with demonstration of pathologic muscle tenderness. The process of palpation is, however, very
subjective, and normal values have not been established. The problem may be remedied by not informing the examiner
of the patient's headache, and we therefore present a blinded study that compares pericranial muscle tenderness in
patients with muscle contraction headache (or tension headache) with findings in a control group consisting of healthy
individuals.

Materials and methods

Forty headache patients and 40 controls entered the study. Headache patients were included after a detailed interview
and neurologic examination, provided they had a history of tension headache (muscle contraction headache) in
accordance with the criteria of the Ad Hoc Committee of the NIH (1). Patients with a history of classic migraine or
frequent common migraine (more than one attack per month) were excluded. The headache patients were recruited by
mailed questionnaire among
patients who had consulted the Copenhagen Acute Headache Clinic (17 patients), a private neurology clinic (10
patients), or a neurologic hospital department (13 patients). The male to female ratio among patients was 11:29; the
median age was 44 years, and the range, 24-70 years.

The controls were recruited among teachers from nearby schools. They were informed that the study involved
manual registration of muscle tenderness, but the aim of the study was withheld until after the examination, to avoid a
biased distribution of headache sufferers among the controls. The usual frequency of headache was registered after the
examination. The male to female ratio among controls was 13:27; median age was 42 years, and the range, 20-68
years. For all subjects, the presence or absence of headache at the time of the examination was registered. Intensity
was scored on a four-point scale (0 = none, 1 = headache not interfering with daily activities, 2 = headache interfering
with daily activities, and 3 = headache preventing daily activities). No interference with patients' usual drug intake was
attempted.

Patients and controls were instructed not to talk to the observer and were then presented randomly and under
identical circumstances to the same observer (J. Olesen). No information about the subjects' headache history was
available to the observer, and all subjects were unknown to him.

Tenderness in 10 pericranial muscles on each side of the head was evaluated by palpation and rated by the
observer on a scale from 0 to 3. The scoring was defined as follows: 0 = no visible reaction and denial of tenderness; 1
= no visible reaction but verbal report of discomfort or mild pain; 2 = verbal report of painful tenderness, facial
expression of discomfort or no reaction; and 3 = marked grimacing or withdrawal, verbal report of marked painful
tenderness and pain.

Examinations were performed extraorally and always in the same order. The areas palpated were the frontalis,
temporal, lateral and medial pterygoid, masseter, and sternocleidomastoid muscles and the neck muscle insertions, the
mastoid process (insertion of the sternocleidomastoid muscle), and the coronoid process (insertion of the temporal
muscle). Palpation was done with the second and third finger, which performed small rotating movements and pressure
while the other hand supported the head. Each muscle was systematically examined point by point.

A Total Tenderness Score (TTS) was cal-

culated for each patient by simply adding the scores from the 10 right and 10 left palpated muscle insertions.

Results

The headache frequency in patients and controls is shown in Fig. 1.

The distribution of patients and controls by Total Tenderness Scores is shown in Fig. 2. The headache
patients had significantly higher scores than the controls (p < 10-7, Mann-Whitney-Wilcoxon test).

The median tenderness score for each palpated muscle is given with quartiles in Table 1. For each point,
headache patients were scored higher than the controls. All differences were statistically significant (p =
0.013 for the right pterygoid muscle; p < 0.002 for the others; Mann-Whitney test). The median total
tenderness score for controls was 7; the 95% confidence interval for the median was [4;19].

No correlation was found between age and TTS (Spearman's rs = -0.03, p = 0.82).

The sum of the scores from the right side of the head was compared with that from the left side.
Unexpectedly, statistically significant differences were found in both groups. In the headache group median
values were 19 (sum of right-side scores) and 21 (sum of left-side scores) (p < 10-5). In the control group
median values were 3 (sum of right-

side scores) and 4 (sum of left-side scores) (p = 0.02; Wilcoxon paired test).

To evaluate any influence of the observer's handedness on left/right differences, the

Table 1. Tenderness score in 40 controls and 40 headache patients. Median and quartiles are shown.
Controls Headache patients
Right Left Right Left
Frontalis muscle 0 (0;0) 0 (0;0) 1 (0;2) 2 (1;2)
Lat. pterygoid m. 0 (0;1) 0 (0;1) 1 (0;2) 2 (0.5;2)
Masseter muscle 0 (0;1) 0 (0;1) 1 (0;2) 2 (1;3)
Coronoid process 0 (0;0.5) 0 (0;1) 1 (0;2) 2 (0.5;3)
Sternocleidomastoid m. 0 (0;0) 0 (0;0) 1.5 (0;2) 2
(0;2.5)
Med. pterygoid m. 1 (0;1.5) 1 (0;2) 2 (1;2) 2 (1;3)
Trapezius muscle 0 (0;2) 0 (0;1) 2 (1;3) 2 (0.5;3)
Temporalis muscle 0 (0;1) 1 (0;2) 2 (1;3) 3 (2;3)
Mastoid process 0.5 (0;1) 0 (0;2) 3 (1.5;3) 3 (1.5;3)
Neck muscle insertions 1 (0;2) l (0;2) 3 (2;3) 3
(2;3)
mastoid process, trapezius, and neck muscles were analyzed separately. Although not statistically significant,
the tendency toward more tenderness in the patients' left side was confirmed. Thus, 9 patients were more
tender in the left mastoid process, 4 were more tender in the right mastoid process, and 27 showed no
difference. The corresponding values with regard to the neck muscle insertions were 6, 2, and 32 patients.
Results from the left and right side of the trapezius muscle were almost identical in the two groups (4
headache patients were more tender in the right trapezius, 2 were more tender in the left trapezius, and 34
showed no difference). Comparison between right and left in the frontal and temporal muscles showed
significantly higher left-sided tenderness (p < 0.01) in the temporal muscle (both groups) and the frontal
muscle (headache patients).

A positive correlation between the intensity of headache at examination and the Total Tenderness Score
was found among the 40 headache patients (Spearman's r = 0.32, p < 0.05). Among 23 patients complaining
of daily headache, a more pronounced correlation between headache level and TTS was found (Spearman's
r = 0.56, p < 0.01) (Fig. 3). A similar correlation (Spearman's r = 0.55, p < 10-6) found among all subjects
may reflect the generally low TTS levels in the controls and should thus be interpreted cautiously.

Thirteen patients reported migraine attacks 1 to 12 times per year. No correlation could be demonstrated
between frequency of migraine attacks and TTS among the headache patients (Spearman's r = 0.18, p =
0.26).

Discussion

The pathogenetic mechanisms of tension headache are still relatively unknown. Tonic contraction causing
muscular hypoxia and other pain-inducing conditions in pericranial muscles due to disturbed contraction (2),
pure psychologic perception of headache and, more lately, dysfunctioning endogenous pain control have all
been suggested (3-6). Moreover, any of these factors may interact with the others (7-10).

In daily practice the finding of tenderness in any part of the body may imply a local,
pathologic process (fibromyositis) as the cause of pain. It is thus not unreasonable to assume that at least
part of the pathologic processes in tension headache takes place peripherally—that is, pain arises from the
tender spots in the muscles and tendon insertions of the head.

Previous studies of pericranial tenderness

In the evaluation of tenderness, either an apparatus or simple digital palpation can be applied. The use of
a force-registering algometer (algesiometer) gives fairly reproducible results (11), but the method suffers
from the drawbacks that only one small point can be examined at a time and that several muscles are
inaccessible to the transducer. Using digital palpation, the observer may localize small tender spots and
constantly monitor both the exerted finger pressure and the patient's reactions (verbally and non-verbally)
(12). The risk of observer bias is considerable, and, ideally, manual palpation should only be used in blind
comparisons in which all examinations are done by the same observer. Despite such precautions, patients
with severe headache could theoretically be recognized by, for example, facial expression. This was not our
experience in the present study. The different advantages and disadvantages of digital palpation and
algometers (algesiometers) make digital palpation the best choice if effective blinding of the observer is
possible. Definite criteria for scoring are crucial. The suggested criteria for scoring tenderness have proved
their practical applicability, but it should be recognized that results from one investigation cannot be directly
transformed to other centers or other investigators. Algometers (algesiometers) are constantly being
improved, and in many studies digital palpation and the use of algometers can be combined with advantage.

In a previous study 13 patients with muscle contraction headache/tension headache were compared with
25 controls who had never had headache. The headache patients had tender jaw and neck muscles,
whereas no muscle tenderness was found in the control group, but the study was not performed blindly (13).
Similarly, a correlation between tenderness and headache complaints was found in a study of 739 university
students. Fifty-eight per cent of the subjects with headaches had tenderness of the muscles of the jaw and
head, whereas only 31% of the non-headache students were tender on palpation (14). Further evidence of
pericranial myofascial tissue as the possible site of pain generation in headache came from an investigation
of patients referred to dental treatment for temporomandibular joint dysfunction. A correlation between
severity of headache and temporomandibular joint dysfunction was found, but the correlation between
severity of headache and the dysfunction disappeared if dysfunction was scored without inclusion of
masticatory muscle tenderness (15, 16). Muscle tenderness during migraine attacks has also been described
(17).

Present results

The patients and controls in the present study did not know the purpose of the examination, and the
examiner did not know whether the subjects had headache. It was obvious to the examiner that bias in a
non-blinded study in all probability is considerable.

As a group, patients with tension headache had more tenderness than controls, and the difference was
quite marked, with only a moderate overlap. This is in accordance with previous, unblinded studies (13, 14).
The correlation between tenderness and severity of headache at the time of examination in 23 patients who
complained of daily headaches is further evidence of the importance of tenderness for pain.

The distribution of tenderness in the different muscles is comparable in controls and headache patients,
indicating that the latter have a generalized increase of tenderness in the head, neck, and shoulders. No
pattern with regard to functional type of the muscles afflicted could be seen, possibly because no pericranial
muscles are involved solely in mastication, nor are any involved exclusively in the static positioning of the
head and jaw.

Some of the controls reported no headache but had severe tenderness. Myofascial
abnormalities may have resulted in no pain because of possibly increased activity of the endogenous pain
control system. Although such an explanation at present remains hypothetical, there is ample experimental
evidence concerning the functioning of pain control mechanisms in man and animals (18). On the other
hand, some patients even with daily headache experienced no tenderness. In these patients muscular
abnormalities are unlikely. The co-existence of headache and tenderness in most patients, however, may fit
into a model of a peripheral pathologic condition giving rise nociceptive input, which may be modified, but
rarely extinguished, by the pain control system in the central nervous system (CNS).

To explain the headache on the basis of a decreased activity of the endogenous pain control system
causing normal sensory input to be perceived as painful is not easy, since tone has not been convincingly
shown in this system in healthy individuals (18). However, pain modification may occur at several levels of the
CNS (17), and one may speculate that patients without tenderness may have a dysfunction of pain perception
which is more complex than a simple lack of morphine-like neurotransmitters.

There is general agreement internationally that the current definition of tension headache is
unsatisfactory. Pericranial muscle and tendon tenderness should be included in the diagnostic criteria as
substantiated by the present study. The study also demonstrates that muscle tenderness may be measured
semiquantitatively and hence could be used as a diagnostic criterion.

We found greater tenderness (lower pain threshold) on the left side of the head in accordance with most,
but not all, of the previously published studies. Algometer measurements of pain threshold on thumbs (19) in
normal adults showed a higher threshold for the dominant hand, and a similar, although not consistently
significant, difference has been shown in the temporal region (11). In a study of different types of headache
patients, no statistically significant side differences were found between palpated pericranial muscles (12).
On the other hand, a clinical investigation of the occlusal relationships in 123 dental students showed
myofascial trigger zones in 76 right-sided and 34 left-sided muscles (20).

The present results support the view that a peripheral pathologic condition is present in most patients,
normally diagnosed as muscle contraction headache. The presently available diagnostic criteria (1) may
possibly include several disorders with different pathogenetic backgrounds. Theoretically well-founded and
clinically acceptable criteria are needed, and we find that the presence of muscle tenderness should be
taken into consideration as a criterion for the diagnosis of muscle contraction headache (tension headache).

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