Chronic Daily Headache
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《新英格兰医药杂志》
To the Editor: In his article on chronic daily headache (Jan. 12 issue),1 Dodick did not address one condition that, in my experience as a neurologist in the management of chronic pain and headache, is the most common form of headache seen in the clinic. That condition is chronic daily headache associated with muscle tension (chronic tension-type headache) with periodic migrainous features. This type of headache is often included in the category of migraine or transformed migraine but is characterized by a background of daily headache with tender, tight muscle bands in the head, neck, and shoulder muscles (muscle trigger points), with pain referred to the head. Headache can be reproduced by stimulating the trigger points that refer pain to the head.2,3 Inactivation of the trigger points in these muscles can be an effective treatment in both the chronic and acute states. It is important that clinicians be aware of this type of headache, in addition to the headaches so clearly delineated by Dodick.
Robert D. Gerwin, M.D.
Johns Hopkins University School of Medicine
Baltimore, MD 21287
gerwin@painpoints.com
References
Dodick DW. Chronic daily headache. N Engl J Med 2006;354:158-165.
Gerwin R. Headache. In: Ferguson L, Gerwin R, eds. Clinical mastery in the treatment of myofascial pain. Philadelphia: Lippincott Williams & Wilkins, 2005:1-24.
de las Penas CF, Cuadrado ML, Gerwin RD, Pareja JA. Referred pain from the trochlear region in tension-type headache: a myofascial trigger point from the superior oblique muscle. Headache 2005;45:731-737.
Dr. Dodick replies: I agree with Gerwin that the patient with migraines who has daily or near-daily headaches and tender neck musculature represents a very common phenotype in clinical practice. According to the International Classification of Headache Disorders (ICHD-II),1 despite the presence of muscle tenderness, the vast majority of these patients would be classified as having chronic migraine. The majority of patients with migraine have muscle tenderness and tightness in the head, neck, and shoulders because of the pattern of the referral of pain from the activation and sensitization of central second-order neurons within the trigeminocervical complex.2,3 "Migrainous features" typically become less prominent as migraine "transforms" over time from an episodic to a chronic pattern with nearly daily headache.4 The effectiveness of trigger-point injections, as well as of other therapies, warrants evaluation in clinical trials in which patients are classified according to ICHD-II nomenclature.
David W. Dodick, M.D.
Mayo Clinic College of Medicine
Scottsdale, AZ 85259
dodick.david@mayo.edu
References
Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. 2nd ed. Cephalalgia 2004;24:Suppl 1:1-160.
Kaniecki RG. Migraine and tension-type headache: an assessment of challenges in diagnosis. Neurology 2002;58:Suppl 6:S15-S20.
Bartsch T, Goadsby PJ. The trigeminocervical complex and migraine: current concepts and synthesis. Curr Pain Headache Rep 2003;7:371-376.
Bigal ME, Rapoport AM, Sheftell FD, Tepper SJ, Lipton RB. Chronic migraine is an earlier stage of transformed migraine in adults. Neurology 2005;65:1556-1561.
Robert D. Gerwin, M.D.
Johns Hopkins University School of Medicine
Baltimore, MD 21287
gerwin@painpoints.com
References
Dodick DW. Chronic daily headache. N Engl J Med 2006;354:158-165.
Gerwin R. Headache. In: Ferguson L, Gerwin R, eds. Clinical mastery in the treatment of myofascial pain. Philadelphia: Lippincott Williams & Wilkins, 2005:1-24.
de las Penas CF, Cuadrado ML, Gerwin RD, Pareja JA. Referred pain from the trochlear region in tension-type headache: a myofascial trigger point from the superior oblique muscle. Headache 2005;45:731-737.
Dr. Dodick replies: I agree with Gerwin that the patient with migraines who has daily or near-daily headaches and tender neck musculature represents a very common phenotype in clinical practice. According to the International Classification of Headache Disorders (ICHD-II),1 despite the presence of muscle tenderness, the vast majority of these patients would be classified as having chronic migraine. The majority of patients with migraine have muscle tenderness and tightness in the head, neck, and shoulders because of the pattern of the referral of pain from the activation and sensitization of central second-order neurons within the trigeminocervical complex.2,3 "Migrainous features" typically become less prominent as migraine "transforms" over time from an episodic to a chronic pattern with nearly daily headache.4 The effectiveness of trigger-point injections, as well as of other therapies, warrants evaluation in clinical trials in which patients are classified according to ICHD-II nomenclature.
David W. Dodick, M.D.
Mayo Clinic College of Medicine
Scottsdale, AZ 85259
dodick.david@mayo.edu
References
Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. 2nd ed. Cephalalgia 2004;24:Suppl 1:1-160.
Kaniecki RG. Migraine and tension-type headache: an assessment of challenges in diagnosis. Neurology 2002;58:Suppl 6:S15-S20.
Bartsch T, Goadsby PJ. The trigeminocervical complex and migraine: current concepts and synthesis. Curr Pain Headache Rep 2003;7:371-376.
Bigal ME, Rapoport AM, Sheftell FD, Tepper SJ, Lipton RB. Chronic migraine is an earlier stage of transformed migraine in adults. Neurology 2005;65:1556-1561.