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Headache and central sensitization: all in the head, the brain or are other factors involved?

Central sensitization has been the subject of extensive research in a variety of unexplained pain disorders, such as osteoarthritis, tennis elbow, low back pain, fibromyalgia, chronic fatigue syndrome, chronic whiplash associated disorders amongst others. During the past decade, several studies were performed examining the presence of central sensitization in patients with different types of headache, such as tension-type headache, cluster headache, migraine.

A recent review concluded that generalized hyperalgesia, less efficient conditioned pain modulation and a loss of gray matter structures involved in pain processing are features of patients with (chronic) tension type headache (Bezov et al. , 2011). This suggests that both peripheral and central sensitization may play an important role in the maintenance of the symptoms. The prolonged nociceptive input from pericranial myofascial tissues may lead to sensitization of the spinal dorsal horn/trigeminal nucleus, thereby enhancing supraspinal sensitization in patients with tension-type headache. On the other hand, central neuroplastic changes may influence the regulation of peripheral mechanisms, creating a viscous circle. For example, increased pericranial muscle activity or release of neurotransmitters in the myofascial tissues may maintain the process of sensitization, even after the initial eliciting factors have been normalized (Bendtsen, 2000).

The rehabilitation process of patients with headache is extremely challenging. Firstly, while simple analgesics and non-steroidal anti-inflammatory drugs are recommended for the treatment of episodic tension type headache, one should be aware of the risk for developing medication-overuse headache as a result of frequent and excessive use of all types of analgesics (Bendtsen et al. , 2010). Secondly, stress triggers (more) headache in the majority of the patients with headache (Cathcart et al. , 2010). Recent treatment guidelines highlight the importance of further examining the value of cognitive-behavioral therapy in these patients.

Nathalie Roussel

2014 � Pain in Motion

References and further reading:

Bendtsen L. Central sensitization in tension-type headache--possible pathophysiological mechanisms. Cephalalgia. 2000;20:486-508.

Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J, et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol. 2010;17:1318-25.

Bezov D, Ashina S, Jensen R, Bendtsen L. Pain perception studies in tension-type headache. Headache. 2011;51:262-71.

Cathcart S, Petkov J, Winefield AH, Lushington K, Rolan P. Central mechanisms of stress-induced headache. Cephalalgia. 2010;30:285-95.