1. 2021;24;E1177-E1189Pericranial Total Tenderness Score in Patients with Tension-type Headache and Migraine. A Systematic Review and Meta-analysis
   Systematic Review
   Willem De Hertogh, PhD, Gwendolyne Scholten-Peeters, PhD, Jolanda Maaskant, PhD, Marc Duineveld, MSc, and Rene Castien, PhD.

BACKGROUND: Increased pericranial tenderness is considered to be a typical characteristic of tension-type headache (TTH). Assessment of pericranial tenderness in TTH using the total tenderness score is recommended by the International Classification of Headache Disorders-3 (ICHD-3). However, to what extent pericranial tenderness differs between patients with TTH or migraine and healthy patients is unknown.

OBJECTIVE: To assess the presence and differences in total tenderness score between patients with TTH or migraine, and healthy patients.

STUDY DESIGN: Systematic review and meta-analysis.

METHODS: A literature search was performed in Pubmed/MEDLINE, EMBASE, CINAHL, and Google Scholar databases from inception to August 14, 2020 and identified 4,197 hits. Two independent reviewers selected the studies, extracted data, and performed a risk of bias assessment according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall evidence was assessed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. From the 185 papers identified, 15 case-control and 2 cross-sectional studies were included.

RESULTS: In total 1,200 (327 men, 873 women) patients with TTH or migraine were included in the systematic review. In the meta-analysis, 15 studies were analyzed and showed that the total tenderness score is higher in people with episodic TTH (standardized mean difference [SMD] 0.91; 95% confidence interval [CI]: 0.63 to 1.19), chronic TTH (SMD 1.57; 95% CI 1.24 to 1.91) and migraine (SMD 1.27; 95% CI: 0.91to 1.63) compared to healthy patients.

LIMITATIONS: The description and performance of the total tenderness score differed across the studies. In 7 studies, patients were included with coexisting types of headache.

CONCLUSION: We found moderate quality evidence for higher tenderness in chronic TTH and migraine, and low quality evidence for higher tenderness in episodic TTH compared to healthy patients. Pericranial tenderness is a common finding in patients with headache and healthy patients. These findings apply for a critical evaluation of the total tenderness score in the current ICHD-3 classification of TTH.

KEY WORDS: Tension-type headache, migraine, pericranial muscles, mechanical sensitivity, tenderness, meta-analysis, diagnostic criteria, ICHD-3

The study protocol is preregistered in the Prospective Register of Systematic Reviews under number CRD42019103583.