**2. Research on hypersensitivity**

Langemark and Olesen were the first to focus on pericranial tenderness in adults with TTH [11]. Forty individuals with TTH and 40 controls were palpated by a blinded observer for tenderness in 10 pericranial bilateral sites using a four‐point scale called the Total Tenderness Score (TTS) (**Table 1**). Results indicated a significant difference in tenderness between the two groups. Bendtsen et al. [12] examined later the use of a palpometer, which allowed measure‐ ment of palpation pressure during palpation. The palpometer was a small instrument with an arbitrary scale connected to a pressure‐sensitive plastic device attached to the finger used for palpation. The use of the palpometer was recommended for research. Using the same observer between palpations was recommended to keep the amount of pressure stable. The TTS system was validated with the use of the palpometer [13].

**1. Introduction**

26 Current Perspectives on Less-known Aspects of Headache

worker [7].

Children and adolescents with frequent and chronic primary headaches are, with a prevalence of 2–23% depending ondiagnosis, age, sex andfrequency, a global health concern [1–4].The age span is 3–18 years depending on the disorder. The main consequences of frequent headaches in children and adolescents are more frequent school absences; disturbed health‐related quality

An interdisciplinary specialist team is a relevant health care platform for the professional support to the families in the process of self‐care and recovery. A specialist team is suggested to consist of neuro‐paediatricians, nurses, physiotherapists, psychologist and possibly a social

The diagnosis of the child's headache as a neurological disorder is the first important step in an interdisciplinary team service and is carried out based on the International Classification of Headache Disorders (ICHD‐3‐beta) [8]. The most frequent diagnoses for children are migraine with or without aura, tension‐type headache (TTH) or a combination of both, such as mixed headaches. Girls present the highest prevalence for TTH [4], but there is conflicting

There is a consensus that the aetiology and relevant factors are multi‐dimensional with dynamic interaction between genetic, hormonal, neural and muscular mechanisms but also psycho‐social and environmental factors. Researchers agree that migraine and TTH are two different headache disorders [1], though some see it as a continuum [9]. They may, however, interact, which is why efforts concerning TTH might be beneficial for the child with both disorders. Frequent and chronic types of headache, which means they occur more than 10–15

Research on non‐pharmacological treatment outcomes is sparse. Headache service faces a challenge because possible sensitisation of pain pathways can affect outcomes leading to a delay in becoming symptom free or being cured. It is therefore important to empower children, adolescents and their involved parents to persistently pursue healthy lifestyle strategies, which

A narrative review [10] approach is used in the following sections to describe and discuss relevant areas of interest supported by research that might lead to headache reduction in

Langemark and Olesen were the first to focus on pericranial tenderness in adults with TTH [11]. Forty individuals with TTH and 40 controls were palpated by a blinded observer for tenderness in 10 pericranial bilateral sites using a four‐point scale called the Total Tenderness Score (TTS) (**Table 1**). Results indicated a significant difference in tenderness between the two

could lead to a long‐lasting reduction of headache frequency and prevent disability.

evidence as to whether boys or girls predominantly have mixed headache [1, 9].

of life (HRQOL) [5] and a risk of medication overuse [6].

days a month, present the greatest challenge.

children suffering from primary TTH.

**2. Research on hypersensitivity**

 No visible reaction and denial of tenderness No visible reaction but verbal report of discomfort or mild pain Verbal report of painful tenderness, facial expression of discomfort or no reaction Marked grimacing or withdrawal, verbal report of marked painful tenderness and pain **Table 1.** Langemark and Olesen's four‐point total tenderness score [11].

Further research by Bendtsen et al. [14] focused on pericranial tenderness measured by a palpometer and TTSs; and pressure pain thresholds and tolerance recorded by an electronic pressure algometer at the non‐dominant second finger and at the temporalis muscle. Similar to earlier studies the results showed significantly increased pericranial tenderness of all‐sites‐ pericranial myofascial tissue in adult patients with chronic TTH (CTTH) compared with healthy controls. The results showed a decrease in pressure pain thresholds and tolerance, but these results were considered debatable. Results also showed a shift to the left compared with healthy controls when examining the functions for pressure pain thresholds and tolerance versus pain on both sites. The results were interpreted as indicators of general hypersensitivity in patients with CTTH.

At the time, there were also parallel studies focusing on children with headaches. For example, Carlsson [15] examined 113 Swedish schoolchildren with frequent headaches compared with 109 headache‐free controls. The children were examined by manual palpation of seven bilateral pericranial sites and TTS. Children with headache had significantly higher tenderness, and children with chronic headaches had significantly higher tenderness for all sites, except the frontalis muscles. The mean tenderness scores were significantly correlated with the frequency of chronic tension‐type headache (CTTH).

Additional studies involving children were conducted. Tornoe et al. [16] examined pericranial tenderness in 41 girls 9–18 years of age with frequent episodic TTH (FETTH) and CTTH compared with 41 healthy controls by means of TTS. Results showed significantly higher tenderness scores for girls with headache in all sites. Results showed a significant positive correlation between headache frequency and tenderness.

Soee et al. examined 59 children 7–17 years of age with FETTH and CTTH compared with 57 healthy controls. Examinations were conducted by means of the TTS at seven pericranial myofascial sites and the use of the original palpometer. Children with headache had signifi‐ cantly increased tenderness in all sites. The sites with the highest level of tenderness in children with and without headache were the trapezius descendens and its occipital insertions. Further examinations were conducted by means of algometry of pressure pain thresholds at three pericranial sites and suprapressure pain thresholds [17]. Sensitivity showed no significant increase measured by pressure pain and suprapressure pain thresholds compared with controls. Results from factor analyses indicated an association between pericranial tenderness and the child's general level of pain processing.


**Table 2.** Bilateral pericranial sites originally used in research for total tenderness score in TTH.

In another study, Soee et al. [18] conducted algometry and pain scoring for five increasing pressure intensities at two pericranial sites, the trapezius descendens and temporalis, on the non‐dominant side. Fifty‐eight children with FETTH and CTTH and 57 healthy controls participated. The area under the curve for stimulus‐response functions was analysed. Similar to the results for adults in Bendtsen's [14] study, the stimulus‐response functions for pressure versus pain showed a shift to the left, indicating hypersensitivity, especially for the group of children with CTTH. Soee et al. concluded that the temporalis site was the most sensitive and that quantitative and qualitative changes in pain perception occurred on a continuum, with FETTH representing an intermediate state between healthy individuals and CTTH. In addition, Fernández‐de‐las‐Peñas et al. [19] found bilateral pressure hypersensitivity in a study using the temporalis, trapezius descendens and tibialis anterior muscles in 25 children 5–11 years of age with FETTH compared with 50 healthy controls.

In a randomised controlled intervention trial with specific strength training versus interdisci‐ plinary counselling [20], headache frequency and duration declined significantly over the space of 22 weeks, but pericranial tenderness did not change significantly in a positive direction. These results indicate that generally increased pericranial tenderness and hyper‐ sensitivity might predict a delay in becoming symptom free or being cured.

In summary, in both adults and children with TTH research support the findings of altered pain perceptions with hypersensitivity probably due to changes in both periphery and central pain pathways. A continuum between the healthy children and the children with chronic headaches is seen with the FETTHs as intermediates. The TTS as a palpation test seems an applicable and non‐invasive examination for children in the clinic. To picture hypersensitivity tenderness in all pericranial sites would be expected. There is a need for revalidation of the TTS with the use of a calibrated palpometer in order to avoid large test‐retest variations as found by Tornoe et al. [21] There is also a need for more research in order to establish a cut‐off value between normal and pathological levels of tenderness in children. **Table 2** presents the bilateral pericranial sites originally used in research for TTS.
