**3. Tension patterns and self‐regulation**

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

**Adults Children**

**Jensen et al. (1992–1998)**

**Carlsson (1996)**

**Soee et al. (2013)**

**Tornoe et al. (2011–2016)**

**Bendtsen et al. (1994–1996)**

M. Frontalis X X X X X X

M. Masseter X X X X X X

M. Sternocleido‐Mastoideus X X X X X X M. Trapezius X X X X X X M. Temporalis X X X X X X Processus Mastoideus X X X X X X Occipital Muscle Insertions X X X X X X M. Orbicularis Oculi X X

X

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

X X

X X X

M. Corrugator Supercilii X

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

M. Splenius X

and the child's general level of pain processing.

28 Current Perspectives on Less-known Aspects of Headache

X

Hamulus Pterygoideus X

**Olesen (1987)**

**Pericranial sites/studies Langemark and**

M. Pterygoideus Medialis

M. Pterygoideus Lateralis

Processus Coronoideus

M. Rectus Capitis Posterior

Major

Mandibulae

Other names for TTH were tension headache and muscle contraction headache. Throughout the decades, various hypotheses and findings about the underlying mechanisms have served as a guide to developing a solid, evidence‐based approach. In addition to research on pericra‐ nial myofascial tenderness and hypersensitivity, examining tension patterns in pericranial muscles and how to regulate tension and stress have also been of interest. Surface electro‐ myographic biofeedback (SEMG) and progressive relaxation training have been examined with success in children suffering from TTH, though large‐scale randomised controlled trials are still needed.

Focusing on the frontalis muscles, Grazzi et al. [22] examined SEMG biofeedback in 10 children 12–15 years of age with TTH. The children participated twice a week for 12 sessions and were also encouraged to use daily relaxation techniques at home. The results indicated a significant decrease in EMG activity and headache intensity from the first to the last session. Bussone et al. [23] did a subsequent larger controlled study with follow‐up to 12 months. Their results showed a significant reduction in headache parameters but not in tension levels. The site was frontalis, and the feedback was auditory. In a 3‐year follow‐up study [24], results likewise showed long‐lasting improvements after EMG biofeedback relaxation training for children with TTH, with further gains over the course of 3 years. Other researchers have examined biofeedback and relaxation therapy in various forms and find SEMG frontalis biofeedback to be superior. Results showed a long‐lasting, continuously increasing effect [25]. The continuous effect indicates that children learn how to use and integrate the relaxation techniques into their daily lives.

Hermann and Blanchard [26] reviewed studies evaluating interventions with biofeedback and relaxation for children and reached an overall positive conclusion. They discussed how to distinguish between the input from biofeedback and the use of relaxation techniques, a distinction Kröner‐Herwig et al. also make [25]. The question of whether the positive outcomes relate to an alteration in mental stress, muscular activity or a combination of the two was discussed and is still relevant.

Evidence on repetitive recruitment of motor units followed by pain, possibly altered muscle activation patterns and muscular cellular dysfunctions in adults with computer work‐related trapezius myalgia has also propelled headache research. Even though the trapezius descen‐ dens (the upper trapezius) has been shown to be the most tender myofascial pericranial site in children with TTH, little research has been done on SEMG biofeedback from the trapezius muscle. One study compared frontalis SEMG biofeedback with trapezius SEMG biofeedback and progressive relaxation therapy alone in adults [27]. The results suggested that trapezius SEMG biofeedback training might be more efficacious for CTTH with a significant effect above 50%.

Children under the age of 13, who have not yet fully developed the ability to reason abstractly, need age‐appropriate learning situations. Tornoe et al. [28] evaluated a study involving computer‐animated SEMG biofeedback by placing sensors on the trapezius descendens and by employing an age‐appropriate form of progressive relaxation techniques. The children, 7– 13 years of age, worked with visual and auditory computer‐animated feedback from screens showing brief videos. Additionally, a bar graph gave the child a visible response each time a certain tension threshold was exceeded. The sensor placement on the trapezius muscles provided the children a feedback from posture, breathing, tension and heart rate. Furthermore, SEMG data were also recorded. Comparing the pre‐and post‐treatment means of root mean squares and median frequencies showed a minor non‐significant reduction for nine children across a nine‐session programme. The SEMG results showed a significant within‐session ability to up and down regulate tension. The study results showed a statistically significant reduction in headache frequency.

Oral and written evaluations by the children indicate that they felt they were able to moderate feelings of stress, multiple thoughts and emotions experienced as negative or stressing. The children likewise managed to regulate the way these mental phenomena presented in the body as increased heart rates, hyperventilation and/or muscle tension. Achieving a sufficient level of self‐regulation experience and expertise appeared to require 9–10 sessions. Recent studies examined the additional use of internet‐based self‐help programmes and supported the applicability of the internet for cognitive‐behavioural interventions [29], although evidence on headache reduction is conflicting [30]. **Figure 1** presents learning aspects of self‐regulation.

Children and Adolescents with Primary Tension‐Type Headaches: Research and Practice Perspectives... http://dx.doi.org/10.5772/64971 31

**Figure 1.** Using progressive relaxation techniques to learn self‐regulation. This image belongs to the author of the chapter: PhD Birte Tornøe.

#### **4. Lifestyle‐related physical factors and resources**

effect indicates that children learn how to use and integrate the relaxation techniques into their

Hermann and Blanchard [26] reviewed studies evaluating interventions with biofeedback and relaxation for children and reached an overall positive conclusion. They discussed how to distinguish between the input from biofeedback and the use of relaxation techniques, a distinction Kröner‐Herwig et al. also make [25]. The question of whether the positive outcomes relate to an alteration in mental stress, muscular activity or a combination of the two was

Evidence on repetitive recruitment of motor units followed by pain, possibly altered muscle activation patterns and muscular cellular dysfunctions in adults with computer work‐related trapezius myalgia has also propelled headache research. Even though the trapezius descen‐ dens (the upper trapezius) has been shown to be the most tender myofascial pericranial site in children with TTH, little research has been done on SEMG biofeedback from the trapezius muscle. One study compared frontalis SEMG biofeedback with trapezius SEMG biofeedback and progressive relaxation therapy alone in adults [27]. The results suggested that trapezius SEMG biofeedback training might be more efficacious for CTTH with a significant effect

Children under the age of 13, who have not yet fully developed the ability to reason abstractly, need age‐appropriate learning situations. Tornoe et al. [28] evaluated a study involving computer‐animated SEMG biofeedback by placing sensors on the trapezius descendens and by employing an age‐appropriate form of progressive relaxation techniques. The children, 7– 13 years of age, worked with visual and auditory computer‐animated feedback from screens showing brief videos. Additionally, a bar graph gave the child a visible response each time a certain tension threshold was exceeded. The sensor placement on the trapezius muscles provided the children a feedback from posture, breathing, tension and heart rate. Furthermore, SEMG data were also recorded. Comparing the pre‐and post‐treatment means of root mean squares and median frequencies showed a minor non‐significant reduction for nine children across a nine‐session programme. The SEMG results showed a significant within‐session ability to up and down regulate tension. The study results showed a statistically significant

Oral and written evaluations by the children indicate that they felt they were able to moderate feelings of stress, multiple thoughts and emotions experienced as negative or stressing. The children likewise managed to regulate the way these mental phenomena presented in the body as increased heart rates, hyperventilation and/or muscle tension. Achieving a sufficient level of self‐regulation experience and expertise appeared to require 9–10 sessions. Recent studies examined the additional use of internet‐based self‐help programmes and supported the applicability of the internet for cognitive‐behavioural interventions [29], although evidence on headache reduction is conflicting [30]. **Figure 1** presents learning aspects of self‐regulation.

daily lives.

above 50%.

discussed and is still relevant.

30 Current Perspectives on Less-known Aspects of Headache

reduction in headache frequency.

The neck/shoulder muscles are involved in the underlying pathology of headache. One hypothesis on adult patients with CTTH confirmed in findings was that higher tension levels measured by EMG in the trapezius muscles increase input from myofascial tissue leading to hypersensitivity [31]. Evidence of increased tension levels, however, shows conflicting results in adults, and EMG studies in children are sparse. A summary by Bendtsen and Fernandez‐ de‐las‐Penas [32] points out that prolonged nociceptive stimuli from myofascial input could be a result of continuous activation of local structures followed by microtrauma of selected muscle fibre, thus leading to increased hypersensitivity. They consequently recommended that specific attention be paid to the muscular factors underlying TTH [32]. From this perspective, the involvement of the trapezius muscles in computer‐related workplace research is interest‐ ing. In a study involving adult females with trapezius myalgia, results from muscle biopsies indicated that women with trapezius myalgia had a higher percentage of hypertrophied type‐ I fibres with poor capillarisation. The findings were associated with long‐term working exposure [33]. Recent studies on surface and intramuscular EMG support the involvement of subparts of the trapezius muscles related to both attention tasks and anticipatory motor programming of precise finger typing and manipulation. The latter could be approached with the use of elbow support, which would decrease the need for anticipatory shoulder stabilisa‐ tion. Maintaining work‐related local activity is believed to impair cellular mechanisms, leading to increased input to free nociceptive nerve endings [34]. In conclusion, both headache research and research in physiology and ergonomics support evidence on the involvement and impairment of subparts of the trapezius muscles in continuous daily, and especially work‐ related activities, leading to prolonged nociceptive input and hypersensitivity.

#### **4.1. Posture, muscle activity and the use of electronic devices by children**

Children and adolescents worldwide use iPads, computers and mobile phones for schoolwork and leisure activities. Children with TTH have been associated with more frequent use of computers than healthy controls [35]. Straker et al. [36] examined posture and muscle activity in young children with a mean age 5.6 years who were using either a tablet, desktop or paper. SEMG and 3‐D‐motion data were used to collect data. Desktop computers were associated with a more upright position and less muscle activity than both tablets and paper. On the other hand, desktop computers were associated with a more constrained and monotonous posture, while tablet and paper allowed for greater variation. The use of a tablet was associated with a more flexed posture, elevated shoulders and more muscular activity in the trapezius descen‐ dens muscles and cervical erector spinae. A study of children 10–12 years of age also indicated the same implications for computer use by children as are reported for adults. The mid position of the screen was shown to be the preferred position in terms of gaze, posture and muscle activity in the trapezius descendens and cervical erector spinae [37]. As a result, ergonomic advice and adjustments in the working environment for children with and without headache is recommended, particularly with the widespread use of tablets in schools and the amount of time spent using electronic devices. Straker et al. [38] reviewed the physical aspects of children's interaction with computers. The aim was to set up guidelines on how to use them wisely as a result of concerns about how extensive use of electronic devices might pose a risk to their development and health. A long list of recommendations emerged stressing that parents, teachers and health professionals have a responsibility to act and also to teach children how to use them prudently. Workplace adjustments, computer skills, body awareness (espe‐ cially of bodily signals due to overload), transporting equipment, and physical exercise and activity are important to counter adverse consequences.

#### **4.2. Muscle strength, aerobic power and health**

In a historical review of research on physiology and ergonomics, Sjøgaard [39] shows that research indicates that physical exercise and activity can counteract the negative effects of muscular overload, producing a health‐enhancing effect. Strength training in particular three times weekly for 10 weeks has a positive effect on muscular recovery. A study comprising girls 9–18 years of age with FETTH and CTTH found a significant association between headache and reduced neck/shoulder muscle strength and aerobic power [16]. Specific strength training of the trapezius descendens in particular was hypothesised to lead to significant headache reduction, which was confirmed in a later study [20]. At baseline the girls reported a perceived deficit in physical, emotional and school functioning domains and health measured by HRQOL questionnaires. Exercising and interdisciplinary counselling showed long‐term improvements in these areas. Results indicated that the girls, who were interactive in exercising, gained greater physical results measured by strength and aerobic power than the girls who were verbally counselled to be more physically active.

The awareness of the importance of aerobic power in relation to headache is relatively new. The Norwegian HUNT3 study [40] also showed a significant inverse relationship between any type of headache and measured peak oxygen uptake in a sample of 3899 adults 20–50 years of age. Physical activity (PA) showed a similar relationship. It currently remains unclear as to what is cause and what is effect, but the truth is that perhaps they are both. Generally, muscular fitness, aerobic power (cardiorespiratory/cardiovascular fitness) and speed/agility are consid‐ ered important markers for health in childhood [41], making this an important focus area for future research and interventions for children and adolescents with headache.

#### **4.3. Sleep, nutrition and stress**

**4.1. Posture, muscle activity and the use of electronic devices by children**

32 Current Perspectives on Less-known Aspects of Headache

activity are important to counter adverse consequences.

**4.2. Muscle strength, aerobic power and health**

verbally counselled to be more physically active.

Children and adolescents worldwide use iPads, computers and mobile phones for schoolwork and leisure activities. Children with TTH have been associated with more frequent use of computers than healthy controls [35]. Straker et al. [36] examined posture and muscle activity in young children with a mean age 5.6 years who were using either a tablet, desktop or paper. SEMG and 3‐D‐motion data were used to collect data. Desktop computers were associated with a more upright position and less muscle activity than both tablets and paper. On the other hand, desktop computers were associated with a more constrained and monotonous posture, while tablet and paper allowed for greater variation. The use of a tablet was associated with a more flexed posture, elevated shoulders and more muscular activity in the trapezius descen‐ dens muscles and cervical erector spinae. A study of children 10–12 years of age also indicated the same implications for computer use by children as are reported for adults. The mid position of the screen was shown to be the preferred position in terms of gaze, posture and muscle activity in the trapezius descendens and cervical erector spinae [37]. As a result, ergonomic advice and adjustments in the working environment for children with and without headache is recommended, particularly with the widespread use of tablets in schools and the amount of time spent using electronic devices. Straker et al. [38] reviewed the physical aspects of children's interaction with computers. The aim was to set up guidelines on how to use them wisely as a result of concerns about how extensive use of electronic devices might pose a risk to their development and health. A long list of recommendations emerged stressing that parents, teachers and health professionals have a responsibility to act and also to teach children how to use them prudently. Workplace adjustments, computer skills, body awareness (espe‐ cially of bodily signals due to overload), transporting equipment, and physical exercise and

In a historical review of research on physiology and ergonomics, Sjøgaard [39] shows that research indicates that physical exercise and activity can counteract the negative effects of muscular overload, producing a health‐enhancing effect. Strength training in particular three times weekly for 10 weeks has a positive effect on muscular recovery. A study comprising girls 9–18 years of age with FETTH and CTTH found a significant association between headache and reduced neck/shoulder muscle strength and aerobic power [16]. Specific strength training of the trapezius descendens in particular was hypothesised to lead to significant headache reduction, which was confirmed in a later study [20]. At baseline the girls reported a perceived deficit in physical, emotional and school functioning domains and health measured by HRQOL questionnaires. Exercising and interdisciplinary counselling showed long‐term improvements in these areas. Results indicated that the girls, who were interactive in exercising, gained greater physical results measured by strength and aerobic power than the girls who were

The awareness of the importance of aerobic power in relation to headache is relatively new. The Norwegian HUNT3 study [40] also showed a significant inverse relationship between any type of headache and measured peak oxygen uptake in a sample of 3899 adults 20–50 years of Interdisciplinary counselling along with physical education for children and adolescents with TTH has a significant effect [20]. A recent study of 509 children 9–15 years of age with frequent weekly headaches [42] found that dysfunctional coping strategies for stress are negatively associated with the probability of headache remission. Other psychological variables were not significant. Girls presented higher prevalence and lower probability of remission than boys. Children, and especially girls, appear to need empowered learning on how to manage self‐ care in daily life by using active coping strategies. The perceived areas of deficit, such as physical, emotional and school functions, are of interest. Impaired school functioning is the least recognised area and needs further research. Examining and counselling on how to cope with and reduce stress and optimising sleep quality and nutrition are important areas to explore. An association has been confirmed between sleep difficulties and children with headache, which is why the underlying causes should also be addressed [43].

Enhancing PA is one way to regulate stress and to achieve better quality of sleep. The effect of PA on stress, anxiety, sleep quality and mental wellbeing may even be superior to mindfulness meditation and heart rate variability biofeedback [44, 45]. A certain amount of PA is necessary to maintain and improve aerobic power and health. Families should be empowered to follow the guidelines and recommendations set by the World Health Organization (WHO) [46]. **Figure 2** presents the possible interacting mechanisms underlying paediatric headache.

**Figure 2.** Possible interacting mechanisms underlying paediatric headache. This image belongs to the author of the chapter: PhD Birte Tornøe.
