Authored by Pruneti C*
Abstract
Primary headaches are heterogeneous clinical conditions, characterized by multifactorial etiology and partially unknown eziopathogenesis. In this study, we have investigated the psychophysiological aspects related to autonomic activation and psycho physiological stress response in primary headache patients, in order to identify possible statistically significant relationships between psycho physiological pattern, measured by the PPP (psycho physiological profile) , and the differential neurological diagnosis of primary headaches.The sample consisted of 68 subjects aged between 18 and 70 years (Mean= 39,6; S.D.=12,1), who underwent continuous and simultaneous psycho physiological registration (PPP) of the following parameters: surface electromyography (sEMG), skin conductance level/response (SCL/SCR), heart rate (HR), Inter Beat Interval (IBI) and peripheral temperature (THE).The statistical analysis, performed using non parametric tests, since the data was non-normally distributed, on average showed that: the whole sample reveals already in baseline, an autonomic hyper activation that continues throughout the registration; the category of migraine with aura seems to be physiologically less activated compared to the other diagnostic categories identified.Moreover, we did not detect significant correlations between psycho physiological pattern and clinical neurological diagnosis.In conclusion, it seems reasonably possible to state that these clinical conditions are strongly influenced by stress reaction and management, as an important variable in the disease pathogenesis. This typical stress reaction seems also to have an important role in the disease maintenance and/or worsening, though the strong intra-individual variability.
Keywords: Primary-idiopathic headaches;Psychophysiology;Biofeedback; Neurovegetative activation;Stress response
Introduction
According to the guidelines of the International Headache Society beta version (IHS, 2013), headache can be distinguished in:
• Primary or primitive-idiopathic, not supported by any traceable and / or underlying pathological condition; (traumatic, neoplastic, febrile).
• Secondary or symptomatic, linked to pathologies that have headache symptoms (eg intracranial or systemic).Tra le cefaleeprimario-idiopatiche, la cefalea di tipotensivo (CTT) e l’emicraniasenz’aurarappresentano le categoriepiùfrequenti, considerate patologieadeziologia incerta, caratterizzate da multifattorialità e multicausalità [1,2].
Tension-type headache is the most frequent (90%) of headaches, characterized by severe-constricting head pain, sometimes associated with an increase in the tone of the head and / or neck muscles; pain, non-throbbing, is frequently bilateral, typically mild or moderate.In migraines, the headache is unilateral, pulsating in nature, with a duration that can vary from 2 to 72 hours. Associated symptoms can include nausea, vomiting, photophobia (increased sensitivity to light), phonophobia (increased sensitivity to sound). Pain generally worsens as a result of physical activity. Up to a third of people with migraines experience the aura: a transient visual, sensory, motor or speech disorder that just precedes the occurrence of a headache episode.One of the factors recognized as important in the exacerbation and maintenance of the disorder appears to be psychophysiological stress, a chronic and non-adaptive alteration of the individual’s neurovegetative homeostatic balance, strictly interconnected with a dysfunctional stress management deriving from stimuli present in daily life [3,4].
Headaches present a wide spectrum of clinical manifestations with very varied etiological and symptomatic characteristics. The clinical approach therefore requires in-depth assessment work useful for formulating a correct differential diagnosis with the forms of secondary headaches attributable to organic pathologies. From a psychic point of view, headaches frequently have important psychological connotations: it is in fact known [5,6] that some forms of headache can be an expression of mental disorders such as anxiety or depression.
These are clinical pictures with a predominantly somatic expression, which is why it becomes difficult to establish their clinical autonomy and identify a unique cause [Pellegrino, 2008].However, some precise dysfunctional mechanisms have been identified, such as an excessive sensitivity and excitability of the nociceptive nervous system, fueled by other factors of the psychophysiological area.It is also described an electrophysiological phenomena named “Cortical Spreading Depression” (CSD), a sudden wave of excitement of the neurons of the cerebral cortex followed by an equally rapid “shutdown” that begins at the level of the occipital lobe of the brain, the area where the vision is located, and then propagates anteriorly towards the sensitive and motor areas [7].
According to Pellegrino (2008), in cephalalgic patients there would be an interruption of the physiological and psychological adaptive systems as a manifestation of an altered adaptive response to stress. The daily life distress would induce the individual to seek adequate adaptation responses to preserve biological homeostasis by creating a vicious circle of the “stress-headache-stress” type [8].
The multiplicity of psychological, physiological, social and economic aspects salient in primary headaches, therefore, make it difficult, if not contraindicated, to approach only a single disciplinary area. Specifically, the properly psychophysiological analysis of primary headaches in the literature turned to the study of variables susceptible to empirical verification such as: vulnerability and stress responses, coping styles, neurovegetative regulation, making it clear that different are the psychophysiological parameters involved in development and maintenance of headaches, such as: high levels of sEMG (surface electromyography), THE (peripheral temperature) and BVP (peripheral vasodilation) [9].
In particular, among the pathogenetic mechanisms of tension-type headache (CTT), two aspects are considered fundamental: muscle tension, understood as an increase in the tone of pericranial muscles and the psychological component [10]. Recently, a considerable number of studies suggest the existence of a neurobiological basis: it is, in fact, common opinion that pericranial muscles in CTT are more contracted than the values normally assumed, a conviction that the latter is so widespread that the previous terminology referred to these syndromes with the name of muscle tension headache, thus underlining the muscular implication in the pathogenesis [3]. It is known [5,11,12] that the onset of numerous forms of primary headache can be considered as the result of the action of psycho-social factors (conflicts family, work stress, emotional crises), cyclic hormonal changes (especially related to the female sex), geoclimatic (e.g. changes in external temperature), autonomic (related to the response of pain) on a personality with a low pain threshold (susceptibility cephalalgic): that is, there would be an individual vulnerability to develop cephalalgic clinical pictures together with a natural “physiological acceleration” which translates into a lifestyle characterized by disordered and long-term maladaptive responses; hence the need for an integrated psychosomatic as well as biopsychosocial approach (Pini, 2006).
To conclude, it is necessary to develop multidimensional and multidisciplinary assessment procedures in which to include the assessment of basic psychophysiological activity and subjective reactivity to stress through indicators of psychophysiological activation [13-16]. For this purpose and in the light of the literature examined that was found to be lacking in research aimed at the specific assessment of the psychophysiological structure in primary headaches, the present study aims to investigate the existence of correlations and / or associations between the different subcategories of primary headaches and the psychophysiological trend measured by Psychophysiological Profile (PPP) on a sample of subjects with neurological diagnosis of primary headache [17].
Sample and patient selection
68 subjects (18 men and 50 women), aged between 18 and 70 (Average age = 39.6; SD = 12.1) were subsequently recruited through consecutive sampling, within the Headache Center of the University Hospital of Parma (Figure1). All subjects voluntarily participated in the study by signing a written consent which safeguarded privacy and which explained that the interview and the short psychological questionnaires an psychophysiological test would only slightly extend the time dedicated to usual medical visits. All subjects accepted with pleasure to participate in the research. At the end of the observation, there was an interview, carried out individually between the subject and a clinical psychologist for the discussion of the results that emerged from the reports of the tests carried out.
Inclusion/exclusoion criteria
Subjects presenting with cognitive deficits or degenerative diseases, psychiatric diseases confirmed by documented medical diagnosis, organic neurological damage were excluded. Furthermore, for the purposes of this research, data relating to foreign people with poor understanding of the Italian language have been excluded.
Material and Methods
The assessment of the neurovegetative aspects was carried out through the use of the Satem®Physiolab system for the recording of psychophysiological data during the Psychophysiological Stress Profile (PPP), an assessment procedure which consists in measuring multiple psychophysiological signals continuously and simultaneously [13]. The parameters registered were: surface electromyography (sEMG) (μV, microvolt), for detecting the tension of the head and neck muscles by means of 3 recording electrodes placed in correspondence of the frontal muscle; Skin conductance (SCR / SCL) (μS, microSiemens) for the electro-galvanic response of the skin, detected by Ag / ACl electrodes positioned on the distal phalanges of the first and second fingers of the dominant hand; Peripheral temperature (pTHE) (C°, degrees centigrade), detected by means of a thermistor applied to the tenar eminence of the palm of the non-dominant hand. Heart rate (HR) measured in beats per minute (BPM) and Interval Beat (IBI), detected by means of electrodes placed on the non-dominant forearm. According to Fuller (1979) the registration of the PPP is carried out in three distinct moments: in the first phase, following a period of adaptation and stabilization of the signal, it records the basic activation for a duration of 6 minutes; follows a phase of stress induced by objectively stressful tasks consisting, for example, of mathematical tasks (Mental Arithmetic Task, MAT) lasting 4 minutes; finally, a 6-minute recovery phase is foreseen in which it is possible to monitor the homeostatic recovery capacity (Table 1) [18].
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