Tension-type headache.
Comparison with migraine
without aura and cervicogenic headache.
The Vågå study of headache epidemiology
Ottar Sjaastad, MD, PhDa,b
Leiv Sigmund Bakketeig, MDc
a features. Most workers in the field now would probably
Department of Neurology, St. Olavs Hospital, Trondheim
University Hospitals (NTNU), Trondheim, Norway
b Vågå Communal Health Centre, Vågåmo, Norway
c Norwegian Institute of Public Health, Nydalen, Oslo,
Norway
Corresponding author: Ottar Sjaastad
Gautes gate 12 - N-7030 Trondheim
E-mail: eylert.brodtkorb@ntnu.no
Invited paper
Summary
The aim of the present study was to describe the preva-
lence of tension-type headache (T-TH) in rural Norway,
and 1838 citizens aged 18-65 years were included. Fea-
tures indicating neck involvement were also looked for.
T-TH was compared with migraine without aura and
with cervicogenic headache (CEH) considering both
these features and typical migraine traits.
Face-to-face interviews were carried out, based on an
elaborate questionnaire. The IHS criteria, first version,
were used for T-TH diagnosis. A T-TH prevalence of
34% was found.
In T-TH and migraine without aura, typical CEH fea-
tures, such as reduced range of motion in the neck and
mechanical provocation of pain, were far less promi-
nent than in CEH. Typical migraine traits, e.g. photo-
phobia, were much less frequently present in T-TH and
CEH than in migraine without aura. T-TH is, in all prob-
ability, not a CEH variant and vice versa.
KEY WORDS: cervicogenic headache, migraine without aura, neck
pain, persistent neck complaint with subsequent posterior headache,
tension-type headache.
Introduction
The term “tension headache” originated somewhere
along the way, but the present authors do not know exact-
ly where or when. That there have been uncertainty and
misgivings regarding this term, can for example be seen
from commentaries on the 1962 Ad Hoc Committee crite-
ria (1). Heyck (2), who at a later stage became a member
of this committee (1969), felt that it was hard for a central
European to accept this term. Heyck was one of the
cleverest headache clinicians – ever. Later, the term was
changed to “tension-type headache” (T-TH) (3,4).
The typical T-TH picture (3,4) – also extractable from the
Functional Neurology 2008; 23(2): 71-76
IASP description (5) – roughly seems to be: a tightening,
bilateral, non-pulsating headache of mild-moderate in-
tensity accompanied by few, if any, general autonomic
agree with this description. Nevertheless, T-TH does not
seem to have clear-cut boundaries. Symptomatological-
ly, it may infringe upon the borders of migraine without
aura (MwoA). T-TH may even, as presented nowadays,
consist of more than one entity.
The present work is an integral part of the Vågå study of
headache epidemiology. The prevalence of T-TH at
grass roots level is probably only incompletely known.
This may partly be due to the fact that cervicogenic
headache (CEH) is not accepted/recognised in some
pertinent circles. The principal aim of this study was to
identify, to the best of our knowledge, genuine cases of
T-TH in this circumscribed, geographical area.
Since it has been claimed over and over again that
nuchal traits may be found frequently in both T-TH and
MwoA, and not only in CEH, a comparison of nuchal
features in the three headaches is carried out. Typical
“migraine traits” have also been included in the compar-
ison of the three headaches, to make it more complete.
As regards symptomatology, genuineness has been
preferred over numbers in cases of diagnostic conflict,
and such conflicts inevitably arise. Data for the less gen-
uine T-TH cases will, however, be presented separately,
in order to give an idea of the total magnitude of T-TH in
this area.
Materials and methods
The field work of the Vågå study (6) was carried out dur-
ing the period 1995-1997. Vågå had 3907 citizens just
prior to the start of the study. All accessible citizens in
the age range 18-65 years were invited to participate in
the study, and of these, 1838 (88.6%) could be included.
The study protocol (7) involved face-to-face interviews,
based on an elaborate headache questionnaire (which
the examined individuals were not even allowed to see),
plus a meticulous physical/neurological examination of
the face, head, and neck, and a short-version neurolog-
ical examination of the rest of the body. If deemed nec-
essary, a thorough neurological examination would be
carried out, and, in such cases, even supplementary
studies, like MRI and CT, might be added.
In the present study, intensity of pain was graded ac-
cording to a recently published, sensitive 0-6+ scale (8).
On this scale, 3+ to 5+ correspond to the IHS levels
“mild” to “severe”. The mean intensity in the Vågå series
was 2.81+.
“Features indicative of cervical abnormality”, which we will
refer to as the cervical factor (CF) (9), were calculated for
71
O. Sjaastad et al.
each participant. The CF is based on the presence of fea-
tures/findings in relation to following items: i) Range of
motion in the neck (ROM), i.e. rotation (9); ii) Skin-roll test
in the shoulder area (10); iii-v) Precipitation of pain by
graded external pressure (3-4 kg): against the tendon in-
sertions in the occipital area, against the splenius and up-
per trapezius area, and against the facet joints (9).
The CF as such and the skin-roll test were free vari-
ables; the CF is graded from 0 to 5+. In headache-free
individuals in Vågå (n=246), the mean CF was 0.42+,
whereas in the total study population it was 0.79+.
Tension-type headache and MwoA (and other primary
headaches) were diagnosed according to the IHS, first
version (3), which was in current use at the time.
The correct categorisation of MwoA and T-TH is cum-
bersome. For prevalence estimation, cases with T-TH
coexisting with a clinically separable MwoA were natu-
rally included. If there seemed to be one headache on-
ly, but with properties attributable to both T-TH and
MwoA, this headache was considered non-classifiable
in the present context. Such cases are not included in
either of the rubrics T-TH or MwoA, but will be present-
ed as a separate group. When considering symptoma-
tology, on the other hand, only “pure” T-TH cases were
included, i.e. those in which MwoA had been ruled out,
since it was realised that both examiner and participant
might be unable to decipher adequately the symptoms
of T-TH in the presence of MwoA. CEH was diagnosed
according to the criteria of the CHISG, version I (11),
which was the one in current use at the time. Anaesthet-
ic blockades were not part of the examination, and con-
sequently not of the criteria used in this context. A quan-
titative scale was also introduced, with 6.0+ (fulfilment of
all criteria) as the highest grade. CHISG CEH criteria
(12) were also calculated in each T-TH case and MwoA
case.
For attack frequency, a 10-point scale was applied, with
daily headache and one attack a year as the extremes.
Other anamnestic parameters collected included: age at
onset, total duration of T-TH, prevailing intensity, jabs/
stabbing pain [this was compared with migraine, in which
jabs (icepick-like pain, 13) have been supposed to occur
more frequently than in the population at large], location
of initial and maximal pain of attack, and nuchal symp-
toms and signs. “Migrainous” symptoms, like nausea,
vomiting, and pulsatile pain, were also investigated.
Table I - General information on tension-type headache and headaches with which it can be confused (plus migraine with aura).
T-TH
Age at onset, years 25
Age at examination, years 42
Duration of headache, years ca 17
Sex ratio, F/M* 1.31
Mean intensity (scale: 0-6+)** 3.1
4
Jabs/stabs * (%) 38
Abbreviations and symbols: T-TH=tension-type headache; CEH=cervicogenic headache; MwoA=migraine without aura; M+A=migraine with aura.
* 1.06 in the entire Vågå series (7); ** For grading, see text; *** 4.5+, if cases without a pain phase (with aura only) were excluded; 4* In controls:
35% (7).
72
Symptoms were characterised in various ways, nausea,
for example, being present: “always; frequently; rarely;
never”. The methodological problems concerning the “al-
ways/frequently/rarely/never” issue were considerable.
The combination: “always”/”frequently” seems most suit-
able for representing the solitary clinical feature, like nau-
sea. The “always”/“frequently” combination was com-
pared with its opposite, i.e., “rarely/never”. The results of
the two modes of expression (i.e. pairs of alternatives)
should, more or less, coincide. If so, only one figure is
given – the higher one.
If, instead, the results differ more than just marginally –
which they not infrequently did – both figures are consid-
ered, and a mean is used. It should be appreciated that
if the three alternatives “always”/”frequently”/”rarely”
were combined, the ensuing level would be high, in all
probability too high. If only “always” was used, the result
would be low, probably far too low. This method of rea-
soning is, of course, no guarantee that the alternative
“always”/”frequently” will show a “correct” value.
Two deviations from the IHS criteria were made. First,
we did not feel comfortable with our own palpation tech-
nique for disorder of the pericranial musculature (3). No
results are, therefore, reported concerning 2.1.1 and
2.1.2 (3). Nor has a subclassification into chronic and
episodic T-TH been carried out, because the temporal
pattern can change during life, even more than once. In
a not inconsiderable group, there was some uncertainty
regarding the temporal pattern.
Only lifetime prevalence data are given.
The diagnostic procedure was validated: A) Blinded re-
check of 100 records; B) Blinded re-check of 41 individ-
uals (7), carried out a mean of 14.8 months (range: 4-23
months) after examination I. The subjects in group A
were blinded for name, sex, age, occupation, family his-
tory, and diagnosis.
This study was accepted by the regional ethics commit-
tee and the State Data Inspectorate, and all participants
gave their signed informed consent.
Results
The pain in T-TH was relatively weak showing a mean of
3.1, corresponding to just above “mild” (Table I). The
number of pain days varied markedly. On average, > 3
CEH MwoA M+A
33 18 20
50 40 43
ca 17 ca 22 ca 23
0.71 01.69 1.70
3.8 4.2 ***4.0***
42 38 45
Functional Neurology 2008; 23(2): 71-76
Tension-type headache in Vågå

alternatives were ticked on the scale of frequency. A fre-
quency of between one attack per two months and one
attack per week was ticked by 52%; and between one
attack per three months and two attacks per week was
ticked by 75%.
Prevalence
In 478 cases, the T-TH criteria seemed to be fulfilled,
without any admixture of MwoA: i.e. in 26% of the total
Vågå series (“pure” cases). There were 271 females
and 207 males in this group (57% females and 43%
males); F/M ratio: 1.31 (Table I). The average age at on-
set was: 25 (range: 19-65) years. In 137 cases, a coex-
istence of genuine T-TH and MwoA was believed to be
present. The total number of T-TH cases in Vågå, there-
fore, seemed to be 615; prevalence: 34% (females: 377;
males: 238, or 61% versus 39%; F/M ratio: 1.58). Some
non-decipherable cases of a sort of amalgamation of
T-TH/MwoA were observed: 45 cases in the total Vågå
series (or 2.5%).
“Migrainous” traits
Regardless of the mode used for presenting the fre-
quency of “migrainous” traits, e.g. photophobia, a palpa-
ble difference seemed to exist between T-TH and
MwoA. “Migrainous” symptoms, like phonophobia and
pulsating pain were relatively rare in T-TH, but far from
absent (Table II). These symptoms seemed to be milder
than in migraine; the feeling of “explosion”/”disintegra-
tion” in the head, when the pulsating quality of the pain
is at its peak, that is occasionally observed in MwoA,
was almost non-existent in T-TH/CEH. “Migrainous”
symptoms generally seemed to be present to a similar
extent in T-TH and CEH, while the values in both of
these headaches generally differed widely from those
observed in migraine (Table II). The response to “bend-
ing forwards” also seemed to follow these general lines
(Table II). Nausea seemed to be present >4 times more
frequently in MwoA than in T-TH/CEH. Accentuation up-
on physical activity was most frequently found in MwoA,
but for this trait the difference vs the other headaches
seemed to be less marked. The presence of “local” au-
tonomic signs (Table II) was equally rare in the three
headaches.
Cervicogenic traits
Typical “cervicogenic traits” are detailed in Table III
(over). The pattern seemed to be that T-TH and MwoA
were generally comparable as regards these “traits”,
with only minor/moderate differences emerging between
them. However, the trait of unilaterality clearly distin-
guished T-TH from MwoA; it should be emphasised that
unilaterality is a main criterion in MwoA, whereas bilat-
erality is a criterion in T-TH. The second characteristic
trend, evident from Table III, was that the values of these
traits were clearly higher in CEH than in T-TH/MwoA.
For “posterior” onset of pain, the difference between the
CEH and T-TH values showed a factor of >3; for ipsilat-
eral shoulder complaint, a factor of >5; and for radicular
arm pain, a factor of >10. For both T-TH and MwoA, the
levels of the cervicogenic features were similar to those
of controls in fields where control values could be ob-
tained; e.g. ROM and CF (Table III). Pain provocation
from the neck, subjectively as well as objectively, was a
prominent feature in CEH but not in T-TH/MwoA. This
difference between T-TH and CEH was actually a major
one. The mean number of CEH criteria fulfilled differed
vastly in T-TH/MwoA and CEH (Table III). One reason
why this number of criteria was relatively high in MwoA
(compared to T-TH) is that unilaterality is also a criterion
of MwoA, but not of T-TH. Without the laterality criterion,

Table II - “Migrainous” features and local autonomic features (% of cases) in the three headache forms.

Feature T-TH CEH MwoA

Nausea 9 8 (5*/10**) 39 (46*/32**)

Vomiting 6 (2*/9**) 5 13 (16*/10**)
Throbbing*** 22 20 (494*) 81
Accentuation upon physical activity 23 39 49
Phonophobia 22 28 (24*/31**) 79 (84*/74**)
Photophobia 15 19 (15*/22**) 68 (73*/62**)

Bending forwards:
Increase in pain 20 22 49
Increase in throbbing 8 7 32
Extra symptoms: until resting again 1.7 0 11

Duration of pain >72 hours – 61 Negative (obligatory)

“Local” autonomic features

Lacrimation 3 5 4
Conjunctival injection 2 0 4
Nasal secretion 1 0 2

Abbreviations and symbols: T-TH=tension-type headache; CEH=cervicogenic headache; MwoA=migraine without aura; M+A=migraine with au-
ra; * Based on: “Always/frequent”, see text; ** Based on: The opposite of “never”/”rarely”, see text; *** “Explosions” in the head at pain maxi-
mum, synchronised with the pulse, were noted more often in MwoA (8%) than in T-TH (1.3%) and CEH (2%); 4* 20%,throbbing rather regular-
ly. “Rarely”/”mild”, “not in recent years” etc. in 49% of the cases.

Functional Neurology 2008; 23(2): 71-76 73

O. Sjaastad et al.

Table III - “Cervicogenic traits” in the three headache forms.

Variable T-TH MwoA CEH

Skin-roll test (mm)* 15.3 15.4 19.8

Rotation, neck: a) ≥ 15°, reduction (%)** 17 16 93

a) ≥ 10°, reduction (%) 32 31 98
b) deficit in °, mean*** 5.4 5.1 21.7

CF: (0-5+)4* 0.72 0.93 2.37

Shoulder discomfort, ss (%) 17 19 100

Arm discomfort, diffuse, ss (%) 7 8 7*)1005*
Arm pain, radicular, ss (%) 2.5 1.2 27

Pain onset, posteriorly (%) 30 22 97

Unilaterality (%) 8 52 100

Pain provocation from neck:

Subjectively (%) 4 4 100
Objectively (%)6* ca 1 ca 1 100

CEH criteria, mean no. (0-6+) 0.7 1.2 7*)6.07*

Feeling of “tension”, neck (%) 63 62 93

Feeling of “stiffness”, neck (%) 62 62 93

Abbreviations and symbols: T-TH=tension-type headache; CEH=cervicogenic headache; MwoA=migraine without aura; M+A=migraine with au-
ra; ss=symptomatic side; * Mean, Vågå material: 15.0±5.9 (10); ** Vågå material, headache-free individuals (n=246): 22%; *** Mean, Vågå ma-
terial (n=1838): 6.2°; 4* Mean Vågå material: 0.79+; 5* Among those with adequate information; 6* Tendon insertions, nuchal area; 7* 5.93, if
three slightly doubtful cases are taken into account.

the total sum of CEH criteria fulfilled would have been
more similar in T-TH and MwoA.
Stabs (jabs) occurred frequently in all these forms of
headache; jabs do not seem to be useful in distinguish-
ing between them (Table I). Pain intensity was lowest in
T-TH (Table I). Both migraine with aura and MwoA were
seemingly more severe than CEH. Feelings of “tension”
and stiffness in the neck (not CEH criteria) were of sim-
ilar magnitude in T-TH and MwoA (Table III). These lev-
els were somewhat lower in the individuals with “no
headache” in Vågå (i.e. 46%) than in the subjects with
T-TH and MwoA.
Validation
another individual, the symptoms had abated to the ex-
tent that this patient, at most, seemed to present only a
borderline headache (C). In the sixth individual, the
trend observed was the reverse, T-TH probably not ac-
tually having been present at examination I (E). A simi-
lar/“identical” headache thus seemed to be present, at
follow up, in three cases, or 50% of those considered.
The Kappa value was nevertheless rather high: 0.626
(p<0.01), because the finding of T-TH-“free” individuals
is reflected in the statistics.
The discrepancy between the two examinations could
be due to a real evolution of the complaints, given the
relatively long observation time; alternatively, the indi-
viduals may have explained their complaints in different

Re-check of records (n=100). Among the 100 files re- Table IV - Validation. Comparison of first and second exam-
checked, 33 concerned T-TH cases. In 20 of these cas- ination in six possible tension-type headache patients (out
es, T-TH was the only headache present, while in the of a total of 41 individuals re-assessed).
other 13 cases, it coexisted with other headaches: mi-
graine with and without aura (n=11); CEH (n=1); neural- Pattern Type of constellation on Number
giform headache (n=1). There seemed to be complete examination I / examination II
concurrence between the results at the two examina-
tions in 29 cases (88% of the cases) and complete or A +/+ 1
partial disagreement in the other four, the latter being B +?/+? 2
deemed failures. Kappa statistics showed a value of:
C +/+? 1
0.9065 (p<0.0001).
D +/+ MwoA(?) 1
Re-check of individuals (n=41). Of the 41 individuals re- E 0/+ 1
examined, T-TH was a diagnostic possibility in six. Five
had shown T-TH or T-TH(?) on examination I, of whom Total 6
three showed a more or less identical headache at ex-
Abbreviations and symbols: +=suggestive of tension-type headache;
amination II (A&B, Table IV). In one individual, the symp- 0=not suggestive of tension-type headache; MwoA=migraine without
toms had increased and MwoA was suspected (D). In aura.

74 Functional Neurology 2008; 23(2): 71-76

Tension-type headache in Vågå
ways on the two occasions, or the investigator may have
interpreted the narrative differently on the two occa-
sions.
While a Kappa value of 0.626 is comforting, this result
can be viewed from another angle: for a clinician, 50%
diagnostic accuracy is far from ideal.
Discussion
Prevalence
Tension-type headache is probably the least distinct and
most poorly defined of the major, recurrent headaches.
T-TH is partly characterised by negative criteria. It has
also been described as a wastebasket type of diagnosis.
Nevertheless, it has the reputation of being the most
prevalent recurrent headache, with a prevalence rang-
ing from 30 to 78% in various investigations, according
to the IHS (4); in other words, a rather alarming differ-
ence of >250%. The prevalence of T-TH is highly de-
pendent upon the correctness of the borders separating
it from MwoA and CEH. It sounds like a sigh when
Lance, in a somewhat different context (14), wrote: “...no
trouble in agreeing on the diagnosis of cluster headache
and migraine with aura but found difficulty in finding a di-
viding line between migraine and tension-type
headache”. This was written in 1993, after the advent of
the IHS criteria (3).
In the present study, the prevalence of T-TH was 26% if
only the “pure” cases were calculated, and 34% if cases
mixed with MwoA were included. These are much lower
figures than those presented in studies from recent
years that have used similar techniques, i.e. face-to-
face interviews: 67% (15) and 69% (lifetime prevalence)
(16, 17). Even if we were to add the cases that were a
sort of an amalgamation of MwoA and T-TH, the total in
the present study (ca 37%) would still not reach such
high values.
One particular factor may have influenced the numerical
T-TH/MwoA balance in the geographical area explored:
this is, so to speak, a virgin area as regards the pharma-
cological approach to these headaches; in particular,
regular drug consumption is rare. Typical early-phase
migraine traits may have been effaced by drug therapy
in areas with high drug consumption, the ultimate
headache pattern bearing more resemblance to T-TH. In
Vågå, MwoA may have kept the original migraine char-
acteristics to a higher extent, the prevalence in Vågå be-
ing: MwoA: 31%; migraine with aura: 9.7% (18). No firm
conclusions can be reached with regard to the total im-
pact of the reduced consumption of analgesics in Vågå.
Two other factors have contributed to a numerical reduc-
tion of T-TH in our series: both CEH (4.1%) (19) and
“persistent neck complaint with subsequent, transient,
posterior headache” (6.6%) (20) have been presented
under such headings as integral parts of the Vågå study
and have, at least partly, been excluded from the T-TH
domain – this applies particularly to the latter group. If
we had added these groups, the prevalence could have
been around 45%. The sum of T-TH and migraine with
and without aura prevalence may be of interest. In two
previous, comparable studies, it was 83% (15) and 84%
(16), respectively. In Vågå, it was around 75%. Had
Functional Neurology 2008; 23(2): 71-76
CEH + “persistent neck complaints…” (19, 20) been
added, i.e. 10-11%, this would have taken the total to
around 85%. Therefore, the sum may be strikingly simi-
lar, but the subgrouping differs.
Distinction from MwoA and CEH
Unilaterality is not included among the T-TH criteria,
whereas it is a characteristic trait of both MwoA and
CEH. Nevertheless, indirectly, unilaterality may emerge
as a factor in clinical T-TH series. Situations may arise
in which the bilaterality criterion becomes superfluous,
because a satisfactory number of the remaining criteria
has already been fulfilled in a given case.
Unilaterality (15,21,22) has, probably indirectly, become
a feature of T-TH in a not inconsiderable percentage of
the cases examined in various studies. In Monteiro’s
work, unilateral pain was present in 18.7% of the T-TH
cases (15), while the figure for unilaterality in T-TH in
Rasmussen’s work was 10% (16).
Throbbing has been observed “usually” in ca 60% of
T-TH patients (21), a value higher than that found in mi-
graine patients (ca 51%) observed by the same group
(23). After all, throbbing is an inherent trait of MwoA, not
of T-TH. Also in the present series, a certain percentage
had throbbing; this may, in our cases, be due to a minor
“pollution”, possibly from MwoA. The T-TH criteria, nev-
ertheless, were fulfilled in our cases.
For this reason, these cases were categorised as T-TH
cases and not as “non-classifiable” ones, a group that in
Vågå contained 136 individuals, or 7.4%. Coarse struc-
tural changes, observed for example on MRI, have not
been verified in CEH (24).
Remarkably, in the present study, there were major dif-
ferences between T-TH/MwoA, on the one hand, and
CEH on the other hand, with regard to cardinal CEH
variables. Such variables include: ipsilateral shoulder
and diffuse/radicular arm pain; range of motion in the
neck, and onset of pain in the neck/posterior part of the
head. Incidentally, this pattern corresponded well to the
pain drawings done by CEH patients in another context
(25). Even larger differences were found in relation to
the mechanical precipitation of attacks.
The relative lack of “migrainous traits” is pretty similar in
T-TH and CEH (Table II). Moreover, the age at onset
was clearly different in T-TH/MwoA compared to CEH,
the difference being most marked as regards MwoA
(Table I). Although the latter feature cannot be used di-
agnostically in the solitary case, this feature too may in-
dicate differences in pathogenesis.
Validation
The tendency reported in our previous communications
from the Vågå study seemed to be present in this study,
too: a constellation of symptoms and signs set forth in a
written format, stemming from a solitary individual, can
more easily lead to repeated, similar interpretation than
a repeated questioning of that individual. An appreciable
interval between two questionings may enhance this
tendency. A more than minor change in headache de-
gree may lead to a change of headache category; thus,
in the present validation: from zero headache to mild
75
O. Sjaastad et al.
T-TH; and from T-TH to “possible MwoA” (Table IV, cas-
es E&D). Such a change is probably not less under-
standable than the change taking place from day 1 to
day 3 in a solitary migraine attack. If one were confront-
ed directly with a patient on the third day of the attack,
without any information on what the situation had been
like 1-2 days earlier, one would, not infrequently, find it
very difficult to arrive at a correct categorisation; the late
headache phase is, nevertheless, still part of a migraine
attack. Also, the amelioration with age in Bille’s (26)
childhood migraine patients fits in with this view.
The level of concurrence between examinations I and II
in the six T-TH patients among the 41 re-examined indi-
viduals, is among the lowest recorded in the entire Vågå
study.
Concluding remarks
A minor change in, or a wrong assessment of, intensity
may lead to a change in headache category. It may be
too easy just to push a case into the T-TH category.
It is our considered opinion that the IHS T-TH criteria,
weak as they may be, should be followed strictly, now
and for the foreseeable future.
The finding that, generally, CEH attacks (but generally
not attacks of T-TH/MwoA) start posteriorly, combined
with the fact that exacerbations can be provoked me-
chanically from the neck in CEH, may seem to be cru-
cial factors in distinguishing CEH from T-TH/MwoA, clin-
ically. These major and systematic differences indicate
that these disorders have a different nature: T-TH/MwoA
are unlikely to be CEH variants. Equally, CEH is unlike-
ly to be a T-TH or a MwoA variant.
References
11. Ad Hoc Committee on Classification of Headache. Classi-
fication of headache. JAMA 1962;179:717-718
12. Heyck HS. Headache and Facial Pain. Stuttgart; Thieme
Verlag 1981
13. Headache Classification Committee of the International
Headache Society. Classification and diagnostic criteria for
headache disorders, cranial neuralgias and facial pain.
Cephalalgia 1988;8(Suppl 7):1-96
14. Headache Classification Subcommittee of the Internation-
al Headache Society. The International Classification of
Headache Disorders: 2nd edition. Cephalalgia 2004;24
(Suppl 1):9-160
15. Merskey H, Bogduk N. Classification of Chronic Pain. 2nd
edn. Seattle WA; IASP Press 1994
16. Sjaastad O, Båtnes J, Haugen S. The Vågå study; an out-
line of the design. Cephalalgia 1999;19(Suppl 25):24-30
76
17. Sjaastad O, Pettersen H, Bakketeig LS. The Vågå Study;
epidemiology of headache. I. The prevalence of ultrashort
paroxysms. Cephalalgia 2001;21:207-215
18. Sjaastad O, Fredriksen TA, Petersen HC, Bakketeig LS.
Grading of headache intensity. A proposal. J Headache
Pain 2002;3:117-127
19. Sjaastad O, Fredriksen TA, Petersen HC, Bakketeig L.
Features indicative of cervical abnormality. A factor to be
reckoned with in clinical headache work and research?
Funct Neurol 2003;18:195-203
10. Sjaastad O, Bakketeig LS. Skin-fold thickness and repro-
ducibility of the skin-roll test. Vågå study. J Headache Pain
2003;4:103-110
11. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic
headache: diagnostic criteria. Headache 1990;30:725-726
12. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic
headache: diagnostic criteria. The Cervicogenic Headache
International Study Group. Headache 1998;38:442-445.
13. Raskin NH, Schwartz RK. Icepick-like pain. Neurology
1980;30:203-205
14. Lance JW. Mechanisms and Management of Headache.
5th edn. London; Butterworth/Heinemann 1993
15. Monteiro JP. Cefaleias. Estudo epidemiologico e clinico de
uma população urbana. Thesis. Porto, 1995
16. Rasmussen BK. Epidemiology of headache. Cephalalgia
1995;15:45-68
17. Rasmussen BK. Epidemiology of headache. Thesis.
Copenhagen University 1994
18. Sjaastad O, Bakketeig LS, Petersen HC. Migraine with au-
ra: visual disturbances and interrelationship with the pain
phase. Vågå study of headache epidemiology. J Headache
Pain 2006;7:127-135
19. Sjaastad O. Bakketeig LS. Prevalence of cervicogenic
headache. Vågå study of headache epidemiology. Acta
Neurol Scand 2008;117:173-180
20. Sjaastad O, Wang H, Bakketeig LS. Neck pain and asso-
ciated head pain: persistent neck complaint with subse-
quent, transient, posterior headache. Acta Neurol Scand
2006;114:392-399.
21. Lavados PM, Tenhamm E. Epidemiology of tension-type
headache in Santiago, Chile: a prevalence study. Cepha-
lalgia 1998;18:552-558.
22. Nappi G, Manzoni GC. Manuale delle cefalee. Milan; Mas-
son 2005
23. Lavados PM, Tenhamm E. Epidemiology of migraine
headache in Santiago, Chile: a prevalence study. Cepha-
lalgia 1997;17:770-777
24. Inan N, Yilmaz G, Surer H et al. Is there a role for nitric ox-
ide activity in cervicogenic headache? Funct Neurol 2007;
22:155-157
25. Drottning M, Staff P, Sjaastad O. Cervicogenic headache
(CEH) six years after whiplash injury. Funct Neurol 2007;
22:145-149
26. Bille B. Migraine in childhood and its prognosis. Cephalal-
gia 1981;1:71-75
Functional Neurology 2008; 23(2): 71-76