• Rene Castien, Marc Duineveld, Jolanda Maaskant, Willem De Hertogh, and Gwendolyne Scholten-Peeters.
• Department of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, The Netherlands; Amsterdam Public Health Research Institute, Department of General Practice & Elderly Care Medicine, Vrije Universiteit Amsterdam, The Netherlands; Health care centre, Hoofddorp, The Netherlands.
• Pain Physician. 2021 Dec 1; 24 (8): E1177-E1189.

BackgroundIncreased 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.ObjectiveTo assess the presence and differences in total tenderness score between patients with TTH or migraine, and healthy patients.Study DesignSystematic review and meta-analysis.MethodsA 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.ResultsIn 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.LimitationsThe description and performance of the total tenderness score differed across the studies. In 7 studies, patients were included with coexisting types of headache.ConclusionWe 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.

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