{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T03:02:09Z","timestamp":1776222129053,"version":"3.50.1"},"reference-count":55,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2022,7,10]],"date-time":"2022-07-10T00:00:00Z","timestamp":1657411200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and objectives: Chronic tension-type headache (TTH) is the type of headache with the highest prevalence. The involvement of musculoskeletal structures in TTH is supported by evidence in the scientific literature. Among these, deep cervical muscle strength appears to be related to the function of the cervical spine and the clinical characteristics of TTH. This study aimed to correlate anatomical, functional, and psychological variables in patients with TTH. Materials and methods: An observational descriptive study was carried out with 22 participants diagnosed with TTH for at least six months. The characteristics of headaches, including ultrasound-based deep neck flexor and extensor muscle thickness, range of motion (ROM), and pressure pain threshold (PPT), were recorded. We also conducted the Pain Vigilance and Awareness Questionnaire (PVAQ) and the Craniocervical Flexion Test (CCFT). Results: Moderate\u2013large negative correlations were found between the PVAQ and the muscle thickness of right deep flexors contracted (r = \u22120.52; p = 0.01), left multifidus contracted (r = \u22120.44; p = 0.04), right multifidus at rest (r = \u22120.48; p = 0.02), and right multifidus contracted (r = \u22120.45; p = 0.04). Moderate\u2013large positive correlations were found between the CCFT score and the left cervical rotation ROM (r = 0.53; p = 0.01), right cervical rotation ROM (r = 0.48; p = 0.03), muscle thickness of left multifidus contracted (r = 0.50; p = 0.02), and muscle thickness of right multifidus at rest (r = 0.51; p = 0.02). The muscle thickness of the contracted right deep cervical flexors showed a moderate negative correlation with headache intensity (r = \u22120.464; p = 0.03). No correlations were found between PPT and the rest of the variables analyzed. Conclusions: In patients with TTH, a higher thickness of deep cervical muscles was associated with higher ROM and higher scores in the CCFT. In turn, the thickness of deep cervical muscles showed negative correlations with pain hypervigilance and headache intensity. These results contribute to a better understanding of the physical and psychosocial factors contributing to the development of TTH, which is useful for implementing appropriate prevention and treatment measures.<\/jats:p>","DOI":"10.3390\/medicina58070917","type":"journal-article","created":{"date-parts":[[2022,7,10]],"date-time":"2022-07-10T22:48:00Z","timestamp":1657493280000},"page":"917","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Deep Cervical Muscles and Functionality in Patients with Chronic Tension-Type Headache: An Observational Study"],"prefix":"10.3390","volume":"58","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2689-1767","authenticated-orcid":false,"given":"Guillermo","family":"Garc\u00eda-P\u00e9rez-de-Sevilla","sequence":"first","affiliation":[{"name":"Department of Physiotherapy, Faculty of Sports Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7215-3925","authenticated-orcid":false,"given":"\u00c1ngel","family":"G\u00f3nzalez-de-la-Flor","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy, Faculty of Sports Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel","family":"Mart\u00edn-Vera","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy, Faculty of Sports Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8683-9154","authenticated-orcid":false,"given":"Diego","family":"Dom\u00ednguez-Balmaseda","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy, Faculty of Sports Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9952-356X","authenticated-orcid":false,"given":"Jos\u00e9 \u00c1ngel","family":"del-Blanco-Mu\u00f1iz","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy, Faculty of Sports Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2022,7,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e4","DOI":"10.1017\/S1463423618000324","article-title":"The long and winding road: The journey taken by headache sufferers in search of help","volume":"20","author":"Davies","year":"2019","journal-title":"Prim. Health Care Res. Dev."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1186\/s10194-022-01402-2","article-title":"The global prevalence of headache: An update, with analysis of the influences of methodological factors on prevalence estimates","volume":"23","author":"Stovner","year":"2022","journal-title":"J. Headache Pain"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1177\/0333102417738202","article-title":"Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders","volume":"38","author":"Olesen","year":"2018","journal-title":"Cephalalgia"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"44","DOI":"10.4103\/2277-9175.204587","article-title":"The Prevalence of Osmophobia in Migranous and Episodic Tension Type Headaches","volume":"6","author":"Dashti","year":"2017","journal-title":"Adv. Biomed. Res."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Song, T.-J., Cho, S.-J., Kim, W.-J., Yang, K.I., Yun, C.-H., and Chu, M.K. (2016). Anxiety and Depression in Tension-Type Headache: A Population-Based Study. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0165316"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1046\/j.1468-2982.1999.019004207.x","article-title":"Familial Occurrence of Chronic Tension-Type Headache","volume":"19","author":"Russell","year":"1999","journal-title":"Cephalalgia"},{"key":"ref_7","first-page":"46","article-title":"Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain","volume":"1","author":"Hammarlund","year":"2017","journal-title":"J. Headache Pain"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1186\/s10194-018-0913-8","article-title":"Myofascial trigger points in migraine and tension-type headache","volume":"19","author":"Do","year":"2018","journal-title":"J. Headache Pain"},{"key":"ref_9","first-page":"44","article-title":"Clinical reasoning for manual therapy management of tension type and cervicogenic headache","volume":"22","author":"Cortney","year":"2014","journal-title":"J. Man. Manip. Ther."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"116","DOI":"10.4103\/0028-3886.315986","article-title":"Advances in the Understanding of Pathophysiology of TTH and its Management","volume":"69","author":"Bhoi","year":"2021","journal-title":"Neurol. India"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1016\/j.msksp.2019.04.007","article-title":"Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis","volume":"42","author":"Liang","year":"2019","journal-title":"Musculoskelet. Sci. Pract."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e020984","DOI":"10.1136\/bmjopen-2017-020984","article-title":"Comparing neck extensor muscle function in asymptomatic Canadian adults and adults with tension-type headache: A cross-sectional study","volume":"9","author":"Marchand","year":"2019","journal-title":"BMJ Open"},{"key":"ref_13","first-page":"465","article-title":"Relationship between thickness of deep neck muscles synergy and painful side in patients with cervicogenic headache","volume":"39","author":"Abaspour","year":"2021","journal-title":"Cranio J. Craniomandib. Pract."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.math.2016.02.010","article-title":"International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study","volume":"23","author":"Luedtke","year":"2016","journal-title":"Man. Ther."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.msksp.2018.07.003","article-title":"Relationship between cervical muscle morphology evaluated by MRI, cervical muscle strength and functional outcomes in patients with degenerative cervical myelopathy","volume":"38","author":"Fortin","year":"2018","journal-title":"Musculoskelet. Sci. Pract."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1186\/2193-1801-2-457","article-title":"Prediction of the muscle strength by the muscle thickness and hardness using ultrasound muscle hardness meter","volume":"2","author":"Muraki","year":"2013","journal-title":"SpringerPlus"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1186\/s10194-021-01298-4","article-title":"Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache. A systematic review and meta-analysis","volume":"22","author":"Callesen","year":"2021","journal-title":"J. Headache Pain"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"E105","DOI":"10.1017\/sjp.2014.108","article-title":"Spanish Version of the Pain Vigilance and Awareness Questionnaire: Psychometric Properties in a Sample of Women with Fibromyalgia","volume":"17","author":"Lami","year":"2014","journal-title":"Span. J. Psychol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e20190407","DOI":"10.1590\/1678-2019-0407","article-title":"The association of self-reported awake bruxism with anxiety, depression, pain threshold at pressure, pain vigilance, and quality of life in patients undergoing orthodontic treatment","volume":"28","author":"Machado","year":"2020","journal-title":"J. Appl. Oral Sci."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1186\/s10194-020-01095-5","article-title":"Time trends of major headache diagnoses and predictive factors. Data from three Nord-Tr\u00f8ndelag health surveys","volume":"21","author":"Hagen","year":"2020","journal-title":"J. Headache Pain"},{"key":"ref_21","first-page":"S45","article-title":"Resistance Exercise for Knee Osteoarthritis","volume":"4","author":"Vincent","year":"2012","journal-title":"PMR"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"8","DOI":"10.2519\/jospt.2018.7476","article-title":"Unraveling the mechanisms of manual therapy: Modeling an approach","volume":"48","author":"Bialosky","year":"2018","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_23","first-page":"1623","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observa-tional Studies","volume":"4","author":"Altman","year":"2007","journal-title":"PLoS Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1123\/jpah.2013-0473","article-title":"Qualified Fitness and Exercise as Professionals and Exercise Prescription: Evolution of the PAR-Q and Canadian Aerobic Fitness Test","volume":"12","author":"Shephard","year":"2015","journal-title":"J. Phys. Act. Health"},{"key":"ref_25","first-page":"S0213","article-title":"Headache: What to ask, how to examine, and what scales to use. Recommendations of the Spanish Society of Neurology\u2019s Headache Study Group","volume":"28","year":"2019","journal-title":"Neurologia. Span. Soc. Neurol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1186\/s12998-016-0132-9","article-title":"Musculoskeletal diagnostic ultrasound imaging for thick-ness measurement of four principal muscles of the cervical spine\u2014A reliability and agreement study","volume":"25","author":"Myhrvold","year":"2017","journal-title":"Chiro Pract. Man. Ther."},{"key":"ref_27","first-page":"8908035","article-title":"Assessment of Interrater and Intrarater Reliability of Cervical Range of Motion (CROM) Goniometer","volume":"2020","author":"Guzik","year":"2020","journal-title":"BioMed Res. Int."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"318","DOI":"10.2519\/jospt.2010.3180","article-title":"Validity and between-day reliability of the cervical range of mo-tion (CROM) device","volume":"40","author":"Audette","year":"2010","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Fleckenstein, J., Simon, P., K\u00f6nig, M., Vogt, L., and Banzer, W. (2017). The pain threshold of high-threshold mechanosensitive receptors subsequent to maximal eccentric exercise is a potential marker in the prediction of DOMS associated impairment. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0185463"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1016\/j.apmr.2019.10.194","article-title":"Pressure Pain Threshold in Subjects With Piriformis Syndrome: Test-Retest, Intrarater, and Interrater Reliability, and Minimal Detectible Changes","volume":"101","author":"Tabatabaiee","year":"2020","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1007\/s12529-011-9216-z","article-title":"Empirical Evidence of the Validity of the Spanish Version of the Pain Vigilance Awareness Questionnaire","volume":"20","author":"Esteve","year":"2011","journal-title":"Int. J. Behav. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1016\/S0304-3959(02)00338-X","article-title":"The pain vigilance and awareness questionnaire (PVAQ): Further psychometric evaluation in fibromyalgia and other chronic pain syndromes","volume":"101","author":"Roelofs","year":"2003","journal-title":"Pain"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1080\/10669817.2018.1560946","article-title":"Abnormal performance of cervical stabilizer muscles in individuals with low back pain","volume":"27","author":"Thongprasert","year":"2019","journal-title":"J. Man. Manip. Ther."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"664","DOI":"10.21474\/IJAR01\/12748","article-title":"Interrater and Intrarater Reliability of Pressure Biofeed-Back Unit in Measurement of Transverses Abdominis Muscle Activation in Asympto-Matic Adults","volume":"9","author":"Soni","year":"2021","journal-title":"Int. J. Adv. Res."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"486","DOI":"10.5812\/ijem.3505","article-title":"Normality Tests for Statistical Analysis: A Guide for Non-Statisticians","volume":"10","author":"Ghasemi","year":"2012","journal-title":"Int. J. Endocrinol. Metab."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1249\/MSS.0b013e31818cb278","article-title":"Progressive Statistics for Studies in Sports Medicine and Exercise Science","volume":"41","author":"Hopkins","year":"2009","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1016\/j.jbmt.2016.10.004","article-title":"Correlation between cervical flexor muscle thickness and craniocervical flexion torque in healthy subjects","volume":"22","author":"Ishida","year":"2018","journal-title":"J. Bodyw. Mov. Ther."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/j.math.2016.05.336","article-title":"Does increased superficial neck flexor activity in the craniocervical flexion test reflect reduced deep flexor activity in people with neck pain?","volume":"25","author":"Jull","year":"2016","journal-title":"Man. Ther."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1007\/s11916-011-0216-0","article-title":"The Role of Muscles in Tension-Type Headache","volume":"15","author":"Bendtsen","year":"2011","journal-title":"Curr. Pain Headache Rep."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"445","DOI":"10.2147\/JPR.S146050","article-title":"Neck\/shoulder function in tension-type headache patients and the effect of strength training","volume":"11","author":"Madsen","year":"2018","journal-title":"J. Pain Res."},{"key":"ref_41","first-page":"7296032","article-title":"Chronic Neck Pain and Cervico-Craniofacial Pain Patients Express Similar Levels of Neck Pain-Related Disability, Pain Catastrophizing, and Cervical Range of Motion","volume":"2016","year":"2016","journal-title":"Pain Res. Treat."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1179\/0886963414Z.00000000053","article-title":"Upper cervical range of motion is impaired in patients with temporomandibular disorders","volume":"33","author":"Grondin","year":"2015","journal-title":"Cranio"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"314","DOI":"10.1111\/j.1468-2982.2005.01042.x","article-title":"Forward head posture and neck mobility in chronic tension-type headache: A blinded, controlled study","volume":"26","author":"Cuadrado","year":"2006","journal-title":"Cephalalgia"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"662","DOI":"10.1111\/j.1526-4610.2006.00632.x","article-title":"Myofascial trigger points, neck mobility, and forward head posture in episodic tension-type headache","volume":"47","author":"Cuadrado","year":"2007","journal-title":"Headache"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1016\/j.jcm.2014.01.004","article-title":"Efficacy of manual and manipulative therapy in the perception of pain and cervical motion in patients with tension-type headache: A randomized, controlled clinical trial","volume":"13","year":"2014","journal-title":"J. Chiropr. Med."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1177\/0333102410377362","article-title":"Effectiveness of manual therapy for chronic tension-type headache: A pragmatic, randomised, clinical trial","volume":"31","author":"Castien","year":"2011","journal-title":"Cephalalgia"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Marchand, A.A., Cantin, V., Murphy, B., Stern, P., and Descarreaux, M. (2014). Is performance in goal oriented head movements altered in patients with tension type headache?. BMC Musculoskelet Disord., 15.","DOI":"10.1186\/1471-2474-15-179"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1514","DOI":"10.1177\/0333102410375724","article-title":"Differences in cervical musculoskeletal impairment between episodic and chronic tension-type headache","volume":"30","author":"Sohn","year":"2010","journal-title":"Cephalalgia"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"E201","DOI":"10.36076\/ppj\/2015.18.E201","article-title":"Pressure pain and isometric strength of neck flexors are related in chronic tension-type headache","volume":"18","author":"Castien","year":"2015","journal-title":"Pain Physician"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1186\/s10194-018-0833-7","article-title":"Pressure pain thresholds over the cranio-cervical region in headache: A systematic review and meta-analysis","volume":"19","author":"Castien","year":"2018","journal-title":"J. Headache Pain"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1186\/s10194-021-01278-8","article-title":"High concurrent validity between digital and analogue algometers to measure pressure pain thresholds in healthy participants and people with migraine: A cross-sectional study","volume":"22","author":"Castien","year":"2021","journal-title":"J. Headache Pain"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1016\/j.jpsychores.2016.12.003","article-title":"Generalized hypervigilance in fibromyalgia: Normal interoceptive accuracy, but reduced self-regulatory capacity","volume":"93","author":"Rost","year":"2017","journal-title":"J. Psychosom. Res."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1016\/j.jpsychores.2010.05.002","article-title":"Generalized hypervigilance in fibromyalgia patients: An experimental analysis with the emotional Stroop paradigm","volume":"69","author":"Mercado","year":"2010","journal-title":"J. Psychosom. Res."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1007\/s12160-013-9563-x","article-title":"Pain hypervigilance is associated with greater clinical pain severity and enhanced experimental pain sensi-tivity among adults with symptomatic knee osteoarthritis","volume":"48","author":"Herbert","year":"2014","journal-title":"Ann. Behav. Med."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"413","DOI":"10.1016\/j.math.2011.04.005","article-title":"How to explain central sensitization to patients with \u2018unexplained\u2019 chronic musculoskeletal pain: Practice guidelines","volume":"16","author":"Nijs","year":"2011","journal-title":"Man. Ther."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/58\/7\/917\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T23:47:40Z","timestamp":1760140060000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/58\/7\/917"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,7,10]]},"references-count":55,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2022,7]]}},"alternative-id":["medicina58070917"],"URL":"https:\/\/doi.org\/10.3390\/medicina58070917","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,7,10]]}}}