Path Analysis Models Integrating Psychological, Psycho-physical and Clinical Variables in Individuals With Tension-Type Headache

Published:October 13, 2022DOI:


      • A theoretical model proposes a relationship of psycho-physical and psychological factors in TTH.
      • A data-driven model associates poor sleep, psychological factors, and chronicity of headache.
      • This data-driven model could be leveraged in clinical trials investigating treatment of TTH.


      Tension type headache (TTH) is a prevalent but poorly understood pain disease. Current understanding supports the presence of multiple associations underlying its pathogenesis. Our aim was to compare competing multivariate pathway models that explains the complexity of TTH. Headache features (intensity, frequency, or duration - headache diary), headache-related disability (Headache Disability Inventory-HDI), anxiety/depression (Hospital Anxiety and Depression Scale), sleep quality (Pittsburgh Sleep Quality Index), widespread pressure pain thresholds (PPTs) and trigger points (TrPs) were collected in 208 individuals with TTH. Four latent variables were formed from the observed variables - Distress (anxiety, depression), Disability (HDI subscales), Severity (headache features), and Sensitivity (all PPTs). Structural equation modelling (SEM) and Bayesian network (BN) analyses were used to build and compare a theoretical ( m o d e l t h e o r y ) and a data-driven ( m o d e l B N ) latent variable model. The m o d e l B N (root mean square error of approximation [RMSEA] = 0.035) provided a better statistical fit than m o d e l t h e o r y (RMSEA = 0.094). The only path common between m o d e l b n and m o d e l t h e o r y was the influence of years with pain on TrPs. The m o d e l B N revealed that the largest coefficient magnitudes were between the latent variables of Distress and Disability (β=1.524, P = .006). Our theoretical model proposes a relationship whereby psycho-physical and psychological factors result in clinical features of headache and ultimately affect disability. Our data-driven model proposes a more complex relationship where poor sleep, psychological factors, and the number of years with pain takes more relevance at influencing disability. Our data-driven model could be leveraged in clinical trials investigating treatment approaches in TTH.


      A theoretical model proposes a relationship where psycho-physical and psychological factors result in clinical manifestations of headache and ultimately affect disability. A data-driven model proposes a more complex relationship where poor sleep, psychological factors, and number of years with pain takes more relevance at influencing disability.

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        • Abboud J
        • Marchand AA
        • Sorra K
        • Descarreaux M
        Musculoskeletal physical outcome measures in individuals with tension-type headache: A scoping review.
        Cephalalgia. 2013; 33: 1319-1336
        • Arendt-Nielsen L
        • Castaldo M
        • Mechelli F
        • Fernández-de-las-Peñas C
        Muscle triggers as a possible source of pain in a subgroup of tension-type headache patients?.
        Clin J Pain. 2016; 32: 711-718
        • Carvalho ECAd
        • Vissoci JRN
        • Andrade Ld
        • Machado WdL
        • Paraiso EC
        • Nievola JC
        BNPA: An R package to learn path analysis input models from a data set semi-automatically using Bayesian networks.
        Knowl Based Syst. 2021; 223107042
        • Cathcart S
        • Petkov J
        • Winefield AH
        • Lushington K
        • Rolan P
        Central mechanisms of stress-induced headache.
        Cephalalgia. 2010; 30: 285-295
        • Colombo D
        • Maathuis MH
        • Kalisch M
        • Richardson TS
        Learning high-dimensional directed acyclic graphs with latent and selection variables.
        Ann Stat. 2012; 40: 294-321
        • Cook AJ
        • Brawer PA
        • Vowles KE
        The fear-avoidance model of chronic pain: Validation and age analysis using structural equation modeling.
        Pain. 2006; 121: 195-206
        • De Pauw R
        • Dewitte V
        • de Hertogh W
        • Cnockaert E
        • Chys M
        • Cagnie B
        Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study.
        Musculoskelet Sci Pract. 2021; 52102325
        • Do TP
        • Heldarskard GF
        • Kolding LT
        • Hvedstrup J
        • Schytz HW
        Myofascial trigger points in migraine and tension-type headache.
        J Headache Pain. 2018; 19: 84
      1. Epskamp S. semPlot: Path diagrams and visual analysis of various SEM packages, 2019.

        • Falsiroli Maistrello L
        • Geri T
        • Gianola S
        • Zaninetti M
        • Testa M
        Effectiveness of trigger point manual treatment on the frequency, intensity, and duration of attacks in primary headaches: A systematic review and meta-analysis of randomized controlled trials.
        Func Neurol. 2018; 9: 254
        • Feigin VL
        • Nichols E
        • Alam T
        GBD 2016 eurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016.
        Lancet Neurol. 2019; 18: 459-480
        • Fernández-de-las-Peñas C
        • Ambite-Quesada S
        • Palacios-Ceña M
        • Guillem-Mesado A
        • Guerrero-Peral Á
        • Pareja JA
        • Arendt-Nielsen L
        Catechol-O-Methyltransferase (COMT) rs4680 Val158Met polymorphism is associated with widespread pressure pain sensitivity and depression in women with chronic, but not episodic, tension-type headache.
        Clin J Pain. 2019; 35: 345-352
        • Fernández-de-las-Peñas C
        • Dommerholt J
        Myofascial trigger points: Peripheral or central phenomenon?.
        Curr Rheumatol Rep. 2014; 16: 395
        • Fernández-de-las-Peñas C
        • Dommerholt J
        International consensus on diagnostic criteria and clinical considerations of myofascial trigger points: A Delphi Study.
        Pain Med. 2018; 19: 142-150
        • Fernández-de-las-Peñas C
        • Fernández-Mayoralas DM
        • Arroyo-Morales M
        • Ambite-Quesada S
        • Rivas-Martínez I
        • Ortega-Santiago R
        • Díaz-Rodríguez L
        • Pereja JA
        Lower immunglobulin A levels but not lower cortisol or alpha–amylase activity in children with chronic tension-type headache.
        Cephalalgia. 2011; 31: 481-487
        • Fernández-de-las-Peñas C
        • Fernández-Muñoz JJ
        • Palacios-Ceña M
        • Parás-Bravo P
        • Cigarán-Méndez M
        • Navarro-Pardo E
        Sleep disturbances in tension-type headache and migraine.
        Ther Adv Neurol Disord. 2018; 111756285617745444
        • Fernández-de-las-Peñas C
        • Florencio LL
        • Plaza-Manzano G
        • Arias-Buría JL
        Clinical reasoning behind non-pharmacological interventions for the management of headaches: A narrative literature review.
        Int J Environ Res Public Health. 2020; 17: 4126
        • Fernández-de-las-Peñas C
        • Plaza-Manzano G
        • Navarro-Santana MJ
        • Olesen J
        • Jensen RH
        • Bendtsen L
        Evidence of localized and widespread pressure pain hypersensitivity in patients with tension-type headache: A systematic review and meta-analysis.
        Cephalalgia. 2021; 41: 256-273
        • Ferrante T
        • Manzoni GC
        • Russo M
        • Camarda C
        • Taga A
        • Veronesi L
        • Pasquarella C
        • Sansebastiano G
        • Torelli P
        Prevalence of tension-type headache in adult general population: The PACE study and review of the literature.
        Neurol Sci. 2013; 34: S137-S138
        • Fitzcharles MA
        • Cohen SP
        • Clauw DJ
        • Littlejohn G
        • Usui C
        • Häuser W
        Nociplastic pain: Towards an understanding of prevalent pain conditions.
        Lancet. 2021; 397: 2098-2110
        • Foraita R
        • Friemel J
        • Günther K
        • Behrens T
        • Bullerdiek J
        • Nimzyk R
        • Ahrens W
        • Didelez V
        Causal discovery of gene regulation with incomplete data.
        J R Stat Soc Ser A Stat Soc. 2020; 183: 1747-1775
        • Fordham B
        • Ji C
        • Hansen Z
        • Lall R
        • Lamb SE
        Explaining how cognitive behavioral approaches work for low back pain: Mediation analysis of the back skills training trial.
        Spine. 2017; . 42: E1031-e1039
        • Fuensalida-Novo S
        • Jiménez-Antona C
        • Benito-González E
        • Cigarán-Méndez M
        • Parás-Bravo P
        • Fernández-de-las-Peñas C
        Current perspectives on sex differences in tension-type headache.
        Expert Rev Neurother. 2020; 20: 659-666
        • Gates KM
        • Molenaar PC
        Group search algorithm recovers effective connectivity maps for individuals in homogeneous and heterogeneous samples.
        Neuroimage. 2012; 63: 310-319
        • Georgopoulos V
        • Akin-Akinyosoye K
        • Zhang W
        • McWilliams DF
        • Hendrick P
        • Walsh DA
        Quantitative sensory testing and predicting outcomes for musculoskeletal pain, disability, and negative affect: A systematic review and meta-analysis.
        Pain. 2019; 160: 1920-1932
      2. Headache classification committee of the International Headache Society (IHS) The International classification of headache disorders, 3rd edition.
        Cephalalgia. 2018; 38: 1-211
        • Houle TT
        • Butschek RA
        • Turner DP
        • Smitherman TA
        • Rains JC
        • Penzien DB
        Stress and sleep duration predict headache severity in chronic headache sufferers.
        Pain. 2012; 153: 2432-2440
        • Hübscher M
        • Moloney N
        • Leaver A
        • Rebbeck T
        • McAuley JH
        • Refshauge KM
        Relationship between quantitative sensory testing and pain or disability in people with spinal pain-a systematic review and meta-analysis.
        Pain. 2013; 154: 1497-1504
        • Jacobson GP
        • Ramadan NM
        • Aggarwal SK
        • Newman CW
        The Henry Ford Hospital Headache Disability Inventory (HDI).
        Neurology. 1994; 44: 837-842
        • Jacobson GP
        • Ramadan NM
        • Norris L
        • Newman CW
        Headache disability inventory (HDI): Short-term test-retest reliability and spouse perceptions.
        Headache. 1995; 35: 534-539
        • Jensen RH
        Tension-Type Headache - The normal and most prevalent headache.
        Headache. 2018; 58: 339-345
      3. Jorgensen T, Pornprasertmanit S, Schoemann A, Rosseel Y: semTools: Useful tools for structural equation modeling: R package. 2021.

        • Juang KD
        • Wang SJ
        • Lin CH
        • Fuh JL
        Use of the hospital anxiety and depression scale as a screening tool for patients with headache.
        Zhonghua Yi Xue Za Zhi. 1999; 62: 749-755
        • Leite WL
        • Shen Z
        • Marcoulides K
        • Fisk CL
        • Harring J
        Using ant colony optimization for sensitivity analysis in structural equation modeling.
        Struct Equ Model. 2022; 46: 159-161
        • Liang Z
        • Galea O
        • Thomas L
        • Jull G
        • Treleaven J
        Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis.
        Musculoskelet Sci Pract. 2019; 42: 67-83
        • Liew BXW
        • Peolsson A
        • Scutari M
        • Löfgren H
        • Wibault J
        • Dedering Å
        • Öberg B
        • Zsigmond P
        • Falla D
        Probing the mechanisms underpinning recovery in post-surgical patients with cervical radiculopathy using Bayesian networks.
        Eur J Pain. 2020; 24: 909-920
        • Liew BXW
        • Scutari M
        • Peolsson A
        • Peterson G
        • Ludvigsson ML
        • Falla D
        Investigating the causal mechanisms of symptom recovery in chronic whiplash-associated disorders using bayesian networks.
        Clin J Pain. 2019; 35: 647-655
      4. Little MA, Badawy R: Causal bootstrapping. arXiv preprint. arXiv:191009648 2019.

        • Nagarajan R
        • Scutari M
        • Lèbre S
        Bayesian networks in R with applications in systems biology.
        Springer, New York, NY2013
        • Palacios-Ceña M
        • Wang K
        • Castaldo M
        • Guillem-Mesado A
        • Ordás-Bandera C
        • Arendt-Nielsen L
        Fernández-de-las-Peñas C. Trigger points are associated with widespread pressure pain sensitivity in people with tension-type headache.
        Cephalalgia. 2018; 38: 237-245
        • Pearl J
        Models, Reasoning, and Inference. Cambridge University Press, New York, NY2009
        • Phillip D
        • Lyngberg A
        • Jensen R
        Assessment of headache diagnosis. A comparative population study of a clinical interview with a diagnostic headache diary.
        Cephalalgia. 2007; 27: 1-8
        • Probyn K
        • Bowers H
        • Caldwell F
        • Mistry D
        • Underwood M
        • Matharu M
        • Pincus T
        Prognostic factors for chronic headache: A systematic review.
        Neurology. 2017; 89: 291-301
        • Racine M
        • Tousignant-Laflamme Y
        • Kloda LA
        • Dion D
        • Dupuis G
        • Choinière M
        A systematic literature review of 10 years of research on sex/gender and experimental pain perception - part 1: Are there really differences between women and men?.
        Pain. 2012; 153: 602-618
        • Rains JC
        Chronic headache and potentially modifiable risk factors: Screening and behavioral management of sleep disorders.
        Headache. 2008; 48: 32-39
        • Rosseel Y
        lavaan: An R package for structural equation modeling.
        J Stat Softw. 2012; 48: 1-36
        • Scutari M
        Learning Bayesian networks with the bnlearn R Package.
        J Stat Softw. 2010; 35: 22
        • Scutari M
        • Nagarajan R
        Identifying significant edges in graphical models of molecular networks.
        Artif Intell Med. 2013; 57: 207-217
        • Steel SJ
        • Robertson CE
        • Whealy MA
        Current understanding of the pathophysiology and approach to tension-type headache.
        Curr Neurol Neurosci Rep. 2021; 21: 56
        • Sullivan DP
        • Martin PR
        • Boschen MJ
        Psychological sleep interventions for migraine and tension-type headache: A systematic review and meta-analysis.
        Sci Rep. 2019; 9: 6411
        • Headache Classification Committee of the InternationalHeadache Society (IHS)
        The International Classification of Headache Disorders, 3rd edition (beta version).
        Cephalalgia. 2013; 33: 629-808
        • van Buuren S
        • Groothuis-Oudshoorn K
        mice: Multivariate imputation by chained equations in R.
        J Stat Softw. 2011; 45: 1-67
        • Vandenbroucke JP
        • von Elm E
        • Altman DG
        • Gøtzsche PC
        • Mulrow CD
        • Pocock SJ
        • Poole C
        • Schlesselman JJ
        • Egger M
        • STROBE Initiative
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies.
        PLoS Med. 2007; 4: e297
        • VanderWeele TJ
        Mediation analysis: A practitioner's guide.
        Annu Rev Public Health. 2016; 37: 17-32
        • Zigmond AS
        • Snaith RP
        The hospital anxiety and depression scale.
        Acta Psychiatr Scand. 1983; 67: 361-370