Chapter 39 Tension-Type Headache, Chronic Tension-Type Headache, and Other Headache

Question 1

The pain of a TTH

Answer 1

duller, less intense, and less
localized than that of a migraine or a cluster attack. The
pain usually lasts several hours to a day, but it may continue
for days or weeks.

Question 2

During a severe TTH patients can experience

Answer 2

photophobia, phonophobia, nausea, and occasionally
emesis. Pain referred to the neck is common; patients
also frequently complain of “a knot in the neck,” but the
neurologic examination should be normal.

Question 3

major variants of TTH

Answer 3

those with disorder of the
pericranial muscles, those without disorder of the pericranial muscles, and chronic TTH (CTTH) (with or without disorder of the pericranial muscles).

Question 4

Those with disorder of the pericranial muscles are characterized by

Answer 4

tenderness on palpation of those muscles, increased activity on electromyography
(EMG), or both

Question 5

CTTH, previously

called chronic daily headache, is diagnosed

Answer 5

in a patient with a headache frequency of 15 days per month or 180 headaches per year averaged over a 6-month period.

Question 6

If patient require analgesics

Answer 6

It stands to reason that patients should be advised against using analgesics more than twice per week over a prolonged period of time. If they require analgesics at least twice per week, they should be offered
a prophylactic regimen.

Question 7

In adolescents (age 12 to 14 at the time of diagnosis), the
cause and prognosis of CDH

Answer 7

Many of these children seem to have personal or

family history of migraine.

Question 8

The mainstay of treatment for MOH

Answer 8

total withdrawal
from analgesics for a period of time not shorter than
2 months.

Question 9

The initial several
days to 2 weeks following analgesic withdrawal might be
the most difficult and are frequently punctuated with

Answer 9

a severe rebound headache; antiemetics and maintaining

hydration, as well as patience, are effective

Question 10

characteristic of patients with MOH is that drugs

administered with prophylactic intent tend

Answer 10

to not work unless analgesics are discontinued. Patients whose MOH is typified by the regular use of narcotics or barbiturates may require a controlled tapering off of the drugs as well as management of potential withdrawal symptoms

Question 11

temporal arteritis

Answer 11

should be
considered in an elderly patient with a persistent headache of recent onset whether or not other typical elements are present in the history and physical examination.

Question 12

temporal arteritis diagnosis and treatment

Answer 12

In these
patients an erythrocyte sedimentation rate (ESR) or a
sensitive C-reactive protein (s-CRP) should be ordered
immediately, and consideration should be given to treatment
with a corticosteroid and to a temporal artery biopsy

Question 13

Idiopathic intracranial hypertension (previously

called pseudotumor cerebri) usually presents

Answer 13

in overweight young women with chronic headaches, a normal examination, a normal scan, and papillede —although a subset of these patients do not have papilledema. The diagnosis is made when a lumbar puncture reveals an otherwise normal fluid under high pressure (at least 20 to 25 cm H2O).

Question 14

The muscle contraction

theory of TTH

Answer 14

relates pain to prolonged contraction, or spasm, of cervical or pericranial muscles

Question 15

Most patients with a headache,

migrainous or TTH, have

Answer 15

pericranial muscle tenderness

or sore spots;

Question 16

Cervical pain can be referred to the head from

Answer 16

intervertebral discs, interspinous ligaments, zygapophyseal joints, the periosteum, paracervical muscles, carotid and vertebral arteries, and from irritation of the C1, C2, and C3 nerve roots.

Question 17

The dorsal rami of the first three cervical nerve roots supply the sensory innervation to the

Answer 17

neck and
to the scalp caudal to the innervation of the trigeminal
nerve, and to the meninges and arteries of the posterior
fossa.

Question 18

Headache also can arise from pathology in the area

of the foramen magnum examples

Answer 18

Chiari I malformation, the Dandy-Walker syndrome, atlantoaxial dislocation (e.g., from rheumatoid arthritis), Paget’s disease of the bone, and basilar invagination.

Question 19

Abortive Treatment Strategies

Answer 19

For the occasional TTH, an over-the-counter (OTC)

analgesic preparation is all that is required.

Question 20

OTC analgesic preparations

Answer 20

Several OTC
analgesic preparations involve combinations of drugs
(e.g., aspirin plus acetaminophen) and may contain caffeine.
Caffeine combined with analgesics such as aspirin,
acetaminophen, and ibuprofen enhances their analgesic
effectiveness.

Question 21

Stronger headaches may require an analgesic

Answer 21

(aspirin, acetaminophen, or ibuprofen) in combination

with either codeine or butalbital.

Question 22

If aspirin or acetaminophen, with or without codeine,
butalbital, or caffeine, is ineffective in controlling the
headache, the choice of an alternative analgesic should
proceed

Answer 22

in an orderly fashion by testing in turn members
of different NSAID chemical categories at adequate doses. Indomethacin is reported to be more effective than
alternative NSAIDs for pain of cephalic origin; it is particularly
effective in treating hemicrania

Question 23

The major chemical

categories of NSAIDs include

Answer 23

• Carboxylic acids—includes aspirin, which is an acetylated
  acid, as well as salsalate and choline magnesium trisalicylate, which are nonacetylated
• Propionic acids—ibuprofen, naproxen, ketoprofen, and
  fenoprofen
• Aryl and heterocyclic acids—indomethacin, diclofenac,
  sulindac, and tolmetin
• Fenamic acids—mefenamic acid and meclofenamate
• Enolic acids—piroxicam and phenylbutazone
• Pyrrolo-pyrrole—ketorolac
• Cyclooxygenase 2 (COX-2) inhibitors—celecoxib

Question 24

Prophylactic Treatment Strategies

Answer 24

Antidepressants, particularly amitriptyline or nortriptylene
at a starting dose of 10 to 25 mg at bedtime, are
active prophylactic drugs.16 Most patients who respond to
tricyclic antidepressants (amitriptyline, nortriptyline,
imipramine, or desipramine) usually do so at doses of 25 to
200 mg at bedtime;

Question 25

How does Tricyclics help?

Answer 25

induce sleep, which may constitute

one of the mechanisms by which they help.

Question 26

The major side effects from tricyclics relate to

Answer 26

their anticholinergic effects
and include a dry mouth, excessive daytime sleepiness, dizziness,
urinary retention, glaucoma, cardiac arrhythmias,and photosensitization; they can also cause weight gain.

Question 27

The specific serotonin reuptake inhibitors (SSRIs) and

specific serotonin-norepinephrine reuptake inhibitors

Answer 27

(SNRIs) might be tried in patients who do not respond or who develop intolerable side effects from tricyclic drugs.

Question 28

The major side effects of the SSRIs and SNRIs include

Answer 28

jitteriness, tremors, gastrointestinal distress, decreased libido,
and occasionally headaches

Question 29

SSRIs and SNRIs are relatively contraindicated in patients who

Answer 29

use triptans, as they may suffer from excessive serotonin stimulation (serotonin syndrome)

Question 30

Beta-blockers

Answer 30

propranolol, metoprolol, atenolol, timolol, and nadolol, can be tried and sometimes prove effective. In most healthy people, 60 to 80 mg once per day of a long-acting propranolol preparation can be started and the dosage can be adjusted as necessary.

Question 31

Beta-blockers Side effects

Answer 31

dizziness from bradycardia or hypotension, fatigue,
depression, worsening of symptoms in patients with
asthma or chronic obstructive pulmonary disease, gastrointestinal distress, blunting of hypoglycemic symptoms in patients with diabetes, and vivid dreams.

Question 32

Anticonvulsants

Answer 32

valproic acid (Depakote and
Depakote ER) are sometimes worth a try to prophylax 
against frequent TTH. The usual starting dose for 
Depakote ER is 500 mg/day; the dose should be adjusted 
as necessary at 2- to 6-week intervals

Question 33

Valproic acid can cause

Answer 33

weight gain, hair

loss, tremor, and abdominal distress.

Question 34

botulinum toxin A

Answer 34

injection into the most tender pericranial muscle(s) or directly
into a trigger point

Question 35

“sinus headaches

Answer 35

Most patients complain of

periorbital pain and might also experience a sensation of nasal stuffiness.

Question 36

True sinus pain occurs when

Answer 36

the ability of the sinus to drain is impaired by an acute blockage of the osteum (e.g., following an upper respiratory infection or for some anatomic reason), a bacterial infection takes hold, the mucosa becomes inflamed, and pressure builds in the sinus

Question 37

true sinus or nasal inflammation can be a trigger for

Answer 37

migraine

Question 38

Habitual snoring is increasingly being recognized as

a cause of

Answer 38

chronic daily headache

Question 39

Sleep-disordered
breathing such as that caused by sleep apnea may precipitate
headaches from

Answer 39

the resultant hypoxemia and

hypercapnia (which causes cerebral vasodilation)

Question 40

Hypnic headaches

Answer 40

represent another
syndrome of recurring head pain that awakens patients
from REM sleep. This headache
responds best to treatment with either indomethacin
or lithium.

Question 41

Post-traumatic headache

Answer 41

occurs frequently following
mild to moderate closed head injury or a whiplash injury
(rapid flexion and extension trauma of the neck); loss of
consciousness need not have occurred

Question 42

Post-traumatic headache symptoms

Answer 42

include pain in the neck or
shoulders, dizziness, cognitive complaints, and disturbances
of sleep, mood, and/or personality. The syndrome
should begin within 2 weeks of the injury; it is considered
acute if it lasts 8 weeks or less and chronic if it lasts longer,
although this distinction is arbitrary

Question 43

Post-traumatic headache Etiology

Answer 43

reflect underlying brain injury relating to the trauma and

also injury to the head, face, jaw, and neck

Question 44

Post-traumatic headache treatment

Answer 44

treated in accord with the general principles mentioned
above but with additional consideration being given to
addition of physical therapy and to identification and
treatment of a possible contributing occipital nerve neuralgia

Question 45

occipital neuralgia (also called “cervicogenic” headache)

Answer 45

can arise from injury around the area of the C2–C3 zygapophyseal joint, which is common in whiplash;
the pain, paresthesiae, or dysesthesiae usually are
referred to the occipital scalp. On examination, the nerve
is tender to palpation or percussion along the course of
the dorsal ramus of C2, particularly around the cranial
insertion of the trapezius muscle, lateral to the occipital protuberance

Question 46

occipital neuralgia treatment

Answer 46

is a nerve
block with or without adding a drug useful in the treatment
of neuropathic pain such as gabapentin.

Question 47

Trauma can also result in a chronic cerebrospinal fluid
(CSF) leak with consequent CSF hypotension and a
chronic low-pressure headache.

Answer 47

This headache, usually
associated with an opening CSF pressure of 90 mm
of water or less, typically manifests when the patient
assumes a sitting or standing position and improves
when the patient lies down. Most post-traumatic leaks
arise around the cervico-thoracic junction.

Question 48

chronic low-pressure headache. treatment

Answer 48

Treatment is similar to that of a postlumbar puncture (post-LP)
headache.