Chapter 39 Tension-Type Headache, Chronic Tension-Type Headache, and Other Headache Flashcards
The pain of a TTH
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.
During a severe TTH patients can experience
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.
major variants of TTH
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).
Those with disorder of the pericranial muscles are characterized by
tenderness on palpation of those muscles, increased activity on electromyography
(EMG), or both
CTTH, previously
called chronic daily headache, is diagnosed
in a patient with a headache frequency of 15 days per month or 180 headaches per year averaged over a 6-month period.
If patient require analgesics
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.
In adolescents (age 12 to 14 at the time of diagnosis), the cause and prognosis of CDH
Many of these children seem to have personal or
family history of migraine.
The mainstay of treatment for MOH
total withdrawal
from analgesics for a period of time not shorter than
2 months.
The initial several
days to 2 weeks following analgesic withdrawal might be
the most difficult and are frequently punctuated with
a severe rebound headache; antiemetics and maintaining
hydration, as well as patience, are effective
characteristic of patients with MOH is that drugs
administered with prophylactic intent tend
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
temporal arteritis
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.
temporal arteritis diagnosis and treatment
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
Idiopathic intracranial hypertension (previously
called pseudotumor cerebri) usually presents
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).
The muscle contraction
theory of TTH
relates pain to prolonged contraction, or spasm, of cervical or pericranial muscles
Most patients with a headache,
migrainous or TTH, have
pericranial muscle tenderness
or sore spots;
Cervical pain can be referred to the head from
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.
The dorsal rami of the first three cervical nerve roots supply the sensory innervation to the
neck and
to the scalp caudal to the innervation of the trigeminal
nerve, and to the meninges and arteries of the posterior
fossa.
Headache also can arise from pathology in the area
of the foramen magnum examples
Chiari I malformation, the Dandy-Walker syndrome, atlantoaxial dislocation (e.g., from rheumatoid arthritis), Paget’s disease of the bone, and basilar invagination.
Abortive Treatment Strategies
For the occasional TTH, an over-the-counter (OTC)
analgesic preparation is all that is required.
OTC analgesic preparations
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.
Stronger headaches may require an analgesic
(aspirin, acetaminophen, or ibuprofen) in combination
with either codeine or butalbital.
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
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
The major chemical
categories of NSAIDs include
- 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
Prophylactic Treatment Strategies
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;
