tension and TACs Flashcards
MC type of HA
tension
Over 80% of adults experience TTHA periodically
* Also common in children and adolescents
forms of tension HA
what differentiates them?
- Episodic
- Chronic- (frequency > 15 days/month for 6 months)
most pts who have tension HA and medical care
- Most patients who suffer TTHA do not seek specific medical treatment
- Use OTC medications to combat symptoms
Infrequent episodic Tension Type HA: ICHD Diganostic Criteria
A. how many?
B. duration
C. greater/=2 of the following 4 characteristics:
D. Both of the following:
E. Not better accounted for by?
A. At least 10 episodes of headache occurring on <1 d/mo.and fulfilling criteria B-D
B. Lasting from 30 min to 7 days
C. greater/=2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3 diagnosis
tension bi/uni
bilateral
Tension-Type Headache
Symptoms begin before the age of?
cranial location?
Associated with?
Occurs in relation to?
Symptoms begin before the age 20 years in 40% of patients.
No predilection for any particular cranial location-may involve the frontal, temporal, parietal, or occipital areas alone, or in combination
Associated with pericranial/cervical muscle tenderness-Studies have shown that patients with chronic TTH have a higher incidence of active TrPs in the upper trapezius, SCM, temporalis, as well as the suboccipitals and other posterior cervical muscles than in controls.
Occurs in relation to emotional conflict
tension and migraine HAs as a continuum
Most patients with TTH experience occasional very painful headaches often accompanied by migrainous symptoms.
Epidemiological characteristics of TTH patients not significantly different from migraine patients-
Migraine and TTH also share common triggers (stress, mental tension, fatigue, lack of sleep, and menstruation)
Suggests that these disorders are at two ends of a continuum and many people will experience both types over a lifetime
Non-pharmacological Management of tension HAs: caf/alc
initial result? protocol?
Decrease intake of caffeine and alcohol as well as any medications that have been chronically used by the patient for the headache
May at first increase the frequency and intensity of headaches
After 1-2 weeks the withdrawal should subside
Decrease Caffeine use by 25% every week so caffeine withdrawal headache should not occur
Non-pharmacological Management of tension HAs: stress
Strategies for coping with stress and muscular pain:
Relaxation therapy with EMG biofeedback
Hypnotherapy
Massage therapy and physical therapy
Increase physical activity especially outdoors
Deep breathing exercises
1 minute headspace mini breathing meditation: youtube
Calm app teaches mindfulness and meditation in 10 minute daily presentations
Psychotherapy for cognitive therapy and mindfulness exercises
Pharmacological Management Tension-type Headache:
* Rx class options
* usage frquency?
ANALGESICS: aspirin, acetaminophen
NSAIDs: indomethacin, ibuprofen, naproxen, ketoprofen
COMBINATION: aspirin &/or acetaminophen with caffeine (i.e. Excedrin Migraine)
MUSCLE RELAXANTS: diazepam, methocarbamol (Robaxin), cyclobenzaprine (Flexeril), carisoprodol, baclofen
Usage is on an as needed basis but typically limited time use
mild analgesics and tension HA
Judicious use of mild analgesics may be needed
No more than 2 days per week
adjunctive rx for tension HAs
best taken when?
Low dosages of a tricyclic antidepressant can be helpful in managing the headache
Best taken before bedtime because of their sedative effects
Examples:
Amitriptyline (Elavil),Nortriptyline (Pamelor), Doxepin, Desipramine
Trigeminal autonomic cephalalgias (TACs)
*All TACs are unilateral headaches accompanied by autonomic features
3.1 Cluster headache
3.2 Paroxysmal hemicrania
3.3 Short-lasting unilateral neuralgiform headache attacks
3.4 Hemicrania continua
3.5 Probable trigeminal autonomic cephalalgia
autonomic features of TACs
a) conjunctival injection and/or lacrimation;
b) nasal congestion and/or rhinorrhea;
c) eyelid oedema;
d) fore-head and facial sweating;
e) forehead and facial flushing;
f) sensation of fullness in the ear;
g) miosis and/or ptosis
Cluster headache
A. At least ? attacks fulfilling criteria B-D
B. pain quality/location? duration?
C. Either or both of the following:
1. greater/= 1 of the following ipsilateral symptoms or signs:
2. a sense of ?
D. Frequency?
E. Not better accounted for?
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 min (when untreated)
C. Either or both of the following:
1. 1 of the following ipsilateral symptoms or signs:
a) conjunctival injection and/or lacrimation; b) nasal congestion and/or rhinorrhea; c) eyelid oedema; d) fore-head and facial sweating; e) forehead and facial flushing; f) sensation of fullness in the ear; g) miosis and/or ptosis
2. a sense of restlessness or agitation
D. Frequency from 1-2x/ d to 8x/d for > half the time when active
E. Not better accounted for by another ICHD-3 diagnosis
episodic cluster
A. Attacks fulfilling criteria for 3.1 Cluster headache and occurring in bouts (cluster periods)
B. >/= 2 cluster periods lasting 7 d to 1 y (when untreated) and separated by pain- free remission periods of greater/= 1 month
chronic cluster
A. Attacks fulfilling criteria for 3.1 Cluster headache and criterion B below
B. Occurring without a remission period, or with remissions lasting <1 mo, for greater than/= 1 year
Cluster Headache
Brief attacks are:
provoked by?
frequently occur when?
Provoked by alcohol
Frequently occurs during sleep or napping times
During cluster how do pts act
During an attack, patients will characteristically pace, cry, scream, or pound their fists.
cluster demo
Primarily affects men (4:1) males: females ratio
Age of onset between 20-40
Cluster Headache
% of the patients have chronic symptoms.
HAs occur for how long?
Chronic form may evolve from?
10% of the patients have chronic symptoms.
HAs occur for years before termination or remission.
Chronic form may evolve from the episodic form or may have a chronic pattern from its onset
cluster etiology
Etiology and pathogenesis are unknown-
possible dysfunction of hypothalamus
cluster pain location? radiation?
Pain is usually centered behind or around the orbit or in the temporal area, BUT radiation to the teeth and jaws is common- some patients may seek dental treatment for the pain
Cluster Headache Abortive Treatment options
- 100% Oxygen at 7-10 l./min. for 15 min. using face mask is effective within 10-15 minutes in 60-70% of cases
- Sumatriptan (6 mg S.C. or nasal spray)
- DHE-45 (1.0 mg I.M. or I.V. or Migranol (intranasal)
- Intranasal administration of 1 ml of 4% topical Lidocaine
- Indomethacin (oral or rectal suppositories)- cluster headache MAY respond
