Tension headache Flashcards
Define tension headache.
Episodic or chronic form of headache which is rarely disabling or associated with autonomic phenomena, so usually successfully self treated.
Generalised throughout the head with predilection for involving the frontal and occipital regions. Described as “tight band” around the head. Does not worse with physical activity.
How common are tension headaches? What age groups are most affected?
MOST COMMON type of headache
Global prevalence 42%
The onset of tension-type headaches is generally between 20 to 30 years of age, with prevalence peaking between the ages of 20 to 39 years and then declining.
What is the pathophysiology of tension headaches?
Release and activation of inflammatory agents → sensitisation of peripheral trigeminal afferents and central hypersensitivity. In tension headaches the major nociceptor is probably pericranial musculature*
*whereas in migraine it is the blood vessels and meninges.
S: Where is the pain in a tension headache?
O: Describe the onset.
S: Generalised but usually around frontal and occipital regions.
O: episodic/chronic,
C: What is the pain like in tension headache?
R: Does it spread anywhere?
C: feels like a “tight band” around the head (constricting pain). Often bilateral pressure-like and non-throbbing pain/dull pain.
R: generalised throughout the head with a predilection for involving the frontal and occipital regions.
A: What are the symptoms associated with tension headache?
A: No nausea, no vomiting and no aggrevation by physical activity. If N/V then diagnosis of tension headache is excluded. Photophobia OR phonophobia may be present but not both.
May present with muscle tenderness:
- pericranial tenderness
- sternocleidomastoid muscle tenderness
- trapezius muscle tenderness
- temporalis muscle tenderness
T: How long do tension headaches last? How often do they occur? Any particular time of day?
Classically worsen as the day progresses
What are the risk factors for tension headache?
- stress - most common
- fatigue
- missed meals,
- depression,
- previous tension headaches.
- analgesic overuse.
How is a diagnosis of tension headache established?
Clinical diagnosis of typical headache without associated features (nausea, vomiting) AND normal neurological examination
Other: only in refractory or progressive cases
- CT sinus - exclude sinusitis
- MRI brain - exclude tumour
- LP - consider in refractive cases e.g. sinus venous thrombosis, pseudotumor cerebri
What is defined as chronic tension headaches? What extra treatment can be given for these?
Chronic = >7-9 headache days/month
- Antidepressants - e.g. amitriptyline 10mg OD at night (doses not in range to treat depression)
- Muscle relaxants - tizanidine 4mg TDS (weak evidence for this)
What is the management of tension headaches?
- Acute treatment - 1st line are paracetamol, NSAID or aspirin. Beware of medication-overuse syndrome.
-
Prophylaxis -
- Acupuncture 5-8 weeks;
- Low-dose amitriptyline in chronic tension headaches (x7-9/month). But not supported by NICE.
- Limited evidence: Tizanidine - muscle relaxant used for 3-6 months
Other:
- Prophylaxis - acupuncture 5-8 weeks
- Relaxation therapy
- EMG biofeedback
- CBT
- Myofascial trigger point focused massage / hypnosis
- Physiotherapy - weak evidence
What are the complications and prognosis with tension headaches?
Complications - peptic ulcer from NSAID use
Prognosis - self treatment with simple analgesics is usually enough
What is a mixed headache?
Headache with symptoms of migraine and tension headache
A 27-year-old female presents with “chronic headache” on and off for 2 weeks. She complains of bilateral headache and sensitivity to light. Her previous GP told her that she had migraine. The patient is otherwise well, with no systemic symptoms and no other significant history. Her examination is normal.
You suspect that she may be suffering from tension type headaches instead. Which of the following statements below are true about tension type headaches? Please choose two options,
- Tension type headaches usually occur in isolation from other types of headaches
- In rare cases, neurological findings can be elicited on examination
- There is usually no associated nausea or autonomic symptoms
- Peri-cranial tenderness may be present on palpation
- There is usually no associated nausea or autonomic symptoms
- Peri-cranial tenderness may be present on palpation
Feedback
Tension-type headaches may co-exist with other headache disorders such as migraines, therefore successful management involves identifying and treating all headache disorders. This is where a good history is essential.
Tension type headaches are usually usually bilateral and are described as pressing or tightening (non-pulsating) in nature. They are usually of mild to moderate intensity lasting minutes to days.
The pain is not made worse by the patient’s day activities.
There is no associated nausea or autonomic symptoms, however photophobia or phonophobia may be present in some cases.
Neurological examination should be normal, however in some cases pericranial tenderness on manual palpation can be elicited.
You confirm the diagnosis of tension type headache. Which 4 treatments from this list would you recommend?
- Aspirin
- Paracetamol
- Tricyclic antidepressant for chronic tension headache
- Regular use of co-dydramol for 1 week
- Triptan
- Beta blocker for prophylaxis
- Physical therapy to the neck if there is any stiffness
You treat the patient successfully. She returns many months later saying that the character of her headache has changed and is now not controlled by her usual medication or other measures. What are the warning features strongly suggestive of a secondary headache? Choose five correct answers.
- New onset of headache in a patient over 50 years old
- Thunderclap headache: rapid time of headache pain builds up (seconds to 5 minutes)
- Headache changes with posture
- Headache waking the patient up
- Headache precipitated by physical exertion
- Morning headaches
