Tension headache (N)

Question 1

What is a tension headache?

Answer 1

Primary headache disorder (exact cause unclear) + most common type of headache overall, can be episodic or chronic

Question 2

What are some triggers/risk factors for tension headache?

Answer 2

• stress / anxiety
• mental tension
• squinting
• poor posture
• fatigue
• dehydration
• missing meals
• bright sunlight
• noise

Question 3

What demographics are tension headaches most common in?

Answer 3

• F > M
• 20-39 years

Question 4

What are the clinical features of tension headache?

Answer 4

• episodic (30min to days)
• band-like headache, often bilateral
• may radiate to neck and shoulders
• dull, pressing, non-pulsating (lower intensity than migraines)
• pericranial tenderness common but not invariable
• relieved with painkillers
• headache does not increase with routine physical activity
• no nausea, vomiting, photophobia, phonophobia or auras (vs migraines)

Question 5

What are the symptoms of tension headache? (5)

Answer 5

• dull
• non-pulsatile
• bilateral
• constricting pain (mild to moderate severity)
• pericranial tenderness

Question 6

Describe the history of a patient with tension headache.

Answer 6

• mild to moderate in severity
• pressure/tightness around head - like a tight band
• bilateral pain
• non-pulsatile
• +/- SCM, trap, temporalis, lateral pterygoid, masseter or pericranial muscle tenderness
• neck stiffness
• disabling for a few hours - no specific associated symptoms
• gradual onset
• variable duration
• usually responsive to OTC meds
• check for triggers

Question 7

What is seen on examination of a patient with tension headache?

Answer 7

Examination usually normal

Question 8

What investigations are done for tension headache (1st line + considerations)?

Answer 8

• 1st line: clinical diagnosis by history and features
• consider CT sinus - to exclude sphenoid sinusitis
• consider MRI brain
• consider lumbar puncture
• consider polysomnography

Question 9

What are some differential diagnoses for tension headache?

Answer 9

• chronic migraine - N&V, photo/phonophobia, aggravated by movement, severe
• medicine overuse headache - previously primary headache, analgesic overuse
• sphenoid sinusitis - vertex/frontal pain, ‘pressure’, CT sinus
• giant cell arteritis - >50, scalp soreness, polymyalgia rheumatica, jaw/tongue claudication, elevated ESR/CRP
• temporomandibular disorder
• pituitary tumour
• brain tumour
• chronic subdural haematoma
• pseudotumour cerebri
• cervical pathology (herniated disc on MRI)

Question 10

What is the treatment algorithm (1st and 2nd line) for an acute attack of tension headache?

Answer 10

• 1st line: simple analgesics (paracetamol / NSAIDs e.g. ibuprofen, naproxen, aspirin)
• 2nd line: combination analgesics (containing caffeine)

Question 11

What is the treatment algorithm (1st and 2nd line + considerations) for chronic tension headache (>7-9 headache days/month)?

Answer 11

• 1st line: antidepressants (low-dose TCAs e.g. amitriptyline)
  
  • consider non-pharmacological therapies
  • consider trigger point injections
• 2nd line: muscle relaxants (tizanidine only for 3-6mo)
  
  • consider non-pharmacological therapies
  • consider trigger point injections

Question 12

What are some conservative treatment options for tension headache?

Answer 12

• relaxation training
• CBT
• myofascial trigger point-focused massage
• ## (EMG biofeedback)
• reassurance
• address triggers - stress, reduce mental tension
• advice on avoiding medications that can cause medication overuse headache e.g. opioids
• weight reduction

Question 13

What are some complications of tension headache?

Answer 13

Peptic ulcers (occur secondary to NSAID use)