Tension-type headache

Question 1

Characteristics

Answer 1

Typically symmetrical (bilateral) tightness.

Tend to last for hours and recur each day.

Often associated with cervical dysfunction and stress or tension, although the patient usually does not realise the headaches are associated with tension until it is pointed out.

75% of pts are females

Question 2

Typical distribution of pain in tension-type headache

Answer 2

Question 3

The International Headache Society (IHS3) criteria

Answer 3

A. The patient should have had at least 10 of these headaches.

B. The headaches last from 30 minutes to 7 days.

C. The headaches must have at least 2 of the following 4:

1. non-pulsating quality
2. mild or moderate intensity
3. bilateral location
4. no aggravation with routine physical activity

D. The headaches must have both of the following:

1. no nausea or vomiting
2. photophobia and phonophobia are absent, or one but not the other is present

E. Not attributable to another disorder

Question 4

Clinical features

Answer 4

Site: frontal, over forehead and temples

Radiation: occiput, may radiate to the neck, with subjective neck stiffness

Quality:

• dull ache
• like a ‘tight pressure/pressure inside the head feeling
• heavy weight on top of head
• tight band around head
• may be tightness or vice-like feeling rather than pain

Frequency: almost daily, Episodic pattern may progress to all-day, every-day pattern. May worsen as the day goes on

Duration: hours (can last days)

Onset: after rising, gets worse during day

Aggravating factors: stress or being busy – often denied, or overwork with skipping meals. Patient remains active

Relieving factors: alcohol

Associated features: lightheadedness, fatigue, neck ache or stiffness (occiput to shoulders), perfectionist personality, anxiety/ depression

Physical examination: Neurological examination is normal, muscle tension (e.g. frowning), scalp often tender to touch, ‘invisible pillow’ sign may be positive

Question 5

General Management

Answer 5

Careful pt education:

• explain that the scalp muscles get tight like the calf muscles when climbing up stairs.

Counselling and relevant advice;

• CBT is as effective as any drug in all ages

Learn to relax your mind and body.

During an attack, relax by lying down in a hot bath and practise meditation.

Be less of a perfectionist: do not be a slave to the clock.

Don’t bottle things up, stop feeling guilty, approve of yourself, express yourself and your anger.

Advise stress reduction, relaxation therapy and yoga or meditation classes.

Advise and demonstrate massage of the affected area with a soothing analgesic rub.

Question 6

Medication

Answer 6

1. use mild analgesics such as ibuprofen or paracetamol.
2. discourage stronger analgesics.
3. Potential to progress to medication-overuse headache
4. avoid tranquillisers and antidepressants if possible
5. consider amitriptyline if symptoms warrant medication (10 mg(o) nocte increasing to 75 mg if necessary).