Tension-type Headache

Question 1

Tension headache - define

Answer 1

Bilateral, “tightening” headache (most common headache type)

Question 2

Pathology of tension headache

Answer 2

Increased tenderness of pericardial myofascial structures -> activation of vasculature- surrounding nociceptors -> episodic TH -> prolonged nociceptor stimulation -> pain pathway sensitisation with hyperalgesia -> chronic TH

Question 3

Types of tension headache? (2)

Answer 3

Episodic

- Rare (15 headaches monthly

Question 4

Causes of tension headache

Answer 4

Increased muscle tenderness
Combination of genetic, environmental factors - Episodic TH
Multi factorial inheritance - chronic TH

Question 5

Risk factors for tension headache

Answer 5

White individual who are biologically female of Ashkenazi Jewish decent
Age >40
Stress, anxiety, depression, poor posture

Question 6

Signs and symptoms of tension headache

Answer 6

Moderate, bilateral, non-pulsating head pain
- band-like distribution, without worsening during physical activity, few minutes to one week
Photophobia/phonophobia
Stiffness/tenderness of head, neck, shoulder muscles

Question 7

Treatment for tension headache - medication (immediate symptoms)

Answer 7

Immediate symptoms - analgesics (NSAIDS/paracetamol), caffeine, butalbital (if contraindication for other)

Question 8

Treatment for tension headache - medication (prophylactic management)

Answer 8

Antidepressants - TCA (e.g. amitriptyline), Or mirtazapine/venlafaxine
Anticonvulsants - gabapentin/topiramate

Question 9

Treatment for tension headache - psychotherapy

Answer 9

Behavioural, cognitive-behavioural, biofeedback therapy

Question 10

Other interventions for tension headache

Answer 10

Acupuncture, heat/ice, resting for immediate sypmtoms

Question 11

Tension-type headaches can occur sporadically or represent a debilitating chronic illness. Onset tends to be in a patients’ …’s, and gradually becomes … common with advancing age.

Answer 11

Tension-type headaches can occur sporadically or represent a debilitating chronic illness. Onset tends to be in a patients’ 20’s, and gradually becomes less common with advancing age.

Question 12

Infrequent episodic tension-type headache

Frequency: …

Time: …

Answer 12

Frequency: At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year)

Time: 30 minutes to 7 days

Question 13

Episodic tension-type headache: Characteristics:

Require at least … of the following:

Bilateral location
Pressing or tightening (non-pulsating) quality
Mild or moderate intensity
Not aggravated by routine physical activity such as walking or climbing stairs

Both of:

No …
No more than one of … or …

Answer 13

Require at least two of the following;

Bilateral location
Pressing or tightening (non-pulsating) quality
Mild or moderate intensity
Not aggravated by routine physical activity such as walking or climbing stairs

Both of:

No nausea or vomiting
No more than one of photophobia or phonophobia

Question 14

Infrequent episodic tension-type headache
Vs
Frequent episodic tension-type headache

What is the difference?

Answer 14

Infrequent = Frequency: At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year)

Frequent = Frequency: At least 10 episodes of headache occurring on 1-14 days/month on average for >3 months (≥12 and <180 days/year)

Question 15

Chronic tension-type headache - describe them

Answer 15

The headaches are normally described as bilateral with a pressing/tight sensation of mild-moderate intensity. They last hours to days and may be unremitting. It may be associated with mild nausea, photophobia or phonophobia.

Question 16

Chronic tension-type headache - frequency and time?

Answer 16

Frequency: Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year)

Time: Hours to days, may be unremitting

Question 17

Differential diagnosis for tension headache

Answer 17

Primary headaches:
Migraines
Trigeminal autonomic cephalalgias
Other primary headache disorders

Secondary headaches:
Trauma
Idiopathic intracranial hypertension
Subarachnoid haemorrhage 
Space occupying lesion
Giant cell arteritis
Infection
Drugs and medications
Venous sinus thrombosis
Malignant hypertension
Temporomandibular disorder

Question 18

Red flag characteristics of headache:

Answer 18

Severe sudden onset: consider causes like SAH, venous sinus thrombosis, vertebral artery dissection
Progressive or persistent, acute change: consider space occupying lesions, subdural haematoma
Worse on standing: consider CSF leak
Worse on lying: consider causes of raised ICP; space occupying lesions, venous sinus thrombosis

Question 19

Episodic tension type headache - management

Answer 19

Analgesia: Simple painkillers such as paracetamol of NSAIDs (if no contra-indications), to be taken when headache occurs.
Lifestyle: Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses. Some patients find regular excercise helps.

Question 20

Chronic tension type headache - management

Answer 20

Acupuncture: Offer a course of acupuncture. There is weak evidence that a 8 week course reduces the number of days the patient is affected.
Prophylaxis: Consider low dose amitriptyline. This should be done with care and represents an off label use. Stop if there is no improvement. If the patient show improvement, aim to wean off after 4-6 months. There is significant debate as to whether this offers benefit, with many contradictory guidelines published.
Lifestyle: Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses. Some patients find regular excercise helps.
Referral: If there is no improvement or diagnostic uncertainty refer to neurology.

Question 21

Medication-overuse headache - what is this?

Answer 21

Medication ‘overuse’ itself has been shown to result in chronic headaches.

As the name suggests this occurs when regular analgesia taken for symptomatic relief of headache causes or perpetuates the condition.

The International Headache Society defines it as ‘Headache occurring on 15 or more days/month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped’.

Question 22

Medication-overuse headache - definition

Answer 22

The International Headache Society defines it as
‘Headache occurring on 15 or more days/month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped’.