Tension-type Headache Flashcards
Tension headache - define
Bilateral, “tightening” headache (most common headache type)
Pathology of tension headache
Increased tenderness of pericardial myofascial structures -> activation of vasculature- surrounding nociceptors -> episodic TH -> prolonged nociceptor stimulation -> pain pathway sensitisation with hyperalgesia -> chronic TH
Types of tension headache? (2)
Episodic
- Rare (15 headaches monthly
Causes of tension headache
Increased muscle tenderness
Combination of genetic, environmental factors - Episodic TH
Multi factorial inheritance - chronic TH
Risk factors for tension headache
White individual who are biologically female of Ashkenazi Jewish decent
Age >40
Stress, anxiety, depression, poor posture
Signs and symptoms of tension headache
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
Treatment for tension headache - medication (immediate symptoms)
Immediate symptoms - analgesics (NSAIDS/paracetamol), caffeine, butalbital (if contraindication for other)
Treatment for tension headache - medication (prophylactic management)
Antidepressants - TCA (e.g. amitriptyline), Or mirtazapine/venlafaxine
Anticonvulsants - gabapentin/topiramate
Treatment for tension headache - psychotherapy
Behavioural, cognitive-behavioural, biofeedback therapy
Other interventions for tension headache
Acupuncture, heat/ice, resting for immediate sypmtoms
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.
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.
Infrequent episodic tension-type headache
Frequency: …
Time: …
Frequency: At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year)
Time: 30 minutes to 7 days
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 …
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
Infrequent episodic tension-type headache
Vs
Frequent episodic tension-type headache
What is the difference?
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)
Chronic tension-type headache - describe them
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.
Chronic tension-type headache - frequency and time?
Frequency: Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year)
Time: Hours to days, may be unremitting
Differential diagnosis for tension headache
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
Red flag characteristics of headache:
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
Episodic tension type headache - management
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.
Chronic tension type headache - management
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.
Medication-overuse headache - what is this?
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’.
Medication-overuse headache - definition
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’.
