Tension-type Headache (TTHA) Flashcards
Most common
type of
headache
* Over –% of adults experience TTHA periodically
* Also common in children and adolescents
80
Presents in
two forms
(4)
Episodic
* Chronic- (frequency > 15 days/month for 6 months)
* Most patients who suffer TTHA do not seek specific
medical treatment
* Use OTC medications to combat symptoms
2.1 Infrequent episodic TTH: ICHD
Diganostic Criteria
(A-E)
A. At least 10 episodes of headache occurring on
<1 d/mo. (<12 d/yr.) and fulfilling criteria B-D
B. Lasting from 30 min to 7 days
C. 2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3
diagnosis
Tension-Type Headache
Symptoms begin before the age 20 years in –% of patients.
No predilection for any particular cranial location-may involve the (4) areas alone, or in combination
Associated with pericranial/cervical muscle tenderness-Studies have shown that
patients with chronic TTH have a higher incidence of active TrPs in the (3), as well as the — and other posterior
cervical muscles than in controls.
Occurs in relation to — conflict
40
frontal,
temporal, parietal, or occipital
upper
trapezius, SCM, temporalis
suboccipitals
emotional
Tension-Type Headache
Most patients with TTH experience occasional very painful headaches
often accompanied by — symptoms.
Epidemiological characteristics of TTH patients not significantly
different from migraine patients-
Migraine and TTH also share common triggers (5)
Suggests that these disorders are
migrainous
(stress, mental tension,
fatigue, lack of sleep, and menstruation)
at two ends of a continuum and many
people will experience both types over a lifetime
Non-pharmacological Management
Decrease intake of caffeine and alcohol as well as any medications that have
been chronically used by the patient for the headache
May at first increase the frequency and intensity of headaches
After – weeks the withdrawal should subside
Decrease Caffeine use by –% every week so caffeine withdrawal headache should not occur
1-2
25
Non-pharmacological Management
(8)
Strategies for coping with stress and muscular pain:
Relaxation therapy with EMG biofeedback
Hypnotherapy
Massage therapy and physical therapy
Increase physical activity especially outdoors
Deep breathing exercises
1 minute headspace mini breathing meditation:
https://www.youtube.com/watch?v=cEqZthCaMpo
Calm app teaches mindfulness and meditation in 10 minute daily presentations
Psychotherapy for cognitive therapy and mindfulness exercises
ANALGESICS:
aspirin, acetaminophen
NSAIDs:
indomethacin, ibuprofen, naproxen,
ketoprofen
COMBINATION:
aspirin &/or acetaminophen with
caffeine (i.e. Excedrin Migraine)
skipped
MUSCLE RELAXANTS:
diazepam, methocarbamol
(Robaxin), cyclobenzaprine (Flexeril), carisoprodol,
baclofen
Usage is on an as needed basis but typically limited
time use
Pharmacological Management
Tension-type Headache
Judicious use of mild analgesics may be needed
No more than – days per week
Low dosages of a — can be helpful in managing
the headache
Best taken before bedtime because of their — effects
Examples:
Amitriptyline (Elavil),Nortriptyline (Pamelor), Doxepin, Desipramine
2
tricyclic antidepressant
sedative
- Trigeminal autonomic cephalalgias (TACs)
*All TACs are unilateral headaches accompanied by autonomic
features
(5)
RULE OUT SECONDARY CAUSE!
3.1 Cluster headache
3.2 Paroxysmal hemicrania
3.3 Short-lasting unilateral neuralgiform headache attacks
3.4 Hemicrania continua
3.5 Probable trigeminal autonomic cephalalgia
skipped
3.1 Cluster headache
(A-E)
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 min (when
untreated)
C. Either or both of the following:
1. 1 of the following ipsilateral symptoms or signs:
a) conjunctival injection and/or lacrimation; b) nasal congestion and/or rhinorrhea; c)
eyelid oedema; d) fore-head and facial sweating; e) forehead and facial flushing;
f) sensation of fullness in the ear; g) miosis and/or ptosis
2. a sense of restlessness or agitation
D. Frequency from 1-2x/ d to 8x/d for > half the time when
active
E. Not better accounted for by another ICHD-3 diagnosis
skipped
3.1 Cluster headache
3.1.1 Episodic cluster headache
A. Attacks fulfilling criteria for 3.1 Cluster headache and occurring in bouts (cluster
periods)
B. 2 cluster periods lasting 7 d to 1 y (when untreated) and separated by pain-
free remission periods of 1 month.
3.1.2 Chronic cluster headache
A. Attacks fulfilling criteria for 3.1 Cluster headache and criterion B below
B. Occurring without a remission period, or with remissions lasting <1 mo, for 1
year
Cluster Headache
Brief attacks are:
(3)
Primarily affects men — males: females ratio
Age of onset between —
Provoked by alcohol
Frequently occurs during sleep or napping times.
During an attack, patients will characteristically pace, cry,
scream, or pound their fists.
(4:1)
20-40
Cluster Headache
–% of the patients have chronic symptoms.
HAs occur for years before termination
or remission.
Chronic form may evolve from the
episodic form or may have a chronic
pattern from its onset.
Etiology and pathogenesis are unknown-
possible dysfunction of hypothalamus
Pain is usually centered behind or around
the orbit or in the temporal area, BUT
…
10
radiation to the teeth and jaws is common-
some patients may seek dental treatment
for the pain
Cluster Headache
Abortive Treatment
(5)
100% Oxygen at 7-10 l./min. for 15 min. using face mask is
effective within 10-15 minutes in 60-70% of cases
Sumatriptan (6 mg S.C. or nasal spray)
DHE-45 (1.0 mg I.M. or I.V. or Migranol (intranasal)
Intranasal administration of 1 ml of 4% topical Lidocaine
Indomethacin (oral or rectal suppositories)- cluster
headache MAY respond
skipped
Cluster Headache Treatment
(Prophylactic Treatment)
Episodic Cluster:
(6)
Chronic Cluster:
(4)
Calcium channel blockers
i.e. Verapamil
Ergotamine
Lithium carbonate
Methysergide
Valproate
Prednisone
Verapamil
Lithium carbonate
Methysergide
Gabapentin
Hemicrania
Continua
Common in —
— pain is most
common
Throbbing, aching, sharp, stabbing
Age: 10-77 y.o. (mean range= —
years)
A daily, continuous, strictly —
primary headache
The intensity of the pain may fluctuate
but the headache never remits
Treatment: By definition, hemicrania
continua remits with —
medication
women
Temporal or frontal
35-49
unilateral
indomethacin
3.4 Hemicrania continua
(A-E)
A. Unilateral headache fulfilling criteria B-D
B. Present >3 mo, with exacerbations of moderate or
greater intensity
C. Either or both of the following:
1. 1 of the following ipsilateral autonomic symptoms:
a) conjunctival injection and/or lacrimation; b) nasal congestion and/or rhinorrhea;
c) eyelid oedema; d) fore-head and facial sweating; e) forehead and facial flushing;
f) sensation of fullness in the ear; g) miosis and/or ptosis
2. a sense of restlessness or agitation, or aggravation of pain by movement
D. Responds absolutely to indomethacin
E. Not better accounted for by another ICHD-3 diagnosis
CPH Clinical
Characteristics
Many consider CPH a variant of
— headache
Occurs primarily in — 2:1
Age range is 37-42 (mean age = –
years)
Attacks may be precipitated by
— and occasionally by
— of the neck.
Pain is — and
localized to the … regions.
cluster
women
34
flexion, rotation
Chronic, unilateral
temple, forehead,
ear, eye, or occipital
CPH Clinical
Characteristics
…pain
Severe to very severe pain in
—%
— is common during
attacks
Throbbing, stabbing or boring
88-93
Restlessness
3.2 Paroxysmal hemicrania
(A-F)
A. At least 20 attacks fulfilling criteria B-E
B. Severe unilateral orbital, supraorbital and/or temporal
pain lasting 2-30 min
C. 1 of the following ipsilateral symptoms or signs:
1. conjunctival injection and/or lacrimation
2. nasal congestion and/or rhinorrhoea
3. eyelid oedema
4. forehead and facial sweating
5. forehead and facial flushing
6. sensation of fullness in the ear
7. miosis and/or ptosis
D. Frequency >5/d for > half the time
E. Prevented absolutely by therapeutic doses of
indomethacin
F. Not better accounted for by another ICHD-3 diagnosis
3.2.1 Episodic paroxysmal
hemicrania
(2)
- A. Attacks fulfilling criteria
for 3.2 Paroxysmal
hemicrania and occurring
in bouts - B. 2 bouts lasting 7d to 1
yr. (when untreated) and
separated by pain-free
remission periods of 1 mo
3.2.2 Chronic paroxysmal
hemicrania (66-88%)
(2)
- A. Attacks fulfilling criteria
for 3.2 Paroxysmal
hemicrania - B. Occurring without a
remission period, or with
remission periods lasting <1
mo, for 1 yr.
Paroxysmal Hemicrania Treatment
Absolute responsiveness of CPH to indomethacin is part of
the diagnostic criteria:
Long lasting remissions have been observed
25mg 3x/day up to 50mg 3x/day
3.3 Short-lasting unilateral
neuralgiform headache attacks
(A-E)
A. At least 20 attacks fulfilling criteria B-D
B. Moderate or severe unilateral head pain, with
orbital, supraorbital, temporal and/or other
trigeminal distribution, lasting 1-600 sec and
occurring as single stabs, series of stabs or in a saw-
tooth pattern
C. 1 of the following ipsilateral cranial autonomic
symptoms or signs: 1. conjunctival injection and/or
lacrimation; 2. nasal congestion and/or rhinorrhoea;
3. eyelid oedema; 4. forehead and facial sweating;
5. forehead and facial flushing; 6. sensation of
fullness in the ear; 7. miosis and/or ptosis
D. Frequency 1/d for > half the time when active
E. Not better accounted for by another ICHD-3 diagnosis
3.3.1 Short-lasting unilateral neuralgiform
headache attacks with conjunctival injection
and tearing (SUNCT)
(2)
A. Attacks fulfilling criteria for 3.3 Short-lasting
unilateral neuralgiform headache attacks
B. Both of conjunctival injection and lacrimation
(tearing)
SUNCT VS
Trigeminal
Neuralgia (TN)
TN more common in —,
SUNCT in —
Autonomic features
(Conjunctival injection/tearing)
MUST be present in —, less
common in —
Pain Location: Typically —
area in SUNCT; V1 TN is very
rare
TN has a — PERIOD
females
Males
SUNCT,TN
ocular
REFRACTORY
SUNCT
Treatment
(4)
Lamotrigine
Gabapentin
Topiramate
IV Lidocaine
Referral to Specialists for Diagnosis
& Headache Management
1. PRIMARY REFERRALS:
(5)
6. You SHOULD REFER your patient with facial pain and headache within 2
weeks of your initial treatment if the pain is not being managed and to get a
proper diagnosis and treatment
- Family doctor or Neurologist (American Headache Society website)
- Orofacial Pain Specialist or Pain Management Medical Team
- Secondary referral for pain management once diagnosis is made:
- Psychotherapist
- Acupuncturist
