Episodic tension headache usually is associated with a stressful event. This headache type is of moderate intensity, self-limited, and usually responsive to nonprescription drugs. Chronic tension headache often recurs daily and is associated with contracted muscles of the neck and scalp. This type of headache is bilateral and usually occipitofrontal.
Tension-type headache is the most common type of chronic recurring head pain. In the past, pain etiology was presumed to be the muscular contraction of pain-sensitive structures of the cranium, but the International Headache Society intentionally abandoned the terms muscular contraction headache and tension headache because no research supports muscular contraction as the sole pain etiology. Both muscular and psychogenic factors are believed to be associated with tension-type headache. A study by Kiran and company indicated that patients with chronic tension headaches for longer than 5 years tend to have lower cortisol levels. This was postulated to be due to hippocampus atrophy resulting from chronic stress, a cause of chronic tension headaches. Headaches account for 1-4% of all emergency department visits and are the ninth most common reason for a patient to consult a physician. Physicians classify 90% of headaches reported to them as muscle contraction or migraine headaches.
According to one report, the cumulative 30-year prevalence of headache subtypes in Zurich, Switzerland is reported to be 3.0% for migraine with aura, 36% for migraine without aura, and 29.3% for tension-type headache. No literature suggests that headache frequency is different in other regions of the world. A female preponderance of migraine exists, 14-17%, compared with 5-6% in males. All ages are susceptible, but most patients are young adults. Approximately 60% of headache onset occurs in those older than 20 years. Headache onset is unusual in those older than 50 years. In elderly patients, the practicing physician should never assume that headache onset is due to benign causes, such as tension-type headaches, until pathologic etiologies are explored. Pain onset in tension-type headache can have a throbbing quality and is usually more gradual than onset in migraines. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.
International Headache Society diagnostic criteria for tension-type headaches state that 2 of the following characteristics must be present: pressing or tightening (nonpulsatile quality), frontal-occipital location, bilateral – mild-to-moderate intensity, and not aggravated by physical activity.
Tension-type headache has history of headache for duration of 30 minutes to 7 days. There is no nausea or vomiting, anorexia may occur, photophobia and or phonophobia, minimum of 10 previous headache episodes; fewer than 180 days per year with headache to be considered infrequent, bilateral, and occipitonuchal or bifrontal pain. Pain is described as fullness, tightness, squeezing, pressure, or band-like or vise-like pain may occur acutely under emotional distress or intense worry. Insomnia is often present upon rising or shortly thereafter. There is muscular tightness or stiffness in neck, occipital, and frontal regions. Sufferer gives history duration of more than 5 years in 75% of patients with chronic headaches. There is difficulty concentrating. There is no prodrome. New headache onset in elderly patients should suggest etiologies other than tension headache. The physical examination serves mainly to exclude the possibility of other headache causes.
On examination, patient’s vital signs are normal. Neurologic examination is normal. Tenderness may be elicited in the scalp or neck, but no other positive physical exam findings should be noted. Pain should not be elicited over temporal arteries or positive trigger zones. Some patients with occipital tension headaches may be very tender when upper cervical muscles are palpated. Pain associated with neck flexion and stretching of paracervical muscles must be distinguished from nuchal rigidity associated with meningeal irritation.
Stress may cause contraction of neck and scalp muscles, although no evidence confirms that the origin of pain is sustained muscle contraction. Stress and or anxiety, poor posture, depression may give tension headaches.
Differential diagnoses include brain abscess, depression and suicide, encephalitis, glaucoma, acute angle-closure headache, cluster headache, migraine, meningitis, otitis media, sinusitis, stroke, hemorrhagic stroke, ischemic subarachnoid hemorrhage, subdural hematoma, temporal arteritis, temporomandibular joint syndrome, and trigeminal neuralgia.
Laboratory work should be unremarkable in cases of tension-type headache. Specific tests should be obtained if the history or physical examination suggests another diagnostic possibility.
Head CT scan or MRI is necessary only when the headache pattern has changed recently, the headache cannot be clearly defined by the clinician as a common primary headache disorder that is not a cluster, migraine, or tension-type of headache, or neurologic examination reveals abnormal findings. Such history or physical examination evidence would suggest an alternate cause of headache. Caution should be used in patients with aura in headache that is sensory or motor, or if the aura has changed in character and is not described as typical of their migraine aura. These patients may warrant neuroimaging.
Most patients with severe headache should not receive opiate analgesics until the responsible physician can complete an appropriate history and neurologic examination. High-flow oxygen may be used as an adjunct in the prehospital and hospital setting. While it has been shown to decrease pain scores, most patients will still require other analgesic medications.
In the Emergency Department Care, ascertain that the patient is not overusing medication, shows no evidence of drug dependency, and is not depressed. If headache cause includes dental pathology, sinus disease, trigger points, or CNS pathology, initiate care to treat the specific cause.
While the emergency physician must be able to identify patients with serious headache etiology, more than 90% of patients in the Emergency Department have migraine, tension, or mixed-type benign headache. Therefore, providing symptomatic relief should be a priority. Various modalities are used in the treatment of tension headaches. These include hot or cold packs, ultrasound, and electrical stimulation, improvement of posture, trigger point injections, occipital nerve blocks, stretching, and relaxation techniques. Regular exercise, stretching, balanced meals, and adequate sleep may be part of a headache treatment program. Relaxation techniques such as meditation are effective for chronic headaches as measured by headache parameters. Patients with chronic headaches have been shown to have low levels of cortisol that normalized with the practice of meditation over time.
Nonsteroidal anti-inflammatory drugs may alleviate headache pain by inhibiting prostaglandin synthesis, reducing serotonin release, and blocking platelet aggregation. Although the effects of nonsteroidal anti-inflammatory drugs in the treatment of headache pain tend to be patient specific, ibuprofen is usually the Drug of Choice for initial therapy. Other options include naproxen, ketoprofen, and ketorolac, ibuprofen (Ibuprin, Advil, Motrin). Usually, Drug of Choice for treatment of mild to moderately severe headache, if no contraindications is Naproxen (Naprosyn, Naprelan) for relief of mild to moderately severe pain. Nonsteroidal anti-inflammatory drugs inhibit inflammatory reactions and pain by decreasing enzyme cyclooxygenase activity, thus inhibiting prostaglandin synthesis, Drug of Choice is ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderately severe pain and inflammation, small dosage initially is indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response. Ketorolac (Toradol) inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors. Par oral form offers no advantage over other less expensive par oral nonsteroidal anti-inflammatory drugs. Indomethacin (Indocin, Indochron E-R) are absorbed rapidly; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. This is useful in diagnosis as it helps other headache syndromes, for example, chronic paroxysmal hemicrania.
Acetylsalicylic acids alleviate headache, possibly by inhibiting prostaglandin synthesis. Aspirin (Anacin, Ascriptin, Bayer Aspirin, Bufferin) treats mild to moderately severe pain, it inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.
Barbiturates are used in combination with aspirin and acetaminophen for pain relief and to induce sleep. Caffeine is used to increase its gastrointestinal absorption. However, butalbital is associated with rebound headaches. Increasing use of these combination preparations may fail to provide pain relief and worsen headache symptoms. Butalbital, aspirin, caffeine (Fiorinal) combination is used to relieve tension headaches. Barbiturate component has generalized depressant effect on Central Nervous System. Acetaminophen, butalbital, and caffeine (Fioricet) drug combination is used to relieve tension headaches. Barbiturate component has generalized depressant effect on Central Nervous System.
Analgesics are used in patients with infrequent headaches and are treated with simple analgesics initially like acetaminophen (Tylenol, Panadol, aspirin-Free Anacin) and is Drug of Choice for pain in patients with documented hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs or upper gastrointestinal disease or taking oral anticoagulants. Acetaminophen with codeine (Tylenol #3) is indicated for treatment of mild to moderately severe headache. Acetaminophen and oxycodone (Percocet) is indicated for relief of moderately severe to severe pain; Drug of Choice for aspirin-hypersensitive patients.
Analgesic-antiemetic or sedatives combinations are useful in aborting headache and treating emesis that results from acute pain. Drugs like promethazine (Phenergan), antidopaminergic agent are effective in treating emesis. They block postsynaptic mesolimbic dopaminergic receptors in brain and reduce stimuli to brainstem reticular system. Prochlorperazine (Compazine) may relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine-receptors, through anticholinergic effects, and depressing reticular activating system. In addition to antiemetic effects, has advantage of augmenting hypoxic ventilatory response, acting as respiratory stimulant at high altitude. Metoclopramide (Reglan) can be used as an alternative to prochlorperazine. Studies show prochlorperazine is better. The dopamine antagonist that stimulates acetylcholine release in the myenteric plexus acts centrally on chemoreceptor triggers in the floor of the fourth ventricle, which provides important antiemetic activity.
Ergot alkaloids and derivatives are direct vasoconstrictors of smooth muscle in cranial blood vessels. Their activity depends on the Central Nervous System vascular tone at the time of administration. Drug of Choice is ergotamine tartrate (Cafergot, Cafatine, Cafetrate)
Alpha-adrenergic and serotonin antagonist causes constriction of peripheral and cranial blood vessels. Drug of Choice is dihydroergotamine (D.H.E. 45, Migranal Nasal Spray).
Alpha-adrenergic blocking agent with direct stimulating effect on smooth muscle of peripheral and cranial blood vessels; depresses central vasomotor centers. Mechanism of action is similar to ergotamine; nonselective 5HT1 agonist with wide spectrum of receptor affinities outside 5HT1 system; also binds to dopamine. Thus, has alpha-adrenergic antagonist and serotonin antagonist effect. It is indicated to abort or prevent vascular headache when rapid control is needed or when other routes of administration are not feasible. Available as intravenous or intranasal preparations tends to cause less arterial vasoconstriction than ergotamine tartrate.
Further outpatient care consists of physical therapy for patients with headache include warm and cold packs, ultrasound, and electrical stimulation. Regular exercise, stretching, balanced meals, and adequate sleep is part of a headache prevention program. Trigger point injections, occipital nerve blocks, or changes that improve posture may be used.
Prevention of headache may include physical therapy, biofeedback and relaxation therapy, and cervical traction and injection of trigger points.
Prognosis; headache may become chronic if life stressors are not changed. Most cases are intermittent and do not interfere with work or normal life span.
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