Transcript Tension Type Headache

2008
TENSION TYPE HEADACHE
Diagnostic criteria
 At least 10 episodes fulfilling following criteria
 Headache lasting 30 mins to 7 days
 Has 2 at least 2 of the following
 Bilateral location
 Pressing/tightening (non-pulsating) quality
 Mild or moderate intensity
 Not aggravated by physical activity such as walking or
climbing stairs
 No nausea or vomiting
 < 2 episodes of photophobia or phonophobia
 Not attributable to another disorder
Categories
 Infrequent episodic tension type headache
 Occurs < 1 day per month ( < 12 days/year)
 Frequent episodic tension type headache
 Occurs > 1 and < 15 days/month ( > 12 and <180
days/year)
 Chronic tension type headache
 Occurs > 15 days/month ( 180 or more days/year)
Causes
 Uncertain
 ? Activation of hyper excitable peripheral
afferent neurons from head and neck muscles
 Associated with and aggravated by muscle
tenderness and psychological tension but do not
cause it
 Abnormalities in central pain processing and
generalised increased pain sensitivity are found
in some individuals
 Genetic factors
People at risk
 Prevalence peaks at age 40-49 in both sexes
 Mean life time prevalence is 46%
 Chronic tension type headache affects 3% of
general population
 Female to male ratio is 4:5
 Prevalence increases with educational level
 Can occur in children
Presentation
 Mild to moderate bilateral pain
 Sensation of muscle tightness or pressure
 Lasts hours to days
 Not associated with constitutional or
neurological symptoms
 People with chronic tension headache more
likely to seek help often have a history of
episodic headache but delayed until
frequency and disability are high
Differential diagnosis
 Migraine – in chronic form characteristic
features disappear and pain is less severe
 Neck problems – muscle tenderness of
tension type headache may involve the neck
 Medication overuse headache – consider in
patients taking opioid or combination
analgesics for an average of 10 days/month
Examination and
investigation
 Examination
 Neurological examination
 Manual palpation of pericranial muscles ( frontal,
temporal, masseter, pterygoid, sternomastoid,
splenius and trapezius.
 Fundoscopy for papilloedema
 Investigations
 If neuro examination normal none needed
Investigation
 Neuroimaging should be arranged if
 Atypical pattern of headache
 History of seizures
 Neurological signs or symptoms
 Symptomatic illness – acquired immunodeficiency
syndrome, tumours or neurofibromatosis
Treatment
 Infrequent headache
 Good results from non prescription medication
 May need reassurance
 If require drugs on more than 2-3 days/week
then medical treatment is indicated to
prevent medication misuse headache
Treatment
 Acute therapy for individual attacks
 Simple analgesia
 Aspirin 500 – 1000mg
 NSAIDS
 Paracetamol more effective than placebo less
effective than NSAIDS
 Combination drugs containing simple analgesics and
caffeine are helpful
 Opioids or sedatives should not be used as impair
alertness and can cause overuse and dependence
Treatment
 Preventive treatment
 Consider when headaches are frequent or acute
attacks don’t respond to abortive treatment
 Best evidence is for Amitriptyline 75- 150mg/day. It
helps both pain and muscle tenderness. Works best
when started at low dose and increased weekly
 Mirtazipine 15-30mg/day
 Unhelpful
 SSRI’s
 Botulinium toxin
Treatment
 Preventive treatment
 Should be considered when at least 2
headaches/month as risk of chronic headache
goes up exponentially when frequency reaches
1/week as does severity of pain
 Benefit or preventive treatment is diminished
when patients are simultaneously overusing
abortive treatments. Withdrawal of medication is
advised before starting preventative therapy
Treatment
 Education, lifestyle and non-pharmacological
treatment
 Little evidence exists to support or refute most
dietary or lifestyle recommendations for tension
type headache.
Treatment
 Referral
 Diagnosis is unclear
 Does not respond to treatment
 Complicated by medication overuse
 Require neuroimaging
Prognosis
 45% of adults with frequent or chronic
tension type headache will go into
remission
 39% will carry on with frequent
headaches
 16% will carry on with chronic
headache
Poor prognosis
 Associated with
 Presence of chronic headache at
baseline
 Co-existing migraine
 Not being married
 Sleep problems
Good prognosis
 Associated with
 Older age
 Absence of chronic tension type
headache at baseline
 Important message intervene early
before headaches become chronic