HEADACHE, TENSION

HEADACHE, TENSION - Kaelen Dunican, RPh, PharmD
BASICS
DESCRIPTION
• Headache typically characterized by bilateral mild to moderate pain and pressure
• May be associated with pericranial tenderness
• 2 types
- Episodic Tension-Type Headache (ETTH) divided into
 Infrequent: 1 day per month
 Frequent: 1 but 15 days per month
- Chronic Tension-Type Headache (CTTH): 15 days per month for >3 months
• Synonym(s): Muscle contraction headache; Cephalgia; Stress headache
EPIDEMIOLOGY
Prevalence
• Most common type of primary headache
• Lifetime prevalence ranges from 30-78%
• More prevalent in female gender
• Prevalence of CTTH is 3%
• Prevalence of ETTH decreases with age, whereas the prevalence of CTTH increases with age.
RISK FACTORS
• Associated with triggers/precipitating factors
- Stress
- Change in sleep regimen
- Skipping meals
- Certain foods (caffeine, alcohol, chocolate)
- Physical exertion
- Environmental factors (sun glare, odors, smoke, noise, lighting)
- Poor or sustained posture
- Female hormonal changes
- Medications (e.g., nitrates, SSRIs, antihypertensives)
- Overuse of headache medication
Genetics
Genetic predisposition has been suggested by studies.
PATHOPHYSIOLOGY
• Debatable: Peripheral and/or central mechanisms
• Activation of peripheral nociceptors leads to muscle tenderness in ETTH
• Central sensitization associated with CTTH
- Nitric oxide may have an important role in central sensitization
- Debatable: Low platelet serotonin
• Peripheral may provoke the central mechanism leading from ETTH to CTTH
ETIOLOGY
Stress is most frequently reported precipitating factor.
ASSOCIATED CONDITIONS
• 83% of patients with migraine headaches also suffer from tension-type headaches.
• Debatable: Increased prevalence of comorbid anxiety and depression

DIAGNOSIS
SIGNS AND SYMPTOMS
• Diagnostic criteria provided by the International Headache Society (IHS)
- Headache lasting 30 minutes-7 days
- At least 2 of the following
 Bilateral location
 Pressing/tightening (nonpulsating) quality
 Mild or moderate intensity
 Not aggravated by routine physical activity
- Not associated with nausea or vomiting (chronic type may be associated with nausea)
- No more than 1 of the following: Photophobia or phonophobia
- Not attributed to another disorder
• Fronto-occipital or generalized pain
• Pain is usually described as dull, pressing, or bandlike
• Intensity varies throughout the day
• Often present on arising or shortly thereafter
• Associated symptoms
- Fatigue
- Irritability
- Difficulty concentrating
- Muscular tightness, tenderness or stiffness in neck, occipital and frontal regions
History
• Obtain a thorough headache history (to rule out other headache disorders) including
- Severity, symptoms, onset, location and radiation of pain; quality of pain; concurrent medical conditions and medications; recent trauma or other procedures
Physical Exam
• General physical exam: Vital signs, funduscopic and cardiovascular assessment, and palpation of the head and neck
• Neurologic examination: Mental status, pupillary responses, motor strength testing, deep tendon reflexes, sensation, cerebellar function, gait testing, and signs of meningeal irritation
ALERT
Geriatric Considerations
Onset of new headache in patients >50 years is cause for careful study.
TESTS
Labs and neuro imagining (CT or MRI) are necessary when secondary cause is suspected.
DIFFERENTIAL DIAGNOSIS
• Migraine headache
• Cluster headache
• Head trauma
• Subarachnoid hemorrhage
• Subdural hematoma
• Unruptured vascular malformation
• Ischemic cerebrovascular disease
• Temporal arteritis
• Arterial hypertension
• Cerebral venous thrombosis
• Benign intracranial hypertension
• Intracranial neoplasm, infection, or meningitis
• Low cerebrospinal fluid pressure
• Medication (nonprescription analgesic dependency, nitrates)
• Caffeine dependency
• Metabolic disorders (hypoxia, hypercapnia, hypoglycemia)
• Toxic effects from drugs or fumes
• Temporomandibular joint syndrome
• Eyes: Glaucoma, refractive errors
• Sinusitis or middle-ear infection
• Cervical spondylosis
• Severe anemia or polycythemia
• Uremia and hepatic disorders
• Paget disease of bone
TREATMENT
• Acetaminophen (APAP) and aspirin (ASA) are effective for mild to moderate ETTH (1,2)[A].
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for moderate to severe ETTH (1,3)[A].
• Tricyclic antidepressants (TCAs) are effective prophylaxis of CTTH (1-3)[A].
STABILIZATION
Outpatient treatment
GENERAL MEASURES
• Relief measures: Relaxation routines; rest in quiet, dark room; hot bath or shower; massage of back of neck and temples
• Biofeedback training
Activity
See "Physical Therapy"
Physical Therapy
• Heat, ice, ultrasound, or TENS
• Massage or cervical traction
• Injection of trigger points
• Stretching and strengthening neck exercises for cervical musculature
MEDICATION (DRUGS)
First Line
• For acute attack (ETTH): APAP, ASA, or NSAIDs
• APAP (Tylenol) 500-1000 mg may repeat q6h p.r.n. (maximum 4 g/d)
- Adverse effects (rare): Rash, pancytopenia, liver damage
- Precaution: Hepatic impairment, consumption of 3 alcoholic beverages per day
• Aspirin 500-1000 mg may repeat q6h p.r.n. (maximum 4 g/d)
- Contraindication: ASA or NSAID allergy or bronchospasm, bleeding disorders
- Drug interactions: Anticoagulants, antiplatelet drugs, ACE inhibitors, -blockers, corticosteroids, NSAIDs, sulfonylureas
- Adverse effects: GI irritation/ bleeding, thrombocytopenia
• NSAIDs
- Ibuprofen (Motrin, Advil) 400-800 mg may repeat q8h p.r.n. (maximum 3.2 g/d)
- Naproxen (Naprosyn) 375-500 mg or naproxen sodium (Aleve, Anaprox) 440-550 may repeat q8-12h p.r.n. (maximum 1250 mg naproxen base/d)
- Ketoprofen (Orudis) 12.5-50 mg may repeat q6-8h p.r.n. (maximum 300 mg/d)
- Diclofenac 50-100 mg may repeat q8h p.r.n. maximum 150 mg/d
- Contraindications
 ASA or NSAID allergy or bronchospasm
 Advanced renal impairment
 Bleeding disorders (peptic ulcer disease)
- Precaution: Increased risk of cardiovascular events (MI, stroke, new onset or worsening of hypertension)
- Drug interactions: Antihypertensives, anticoagulants, antiplatelet drugs, ASA, lithium, methotrexate
- Adverse effects
 Epigastric distress, peptic ulcer.
 Rare: Thrombocytopenia, increased risk of cardiovascular events
• Prophylaxis for CTTH: TCAs
• Amitriptyline (Elavil): 10-75 mg/d
• Contraindications: Acute recovery phase of MI, use of monamine oxidase inhibitors (MAOIs) within 14 days
• Drug interactions: Clonidine, MAOIs, quinolone antibiotics, SSRIs, sympathomimetics, azole antifungals, valproic acid
• Adverse effects: Drowsiness, dry mouth, tachycardia, heart block, blurred vision, urinary retention, seizure
Second Line
• For acute attack (ETTH)
- Caffeine combinations: 130 mg caffeine with 500 mg APAP and/or 500 mg ASA q6h p.r.n.
- Isometheptene/dichloralphenazone/APAP (Midrin, Duradrin) 1-2 caps q4h (max 8/d)
- Narcotic analgesics
- Ketorolac 60 mg IM single dose
• For CTTH prophylaxis
- Alternative TCAs
 Desipramine (Norpramin) 50-100 mg/d
 Imipramine (Tofranil) 50-100 mg/d
 Nortriptyline (Pamelor) 25-50 mg/d
 Protriptyline (Vivactil) 25 mg/d
- Venlafaxine XR (Effexor XR) 37.5-300 mg/d
- Tizanidine 2 mg daily increase up to 8 mg t.i.d.
- Topiramate 25-100 mg/d
ALERT
Use of abortive agents >2 days per week may lead to medication-overuse headaches; must withdraw acute treatment to diagnose
Pediatric Considerations
ASA and antidepressants are contraindicated
FOLLOW-UP
PROGNOSIS
• Usually follows a chronic course when life stressors are not changed.
• Most cases are intermittent.
COMPLICATIONS
• Loss days of work and productivity (>CTTH)
• Cost to health system
• Dependence/addiction to narcotic analgesics
• Gastrointestinal bleeding from NSAID use
REFERENCES
1. Ashina S, Ashina M. Current and potential future drug therapies for tension-type headache. Curr Headache Rep. 2003;2:466-474.
2. Moja PL, Cusi C, Sterzi RR, Canepari C. Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. Cochrane Database Systematic Rev. 2006;3.
3. Zhao C, Stillman MJ. New developments in the pharmacotherapy of tension-type headaches. Expert Opin Pharmacother. 2003;4:2229-2237.
4. Clinch CR. Evaluation of acute headaches in adults. Am Fam Physician. 2001;63:685-692.
5. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004;24:1-151.
6. Mueller L. Tension-type, the forgotten headache: How to recognize this common but undertreated condition. Postgrad Med. 2002;111:25-50.
7. Lampl C, Marecek S, May A, Bendtsen L. A prospective, open-label, long-term study of the efficacy and tolerability of topiramate in the prophylaxis of chronic tension-type headache. Cephalalgia. 2006;26:1203-1208.