Tension Headache

Definition and Causes:

Definition:

The most common type of headache. Usually, a non-throbbing, squeezing or band-like pain of mild to a moderate intensity that is present around the head and neck. Maybe intermittent (<15 days/month), or chronic (≥15 days/month). Tension headache (TH) can occur at any age but most commonly begins during adulthood.

Causes:

The precise cause for TH is still unclear but has a significant muscle contraction component around the head and neck. While the brain itself does not “hurt”, imbalances in neurotransmitters (chemicals within the brain) may bring about increased susceptibility to muscle aches and pains around the head that leads to TH. Depression and sleep disorders which are potential underlying causes for TH, are linked with an imbalance of a neurochemical (e.g. serotonin). Unlike migraine, TH is usually not hereditary.

Triggers:

  • Stress
    • Relationships with family and friends
    • Work and school environment
  • Fatigue and exhaustion
  • Sleep
    • Disturbance/deprivation
    • Uncomfortable bed/pillow (sleeping on sofas, etc.)
  • Neck strain/pain
  • Poor posture
  • Poor work station ergonomics
  • Eyestrain
  • Jaw dysfunction
    • Sleep disturbances
    • Neck strain/ pain

Failure to address and change the potential trigger may ultimately lead to chronic TH.

Symptoms:

It usually starts from one location, then spreads over the entire head, and worsens as the day progresses.

  • May lasts from minutes to hours, but sometimes for days if is chronic
  • The onset is gradual and comes without warning
  • Pain is of mild to moderate in intensity
  • Often associated with periods of stress
  • May increase in intensity towards the end of the day
  • Occasional mild photophobia and phonophobia may be present
  • Nausea and vomiting are not common
  • Chronic (persistent) headaches usually fluctuate in intensity

Investigations and Treatment:

Diagnosis is usually made on the basis of characteristic symptoms, and normal physical /neurological examination.

History:

Physician may inquire about the features of the headache:

  • The nature of pain, e.g. dull, sharp, throbbing, burning, etc.
  • Severity and intensity
  • Location/frequency/duration
  • Are they new or longstanding
  • Intermittent or chronic
  • Light and sound sensitivity
  • Presence of nausea or vomiting
  • Identifiable triggers
  • Family history of headaches

Physical exam might include:

  • Blood pressure, heart rate, and temperature together with a neurological examination

Investigations:

Blood tests:

  • Routine blood test (electrolytes, glucose, hemoglobin, etc.)
  • Thyroid function tests
  • Liver and kidney function tests
  • Urinalysis

For those with atypical or unusual headache presentation or detection of an abnormality on physical examination, a CT scan and MRI of the brain may be requested.

Computed Tomography (CT) Scan:

  • This device uses x-rays. Patients will lie on a table with the head placed inside of the scanner (resembles a large donut). Computer analyses detailed images of the brain which are obtained by the scanner. The scanning time is usually very rapid (less than 1 minute). In special circumstances, a dye might be injected into the veins just before the scan (CT with contrast). This can sometimes help to identify areas of infection (abscesses), inflammation, tumors, aneurysms, etc.

Magnetic Resonance Imaging (MRI):

  • This does not use x-rays. Instead, MRI uses magnetic fields over the body. The device looks like a long cylindrical tube. Patients will lie on a table that slides into the hollow tube. Computer analysis of magnetic fields within the machine can generate images of the internal structures of the body’s organs, including the brain. MRI of the brain will show the normal structures, plus any area(s) of brain injury caused by the inflammation, tumors, previous stroke, etc. Patients must lie still inside the MRI machine for about 15-30 minutes. In some circumstances, a dye might be injected into the veins (enhanced MRI) just before the scan to help improve the detection of abnormalities. Patients who complain of claustrophobia or discomfort may be given a mild sedative to help relax prior to MRI scanning

TREATMENT:

Conservative management:

Involves identification of the potential triggers, their avoidance, and lifestyle adjustments as follows:

  1. Avoiding stressful environments
  2. Learning appropriate techniques for rest and relaxation
  3. Massage therapy
  4. Improving sleep hygiene, i.e. ensuring adequate, uninterrupted sleep in a quiet comfortable environment
  5. Improving workstation ergonomics
  6. Avoid carrying heavy bags on back/shoulders
  7. Avoid next strain

Medical management:

Over the counter (OTC) pain killers such as acetaminophen, aspirin, ibuprofen, and other NSAIDs can be used for pain relief. However, avoid excess daily use of pain medications as this practice can sometimes lead to medication-induced “chronic daily headaches.”

Headaches are best treated at the onset, and may not respond well to medication as time passes by, with an increase in severity and frequency.

If headaches do not respond to usual OTC medications, the physician may prescribe alternative agents for immediate relief or daily preventive medications. Coexisting medical conditions are taken into account when prescribing medications.

Abortive Therapy (drugs used for immediate pain relief)

1. Analgesics, opiates, barbiturates, and muscle relaxants:

  • Some of the examples are shown below with the trade names

Image-Pt-TH-NSAIDs

Preventative Therapy

Note: Daily use of this therapy prevents headaches in those, who are prone to frequent episodes.

  • Antidepressants (amitriptyline, nortriptyline), and anticonvulsants (topiramate, valproate)

Image-Pt-TH- Antidepressants

Note: While there are potential side effects from using these medications, there are also beneficial effects. Consequently, the treating physician will assess the side effects risks versus the benefits in controlling symptoms and improving quality of life (risk versus benefit ratio), before recommending treatment. If the patient has other medical conditions or using other medications, these are taken into account when prescribing medications. The patient is advised to take note of and report potential side effects to the treating physician.

Risk Factors and Prevention:

Lifestyle changes may prevent headaches; such as maintaining a good sleep routine, and reducing stress factors may reduce the frequency of headaches.

Outcome:

It is considered a harmless medical condition, responding usually well to OTC and relieve pain.

In some people with episodic tension-type headache, overuse of medications cause pain to progress into chronic tension-type headaches.