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SOURCE

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Source: Minor DS, Harrell TK. Headache disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146063736. Accessed May 16, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Tension headache.

  • Stress headache.

  • Muscle contraction headache.

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DEFINITION

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  • Dull pain that feels like pressure on head; most common form of headache.

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ETIOLOGY

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  • Tightened muscles in back of neck and scalp usually resulting from:

    • Inadequate rest.

    • Poor posture.

    • Emotional or mental stress.

    • Anxiety.

    • Fatigue.

    • Hunger.

    • Overexertion.

  • Cause is unknown when tightened muscles are not part of headache.

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PATHOPHYSIOLOGY

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  • Pain originates from myofascial factors and peripheral sensitization of nociceptors as well as central mechanisms also involved.

  • After activation of supraspinal pain perception structures, headache occurs because of central modulation of incoming peripheral stimuli.

  • Initiating stimuli may include:

    • Mental stress.

    • Nonphysiologic motor stress.

    • Local myofascial release of irritants.

    • Combination of above.

  • In predisposed individuals, chronic tension-type headache can evolve from episodic tension-type headache.

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EPIDEMIOLOGY

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  • Most common type of primary headache.

  • One-year prevalence ranges from 38% to 86%.

  • Prevalence peaks in fourth decade and is higher among women.

  • Incidence decreases with age.

  • Infrequent episodic tension-type headache (<1 episode per month) experienced by 64%, whereas 22% have frequent episodic tension-type headache (episodes on 1–14 days per month).

  • Prevalence of chronic tension-type headache (≥15 days per month): 0.9–2.2%.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Pain usually mild to moderate, bilateral, nonpulsatile tightness or pressure, and in frontal and temporal areas; occipital and parietal areas can also be affected.

  • Mild photophobia or phonophobia may occur.

  • Pericranial or cervical muscles may have tender spots or localized nodules.

  • No premonitory symptoms or aura.

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DIAGNOSIS

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  • Based on characteristic presenting symptoms and after exclusion of other causes of headache.

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DIFFERENTIAL DIAGNOSIS
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  • Migraine without aura.

  • Temporomandibular joint disorders.

  • Exclude secondary causes:

    • Head trauma.

    • Spinal and vascular disorders.

    • Sinus and brain infections.

    • Intracranial pressure or lesions.

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DESIRED OUTCOMES

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  • Rapid headache relief with minimal adverse effects.

  • Minimal disability and emotional distress.

  • Avoidance of emergency department or physician office visits.

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TREATMENT: GENERAL APPROACH

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  • Simple analgesics (alone or in combination with caffeine) and nonsteroidal anti-inflammatory drugs (NSAIDs) mainstays of acute therapy.

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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • Stress management.

  • Relaxation training.

  • Biofeedback.

  • Physical options (eg, heat or cold packs, ultrasound, electrical nerve stimulation, massage, acupuncture, manipulations, ergonomic instruction, trigger point injections, and occipital nerve blocks) have inconsistent results.

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TREATMENT: PHARMACOLOGIC THERAPY

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  • Effective first-line options:

    • Acetaminophen.

    • Aspirin.

    • Diclofenac.

    • Ibuprofen.

    • Naproxen.

    • Ketoprofen.

    • Ketorolac.

  • Effective alternatives include high-dose NSAIDs and combination of aspirin or acetaminophen with butalbital (or rarely, codeine).

  • Acute medication for episodic headache ...

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