Headache, Tension-Type

SOURCE

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.

CONDITION/DISORDER SYNONYMS

• Tension headache.

• Stress headache.

• Muscle contraction headache.

DEFINITION

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

ETIOLOGY

• 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.

PATHOPHYSIOLOGY

• 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.

EPIDEMIOLOGY

• 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%.

CLINICAL PRESENTATION

SIGNS AND SYMPTOMS

• 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.

DIAGNOSIS

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

DIFFERENTIAL DIAGNOSIS

• Migraine without aura.

• Temporomandibular joint disorders.

• Exclude secondary causes:

  • Head trauma.

  • Spinal and vascular disorders.

  • Sinus and brain infections.

  • Intracranial pressure or lesions.

DESIRED OUTCOMES

• Rapid headache relief with minimal adverse effects.

• Minimal disability and emotional distress.

• Avoidance of emergency department or physician office visits.

TREATMENT: GENERAL APPROACH

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

TREATMENT: NONPHARMACOLOGIC THERAPY

• 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.

TREATMENT: PHARMACOLOGIC THERAPY

• Effective first-line options:

  • Acetaminophen.

  • Aspirin.

  • Diclofenac.

  • Ibuprofen.

  • Naproxen.

  • Ketoprofen.

  • Ketorolac.

• Effective alternatives ...