Source: Minor DS. Headache Disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7986542. Accessed June 9, 2012.
- Tension headache
- Stress headache
- Muscle contraction headache
- Dull pain that feels like pressure on head; most common
form of headache.
- Tightened muscles in back of neck and scalp usually resulting
- Inadequate rest
- Poor posture
- Emotional or mental stress
- Cause unknown when tightened muscles are not part of headache.
- Pain originates from myofascial factors and peripheral
sensitization of nociceptors. Central mechanisms also involved.
- After activation of supraspinal pain perception structures,
headache occurs because of central modulation of incoming peripheral
- 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.
- One-year prevalence ranges from 31–86%.
- 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
- Prevalence of chronic tension-type headache (15 days per month):
- Pain usually mild to moderate, bilateral, nonpulsatile,
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
- No premonitory symptoms or aura
- Based on characteristic presenting symptoms and after
exclusion of other causes of headache.
- Migraine without aura
- Temporomandibular joint disorders
- Exclude secondary causes:
- Head trauma
- Spinal and vascular disorders
- Sinus and brain infections
- Intracranial pressure or lesions
- Rapid headache relief with minimal adverse effects
- Minimal disability and emotional distress
- Avoidance of emergency department or physician office visits
- Simple analgesics (alone or in combination with caffeine)
and nonsteroidal anti-inflammatory drugs (NSAIDs) mainstays of acute
- Reassurance and counseling
- Stress management
- Relaxation training
- Physical options (e.g., heat or cold packs, ultrasound, electrical
nerve stimulation, massage, acupuncture, trigger point injections,
and occipital nerve blocks) have inconsistent results.
- Effective first-line options:
- Effective alternatives include high-dose NSAIDs and combination
of aspirin or acetaminophen with butalbital (or rarely, codeine).
- Acute medication for episodic headache should be taken no
more often than 9 days/month to prevent development of
chronic tension-type headache.
- No evidence supports efficacy of muscle relaxants.
- Consider prophylaxis if headache frequency is >2 per week,
duration is >3–4 hours, or severity results in medication
overuse or substantial disability.
- Tricyclic antidepressants
used most often for prophylaxis.
- Venlafaxine and mirtazapine may also be effective.
- Injection of botulinum toxin into pericranial muscles has
inconsistent efficacy and not recommended.
- Assess frequency, intensity, and duration of headaches
and for changes in headache pattern.
- If headaches are frequent, encourage patients to keep a headache
diary to document:
- Treatment response
- Potential triggers
- Risk factors associated ...