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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.

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  • Tension headache
  • Stress headache
  • Muscle contraction headache

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

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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 unknown when tightened muscles are not part of headache.

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

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Signs and Symptoms

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  • 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 nodules.
  • No premonitory symptoms or aura

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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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  • Rapid headache relief with minimal adverse effects
  • Minimal disability and emotional distress
  • Avoidance of emergency department or physician office visits

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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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  • Reassurance and counseling
  • Stress management
  • Relaxation training
  • Biofeedback
  • Physical options (e.g., heat or cold packs, ultrasound, electrical nerve stimulation, massage, acupuncture, trigger point injections, and occipital nerve blocks) have inconsistent results.

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  • Effective first-line options:
    • Acetaminophen
    • Aspirin
    • Ibuprofen
    • Naproxen
    • Ketoprofen
    • Indomethacin
    • Ketorolac
  • 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.

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  • 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:
    • Frequency
    • Duration
    • Severity
    • Treatment response
    • Potential triggers

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  • Risk factors associated ...

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