Headache

Migraine Headache
Tension-Type Headache 
Rebound Headache

Tension-Type Headache
Symptoms
The Diagnosis of Tension-Type Headache

Treatments for Tension-Type Headache
Drug Therapy
Non Drug Therapy

Symptoms of tension-type headache include:

	pain on both sides of the head
	pressing/tightening quality ("like a tight belt around my head")
	perhaps a mild degree of photophobia (sensitivity to light) or phonophobia (sensitivity to sound)
	tight and tender neck shoulder muscles

The Diagnosis of Tension-Type Headache

The diagnosis of a tension-type headache is only based upon the patient's description of the headache along with a normal neurological examination. The International Headache Society (IHS) criteria include:

1.	At least 10 previous attacks that fulfill Items 2 - 4 below
2.	Headache attacks last 30 minutes to 7 days (untreated or unsuccessfully treated)
3.	At least two of the following:
		bilateral (both sides of the head)
		pressing/tightening quality
		mild or moderate intensity (may inhibit but does not prohibit activities)
		not made worse by walking stairs or similar routine physical activity
4.	During headache, both of the following:
		no nausea or vomiting
		photophobia (sensitivity to light) and phonophobia (sensitivity to sound) are absent, or one but not the other is present
5.	History, physical and neurologic examination do not suggest a brain tumor, infection, or blood vessel abnormality (very rare)

Although neurological examination is normal, the majority of patients with tension-type headache have tight muscles in their temples, neck and shoulders. Some have poor movement of the neck.

The Causes of Tension-Type Headache

The causes of tension-type headache are controversial. Prior to 1998, when the International Headache Society's (IHS) new classification schema was developed, this headache syndrome was called muscle contraction headache because most experts believed that the underlying cause of this headache was tight and spastic muscles in the shoulders, neck, and head. Today some experts continue to believe that muscle spasm causes the pain, but others believe that brain chemicals and stress/psychological problems may also play a role. Importantly, the name tension-type headache does not imply that the headache is thought to be due to primarily a psychological problem.

Tension-type headache is much more common than migraine headache. It is thought that up to 60-70% of people suffer from a tension-type headache every year.

All tests are normal in tension-type headache. Like migraine, there is no reason to have a brain MRI or CT scan if the history and examination are consistent with uncomplicated tension-type headache.

Drug Therapy

Drug therapy is often recommended for tension-type headache. Drugs for headache are divided into two types:

abortive/symptomatic medications
prophylactic medications

Unlike migraine headache, however, many patients with tension-type headache do not experience excellent pain relief from drugs. For these patients, non-drug therapy may be more important.

Abortive/symptomatic medications are those drugs that are taken at the onset or during a headache attack in the hopes of stopping the headache from occurring or decreasing associated symptoms. When prescribing abortive/symptomatic medications, it is very important to remember the following points:

Each patient is different; it is not possible to predict whether a particular person will respond favorably to a drug.

If abortive/symptomatic medication is used excessively, the development of Rebound Headache Syndrome can result. (Rebound headache means headache that is actually worsened by the overuse of short-acting abortive medication). Some authorities recommend that a patient take no more than 10 doses of abortive/symptomatic headache medication per month. Others allow more but become very concerned when abortive/symptomatic drugs are needed more than a few times each week.

Abortive/symptomatic headache medications include:

	over-the-counter analgesics (such as aspirin, acetaminophen, ibuprofen, naproxen, etc.)
	prescription nonsteroidal anti-inflammatory drugs (such as diclofenac, ketorolac, etc.)
	barbiturates (such as butalbital)
	ergots (such as ergotamine or dihydroergotamine)
	antiemetics (such as prochlorperazine)
	"muscle relaxants" (such as Flexeril, Soma, etc.). (Note that these drugs do not actually relax skeletal muscles directly, but rather are analgesic [pain-relieving] drugs that act on a patient's brain.)
	opioids (such as meperidine, morphine, etc.)

Prophylactic headache medications are those drugs that are taken every day, regardless of whether a headache is being experienced, in the hopes of preventing headache attacks. These daily medications should only be prescribed when patients have frequent headaches (e.g., three or more times per month) that are significantly interfering with quality of life.

When prescribing prophylactic headache medication, it is very important to remember the following points:

	every tension-type headache patient is different; response to a drug cannot be predicted
	only one drug should be prescribed at a time
	most drugs should have careful dose adjustment. The first dose is relatively low, and the dose is gradually increased if a headache occurs and if no intolerable side effects are experienced by the patient.

Prophylactic medications for tension-type headache include:

	antidepressants (such as amitriptyline, nortriptyline, desipramine, doxepin, venlafaxine, etc.) These drugs act on headache independent of their effects on depression. They typically work for headache at lower doses than are needed to treat affective disorders; the tricyclic antidepressant drugs also may improve sleep, which is often disturbed in headache patients.
	alpha-2 adrenergic agonists (such as tizanidine)
	opioids
	some physicians try gabapentin for these headaches

Nondrug Therapy

Biofeedback
Many studies have shown biofeedback to be very effective treatment for tension-type headache.

Acupuncture
Some patients may obtain benefit from acupuncture.

Physical Therapy
Studies have shown that aerobic conditioning (getting in shape) can reduce the amount and intensity of tension-type headaches. Also, some patients find that techniques that may reduce the degree of muscle tension in the neck and shoulder musculature can reduce the frequency of headache; methods include trained stretching exercises, osteopathic manipulation, and craniosacral manipulation.

TENS (Transcutaneous Electrical Nerve Stimulation)
Some patients report that applying a transcutaneous nerve stimulation device on their neck and shoulder muscles helps with tension-type headache.

Stress Management
Many studies have found that stress is a common trigger for tension-type headache (in over 60% of patients). Techniques that help relieve stress, such as relaxation, imagery, and even yoga, have been shown in studies to be very effective.

Trigger Point Injections
Some patients report benefit from trigger point injections. A needle is inserted directly into a specific tender site within a muscle. A variety of trigger point injection techniques are used; some doctors just insert a needle, others inject local anesthetic (like Novocaine), and others inject a safe form of botulinum toxin.

Headache/Pain Clinic Treatment
Most often, tension-type headache patients can be successfully managed by one physician, without the need for a comprehensive pain clinic treatment. However, some patients with severe headaches that fail to respond to routine measures may need a multidisciplinary approach involving several headache specialists, which may be provided in headache and pain clinics.