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tension headache (stress headache)

Etiology: 1) tiredness 2) anorexia 3) psychosocial stress - pericranial muscle tension/tenderness 4) analgesia abuse 5) cutaneous allodynia [8] Epidemiology: - common Clinical manifestations: 1) typically described as bilateral, dull, constant pain in a band like distribution 2) pressure or tight quality 3) trigger points common [6] (bilateral) a) right upper trapezius b) sternocleidomastoid c) temporalis muscle 3) abnormal forward head posture common [6] 4) duration 3 minutes to 7 days [8] 5) generally not disabling, does not prohibit activity 6) not associated with nausea [8] 7) may be associated with photophobia or phonophobia, but not both [13] Diagnostic criteria: - at least 10 headaches fulfilling criteria* - headaches (untreated or unsuccessfully treated) lasting 30 minutes to 7 days - headaches with at least 2 of the 4 following characteristics - bilateral - pressing/tightening (tension) & non-pulsating - mild to moderate severity - not aggravated by routine physical activity - walking, climbing stairs - headache without nausea/vomiting - no more than 1 episode of photophobia or phonophobia per headache - not accounted for by more likely diagnosis [8] * International Headache Society criteria Radiology: - neuroimaging not indicated [8] Differential diagnosis: - chronic tension headaches may share characteristics of migraine headache thus the term 'mixed tension-vascular headache' Complications: - little of no disability - unlike migraine with aura, not associated with increased risk of stroke (see migraine) Management: 1) conservative measures a) warm/cold compresses b) stress reduction c) exercise d) drug reduction (post analgesic syndrome) e) biofeedback f) relaxation therapy g) cognitive behavioral therapy [8] 2) pharmacologic agents a) acetaminophen 325-650 mg every 4-6 hours PRN b) NSAIDs 1] aspirin 325-650 mg every 4-6 hours PRN 2] ibuprofen, naproxen 3] generally more effective than tricyclic antidepressants [8] c) caffeine-containing compounds [8] - Fioricet d) not indicated: - benzodiazepines, muscle relaxants, opiates, Botox [8] e) tramadol f) isometheptene compounds 1] Midrin 2] Isocom g) barbiturates when other treatment options have failed [12] h) chronic headache (prophylaxis) 1] cognitive behavioral therapy [8] 2] antidepressants a] amitriptyline 25-50 mg QHS b] tricyclic antidepressants more useful than SSRI in patients with migraine or tension headaches [9] 3] gabapentin, titrate up to 2400 mg QD [3] 4] mirtazapine may be useful in patients without depression [4] 3) acupuncture benefit may be due to placebo effect [5] 4) no benefit of prophylaxis [11] 5) no strong recommendations [14]

Related

migraine headache

General

headache

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1028-31
  2. Kaiser Permanente Videoconference, 9/9/99, Fresno, CA
  3. Journal Watch 24(3):23, 2004 Spira PJ et al Gabapentin in the prophylaxis of chronic daily headache: a randomized, placebo-controlled study. Neurology 61:1753, 2003 PMID: 14694042 Silberstein SD, Neurology 61:1637, 2003
  4. Journal Watch 24(14):116, 2004 Bendtsen L, Jensen R. Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Neurology. 2004 May 25;62(10):1706-11. PMID: 15159466
  5. Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes M, Hummelsberger J, Irnich D, Weidenhammer W, Willich SN, Linde K. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ. 2005 Aug 13;331(7513):376-82. Epub 2005 Jul 29. PMID: 16055451
  6. Fernandez de-las-Penas C et al, Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache. Headache 2006, 46:1264 PMID: 16942471
  7. Bigal ME, Ashina S, Burstein R, Reed ML, Buse D, Serrano D, Lipton RB; AMPP Group. Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology. 2008 Apr 22;70(17):1525-33. PMID: 18427069
  8. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  9. Jackson JL et al. Tricyclic antidepressants and headaches: Systematic review and meta-analysis. BMJ 2010 Oct 20; 341:c5222 PMID: 20961988 http://www.bmj.com/content/341/bmj.c5222/T5.expansion
  10. Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. 2008 Jan;7(1):70-83. PMID: 18093564
  11. Verhagen AP, Damen L, Berger MY, Passchier J, Koes BW. Lack of benefit for prophylactic drugs of tension-type headache in adults: a systematic review. Fam Pract. 2010 Apr;27(2):151-65 PMID: 20028727
  12. Windle ML Rapid Rx Quiz: Headache Medications Medscape. Sept 12, 2022 https://reference.medscape.com/viewarticle/980181 - Blanda M, Taylor JP Tension Headache Medscape, Nov 16, 2022 https://emedicine.medscape.com/article/792384-overview
  13. NEJM Knowledge+ Neurology
  14. Sico JJ, Antonovich NM, Ballard-Hernandez J et al 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache. Ann Intern Med. 2024 Oct 29. PMID: 39467289