Tension-Type Headache

THE CLINICAL SYNDROME

Tension-type headache, formerly known as muscle contraction headache, is the most common type of headache that afflicts mankind. It can be episodic or chronic, and may or may not be related to muscle contraction. Significant sleep disturbance usually occurs, along with depression and, in some patients, somatization.

The term tension-type headache refers to nonvascular headaches, which can be episodic or chronic. Until recently, the condition was known as muscle contraction headache. However, because many patients with this disorder have no demonstrable contraction of skeletal muscle associated with their pain, the international Headache Society has returned to use of an earlier name for this constellation of symptoms-tension-type headache. Patients with tension-type headaches may be characterized as individuals with multiple unresolved conflicts surrounding work, marriage, social relationships, and psychosexual difficulties. These patients are often depressed, although Minnesota Multiphasic Personality Inventory (MMPI) testing in large groups of tension-type headache patients reveals not only borderline depression but somatization as well. Most researchers believe that, in at least some patients, this somatization takes the form of abnormal muscle contraction and, in others, simply of headache.

SIGNS AND SYMPTOMS

Tension-type headache is usually bilateral but can be unilateral, and often involves the frontal, temporal, and occipital regions. It may present as a bandlike nonpulsatile ache or tightness in the aforementioned anatomic areas. There often is associated neck symptomatology. Tension-type headache evolves over a period of hours or days and then tends remain constant without progressive symptomatology. There is no aura associated with this headache. Significant sleep disturbance is usually present. This may manifest itself as difficulty in falling asleep, frequent awakening at night, or early awakening. These headaches most frequently occur between 4 and 8 AM and between 4 and 8 PM. Although both sexes are affected, females predominate. There is no hereditary pattern to tension-type headache, but it may occur in family clusters as children mimic and learn the pain behaviors of their parents.

The triggering event for acute episodic tension-type headache is invariably either physical or psychological stress. This may take the form of a fight with a coworker or spouse, or an exceptionally heavy workload. Physical stress such as a long drive, working with the neck in a strained position, acute cervical spine injury due to whiplash, or prolonged exposure to the glare from a cathode ray tube may also precipitate a headache. A worsening of preexisting degenerative cervical spine conditions, such as cervical spondylosis, can also trigger a tension-type headache. The pathology responsible for the development of tension-type headache can also produce temporomandibular joint dysfunction.

TREATMENT

Abortive Treatment

In determining treatment, the physician must consider the frequency and severity of headaches, however the headaches affect the patient’s lifestyle, the results of any previous therapy, and previous drug misuse and abuse. If the patient suffers from an attack of tension-type headache only once every 1 or 2 months, the condition can often be managed through teaching the patient to reduce or avoid stress. Analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) can provide symptomatic relief during acute attacks. Combination analgesic drugs used concomitantly with barbiturates and/or narcotic analgesics have no place in the management of headache patients. The risk of abuse and dependence more than outweighs any theoretical benefit. The physician should also avoid an abortive treatment approach in patients with a prior history of drug misuse or abuse. Many abortive drugs, including simple analgesics and NSAIDs, can produce serious consequences if abused.

Prophylactic Treatment

If the headaches occur more frequently than once every 1 or 2 months or are of such severity that the patient repeatedly misses work or social engagements, the following prophylactic therapy is indicated.

Antidepressants

These are generally the drugs of choice for prophylactic treatment of headaches. The antidepressants not only help decrease the frequency and intensity of tension-type headaches but also normalize sleep patterns and treat underlying depression. Patients should be educated about the potential side effects of sedation, dry mouth, blurred vision, constipation, and urinary retention that may be experienced when using this class of drugs. They should also be told that relief of headache pain generally takes 3 to 4 weeks. However, the normalization of sleep that occurs immediately may be enough to noticeably improve the headache symptomatology.

Amitriptyline, started at a single bedtime dose of 25mg, is a reasonable initial choice. The does may be increased in 25-mg increments as side effects allow. Other drugs that can be considered if the patient does not tolerate the sedation and anticholinergic effects of amitriptyline include trazodone (75 to 300 mg at bedtime) or fluoxetine (20 to 40 mg at lunch time). Because of the sedation nature of these drugs (with the exception of fluoxetine), they must be used with caution in the elderly or in patients who are at risk for falling. Care should also be exercise when using these drugs in patients prone to cardiac arrhythmia because these drugs may be arrhythmogenic. Simple analgesics or the longer-acting NSAIDs may be used with the antidepressant compounds to treat exacerbations of headache pain.

Biofeedback

Monitored relaxation training combined with patient education about coping strategies and stress reduction techniques may be of value in the motivated tension-type headache sufferer. Appropriate patient selection is of paramount importance if good results are to be achieved. If the patient is significantly depressed at the time of initiation of therapy, it may be beneficial to treat the depression before trying biofeedback. The use of biofeedback may allow the patient to control the headache while at the same time avoiding the side effects of medications.

Cervical Steroid Epidural Nerve Blocks

Multiple studies have demonstrated the efficacy of cervical steroid epidural nerve blocks (CSENBs) in providing long-term relief of tension-type headache in a group of patients for whom all treatment modalities failed. CSENBs may be used early in the course of treatment while waiting for the antidepressant compounds to become effective. CSENBs may be performed on a daily to weekly basis as clinical symptoms dictate.

Although tension-type (muscle contraction) headache occurs frequently, it is commonly misdiagnosed as migraine headache. By obtaining a targeted headache history and performing a targeted physical examination, the physician can make a diagnosis with a high degree of certainty. The avoidance of addicting medications coupled with the appropriate use of pharmacologic and nonpharmacologic therapies should result in excellent palliation and long-term control of pain in the vast majority of patients suffering from this headache syndrome.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue .Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age –related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.