Tension Type Headaches
Case Presenation
Mary is 44 years old and is complaining of terrible headaches.
Ok Mary tell me more about your headaches.
Well I get terrible headaches. Nearly every day I seem to get a headache and nothing I do
helps them. I am so used to them that I can continue working but it just makes life
miserable. I have always been prone to headaches but the last few years they have gotten
worse.
Can you describe the pain to me?
Well it starts at the back of my neck and then moves to both sides at the front of my head.
It feels like someone is tightening a band around my head. Also the light sometimes hurts
my eyes.
Has the type of headache you get changed at all over the last couple of years and how
often does it occur?
No it’s the same headache I just get it more often. I used to get one or two a month but
now I get about 6 a week.
Do you get any nausea or vomiting with the headache?
No.
Tell me about your job and who is at home with you, particularly if you have any major
stresses in your life.
I work in a small grocery store part time, I’m divorced and my two sons are grown up
now so I live alone. I have been on disability since I hurt my back 5 years ago but these
headaches I get are far worse than my back pain.
Do you feel depressed or anxious at all?
Well sometimes I do feel anxious especially about money, which is a constant worry for
me. But I don’t think I’m depressed.
What do you take for your headaches?
I usually take Motrin but now find that it does not help at all in fact I am getting more and
more headaches. Sometimes I take eight a day trying to get rid of the pain.
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Diagnosis
Mary has tension type headaches that are bilateral mild to moderate headaches that she
describes as a tight feeling around her head. She is able to continue her usual daily
activities with the headaches and has no associated symptoms of nausea, vomiting, or
phonophobia although she does have some photophonia. (Table 1). She has chronic
tension headaches as they occur more than 15 days a month. Tension headaches that
occur less than 15 days a month are called episodic tension type headaches. She may also
be getting medication overuse or rebound headaches that are associated with frequent use
of any analgesic medication and will not improve until the medication is stopped. She
should be screened for depression and anxiety as psychiatric co-morbidity is common in
patients with tension type headaches (15)
Treatment of episodic tension type headache
1. Simple analgesics, e.g. acetaminophen and ibuprofen, are both more effective
than placebo at relieving the pain from tension type headaches. Ibuprofen is more
effective than acetaminophen. (17). Level A.
2. Analgesics can be combined with a sedating antihistamine such as promethazine
or diphenhydramine.. Level C.
3. Limit treatment to 2 days a week to prevent rebound headaches.
Prevention of chronic tension type headache
To prevent the onset of medication overuse headache it is preferable to use preventive
treatment for chronic tension type headaches.
1. Antidepressants: the tricyclic antidepressants amitriptyline, imipramine and
nortriptyline have been shown to prevent chronic daily headaches (CDH) .(1, 11).
Start at 10 mg at bedtime and gradually titrate it up. (Level A.) The efficacy of
amitriptyline and nortriptyline is higher when combined with stress
management.(1).
2. Stress management eg relaxation and cognitive coping. This is more effective
when combined with antidepressant medication(1). Muscle relaxation techniques
with or without biofeedback training can be used to teach the patient awareness of
and control of their physiologic responses. In one study adding biofeedback to
relaxation training increased the proportion of patients with a decrease in their
headaches from 39% to 54%.(20).
3. Tizanidine has been shown to reduce the frequency and intensity of chronic daily
headaches. (14)
4. SSRIs. There is not much research looking at the effectiveness of SSRIs but they
may be helpful particularly in patients with co-morbid depression. Prozac has
been shown to increase headache free days and decrease headache intensity. (10)
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5. Botulinium toxin has been shown to prevent migraines and there is some evidence
it may be effective in the prevention of CDH. (2, 3)
6. Anticonvulsants. Both gabapentin and topiramate have been shown to decrease
headache frequency in small studies.(12, 13)
7. Combination therapy with an antidepressant and an anticonvulsant.
8. Acupuncture has been shown to decrease the severity and frequency of headaches
although many of he RCTS were of poor quality. (19, 22).(Level B)
Medication Overuse Headache (MOH) or Rebound Headaches
Medication overuse headaches can occur when a patient has been taking headache
medication usually daily but may be as infrequently as four times a week. The
medication may alleviate the headache but as it wears off the headache recurs.
Patients with episodic tension type headaches are at risk of developing MOH due to
medication overuse. The most common cause of a mix of migraine and tension type
headaches occurring on more than 15 days a month is MOH. These patients may have
headaches that gradually shift from a migraine type headache to a tension type
headache even within a day as the analgesia wears off and the rebound headache
develops.
The diagnosis of medication overuse headache is important to make as patients rarely
respond to prophylactic medication whilst they are overusing acute headache
medications.
The pathophysiology of MOH is poorly understood but the fact that sometimes the
headache does not resolve with the cessation of the medication suggests that there
may be permanent changes in the CNS resulting from medication overuse for
prolonged periods.
The mean duration for the onset of MOH is shortest for triptans (1.7 years) and
longest for analgesics (4.7 years). The average monthly dosing associated with onset
of MOH is lowest for triptans (18 doses a month) and highest for analgesics (37 doses
a month). (4). The drugs most likely to cause MOH are the combination analgesic and
caffeine containing medication probably due to their availability over the counter and
relatively low cost.
Management of MOH.
The key to the resolution of MOH headaches is the cessation of the medication.
Ideally the medication is abruptly stopped although if the patient is unable to tolerate
this due to withdrawal symptoms the dose will have to be titrated down over a twoweek period. In patients using particularly high doses of analgesic medication a day
(over 12 tablets) it is preferable to gradually decrease the medication because of
serious withdrawal symptoms. (23). Different medications have been used whilst
titrating down the medication that is being withdrawn. (Table 3). Non
pharmacological methods such as biofeedback may help reduce the withdrawal
symptoms. The success rate for treating MOH varies from 50-90%. There is a need
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for both physicians and patients to be aware of the risks of MOH and reduce the
amount of acute headache medication used and increase the amount of prophylactic
medication used.
Level A evidence: From multiple well designed RCTS, meta-analyses and systematic
reviews.
Level B evidence: Scientific support is weaker for example poorly done RCTS,well
designed non randomized trials, case control studies, or inconsistent RCTS.
Level C: evidence from consensus viewpoint or expert opinion
IHS Criteria for Analgesic Overuse
Headache. (MOH)
1. Headache for 15 days a month
fulfilling at least one of the following
characteristics and criteria 3 and 4.
a. Bilateral
b. Pressing/tightening non
pulsating in quality
c. Mild/moderate intensity.
2. Intake of simple analgesics for>15
days a month for 3 months
3. Headache has developed or worsened
during analgesic overuse
4. Headache resolves or reverts to its
previous pattern of analgesic overuse
within 2 months after discontinuation
of analgesic.
Table 3. Expert opinion rather than evidence suggests that analgesia needs to be used
over 15 days a month to induce MOH.
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IHS Criteria for Tension Headache
Medications used in the Treatment of
Medication Overuse Headache
1.
Parenteral DHE
2.
Oral steroids. Level B.
3.
Tizanidine. Level B.
4.
Triptans.
A. Headache lasts from 30 mins to 7
days.
B. Headache has at least 2 of the
following characteristics.
a. Bilateral
b. Pressing/tightening non
pulsating quality
c. Mild/moderate intensity.
d. Not aggravated by routine
physical activity.
5,6,8,9,18, 21
C. Both of the following:
a. No nausea or vomiting
b. No more than one of
photophobia or phonophobia.
D. Not attributed to another disorder.
References
1.
2.
3.
4.
5.
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