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Tension Headache
Background: The
International Headache Society (IHS) began developing a classification
system for headaches in 1985. Finalized in 1988, this system includes a
tension-type headache category, further defined as either episodic or
chronic. Headache categories also are defined by whether they are
associated with pericranial muscle disorders.
Episodic tension headache usually is associated with a stressful event.
This headache type is of moderate intensity, self-limited, and usually
responsive to nonprescription drugs.
Chronic tension headache often recurs daily and is associated with
contracted muscles of the neck and scalp. This type of headache is
bilateral and usually occipitofrontal.
Tension-type headache is the most common type of chronic recurring head
pain. In the past, pain etiology was presumed to be the muscular
contraction of pain-sensitive structures of the cranium, but the IHS
intentionally abandoned the terms muscular contraction headache and
tension headache because no research supports muscular contraction as the
sole pain etiology.
Pathophysiology: Both muscular and psychiatric factors
are believed to be associated with tension-type headache.
Frequency:
- In the US: Headache is the ninth most common reason
for a patient to consult a physician. Physicians classify 90% of
headaches reported to them as muscle contraction or migraine headaches.
- Internationally: No literature suggests that
headache frequency is different in other regions of the world.
Sex: A female preponderance exists.
Age: All ages are susceptible, but most patients are
young adults.
- Approximately 60% of headache onset occurs in those older than 20
years.
- Headache onset is unusual in those older than 50 years.
- In elderly patients, the practicing physician should never assume
that headache onset is due to benign causes, such as tension-type
headaches, until pathologic etiologies are explored.
History: Pain onset in
tension-type headache can have a throbbing quality and is usually more
gradual than onset in migraines. Compared with migraines, tension-type
headaches are more variable in duration, more constant in quality, and
less severe.
- IHS diagnostic criteria for tension-type headaches states that 2 of
the following characteristics must be present:
- Pressing or tightening (nonpulsatile quality)
- Frontal-occipital location
- Bilateral - Mild/moderate intensity
- Tension-type headache history is as follows:
- Duration of 30 minutes to 7 days
- No nausea or vomiting (anorexia may occur)
- Photophobia and/or phonophobia
- Minimum of 10 previous headache episodes; fewer than 180 days per
year with headache
- Bilateral and occipitonuchal or bifrontal pain
- Pain described as "fullness," "tightness/squeezing," "pressure,"
or "bandlike/viselike"
- May occur acutely under emotional distress or intense
worry
- Often present upon rising or shortly thereafter
- Not aggravated by physical activity
- Muscular tightness or stiffness in neck, occipital, and frontal
regions
- Duration of more than 5 years in 75% of patients with chronic
headaches
- New headache onset in elderly patients should suggest etiologies
other than tension headache.
Physical: The physical examination serves mainly to
exclude the possibility of other headache causes.
- Vital signs should be normal.
- Tenderness may be elicited in the scalp or neck, but no other
positive physical exam findings should be noted.
- Pain should not be elicited over temporal arteries or positive
trigger zones.
- Some patients with occipital tension headaches may be very tender
when upper cervical muscles are palpated.
- Pain associated with neck flexion and stretching of paracervical
muscles must be distinguished from nuchal rigidity associated with
meningeal irritation.
Causes: Stress may cause contraction of neck and scalp
muscles, although no evidence confirms that the origin of pain is
sustained muscle contraction.
- Psychological or social problems
DIFFERENTIALS
Depression and Suicide
Encephalitis
Glaucoma, Acute Angle-Closure
Headache, Cluster
Headache, Migraine
Meningitis
Otitis Media
Sinusitis
Stroke, Hemorrhagic
Stroke, Ischemic
Subarachnoid Hemorrhage
Subdural Hematoma
Temporal Arteritis
Temporomandibular Joint Syndrome
Trigeminal Neuralgia
Other Problems to be Considered:
Fever
Anoxia
Cervical spondylosis
Tumor
Caffeine
dependency
Nonprescription analgesic dependency
Severe anemia or
polycythemia
Uremia
Hepatic disorders
Toxic effects from drugs or
fumes (carbon monoxide)
Dental disease
Paget disease of
bone
Refractive error
Hypertension
Hypoxia
Lesions of the eye
or middle ear
Lesions of the oral cavity
Lab Studies:
- Laboratory work should be unremarkable in cases of tension-type
headache. Specific tests should be obtained if the history or physical
examination suggests another diagnostic possibility.
- Head CT scan or MRI is necessary only when the headache pattern has
changed recently or neurologic examination reveals abnormal findings.
Such history or physical exam evidence would suggest an alternate cause
of headache.
TREATMENT
Prehospital Care: Most
patients with severe headache should not receive opiate analgesics until
the responsible physician can complete an appropriate history and
neurologic examination.
Emergency Department Care:
- Ascertain that the patient is not overusing medication, shows no
evidence of drug dependency, and is not depressed.
- If headache cause includes dental pathology, sinus disease, trigger
points, or CNS pathology, initiate care to treat the specific
cause.
MEDICATION
While the emergency physician must be
able to identify patients with serious headache etiology, more than 90% of
patients in the ED have migraine, tension, or mixed-type benign headache.
Therefore, providing symptomatic relief should be a priority.
Various modalities are used in the treatment of tension headaches.
These include hot or cold packs, ultrasound, electrical stimulation,
improvement of posture, trigger point injections, and occipital nerve
blocks.
Regular exercise, stretching, balanced meals, and adequate sleep may be
part of a headache treatment program.
Drug Category: Nonsteroidal anti-inflammatory drugs
(NSAIDs) -- These agents may alleviate headache pain by
inhibiting prostaglandin synthesis, reducing serotonin release, and
blocking platelet aggregation. Although the effects of NSAIDs in the
treatment of headache pain tend to be patient specific, ibuprofen is
usually the DOC for initial therapy. Other options include naproxen,
ketoprofen, and ketorolac.
Drug Name
|
Ibuprofen (Ibuprin, Advil, Motrin)
-- Usually DOC for treatment of mild to moderately severe headache,
if no contraindications.
|
| Adult Dose |
200-800 mg PO q4-6h while symptoms
persist; not to exceed 3.2 g/d
|
| Pediatric Dose |
6 months to 12 years: 20-40 mg/kg/d
PO divided tid/qid; start at lower end of dosing range and titrate
upward; not to exceed 2.4 g/d
>12 years: Administer as in
adults
| Contraindications |
Documented hypersensitivity; peptic
ulcer disease; recent GI bleeding or perforation; renal
insufficiency; high risk of bleeding; third trimester of pregnancy
|
| Interactions |
Aspirin increases risk of inducing
serious NSAID-related adverse effects; probenecid may increase
concentrations and, possibly, toxicity; may decrease effects of
hydralazine, captopril, and beta-blockers; may decrease diuretic
effects of furosemide and thiazides; may increase PT in patients
taking anticoagulants—monitor PT closely and instruct patients to
watch for signs of bleeding; may increase risk of methotrexate
toxicity; may increase phenytoin levels
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Category D in third trimester of
pregnancy; caution in congestive heart failure, hypertension, and
decreased renal and hepatic function; caution in coagulation
abnormalities or during anticoagulant therapy | |
Drug Name
|
Naproxen (Naprosyn) -- For relief
of mild to moderately severe pain. Inhibits inflammatory reactions
and pain by decreasing enzyme cyclooxygenase activity, thus
inhibiting prostaglandin synthesis.
|
| Adult Dose |
500 mg PO, followed by 250 mg
q6-8h; not to exceed 1.25 g/d
|
| Pediatric Dose |
<2 years: Not
established
>2 years: 2.5 mg/kg/dose; not to exceed 10
mg/kg/d
| Contraindications |
Documented hypersensitivity
|
| Interactions |
Aspirin increases risk of inducing
serious NSAID-related adverse effects; probenecid may increase
concentrations and, possibly, toxicity; may decrease effects of
hydralazine, captopril, and beta-blockers; may decrease diuretic
effects of furosemide and thiazides; may increase PT in patients
taking anticoagulants—monitor PT closely and instruct patients to
watch for signs of bleeding; may increase risk of methotrexate
toxicity; may increase phenytoin levels
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Category D in third trimester of
pregnancy; acute renal insufficiency, interstitial nephritis,
hyperkalemia, hyponatremia, and renal papillary necrosis may occur;
patients with preexisting renal disease or compromised renal
perfusion risk acute renal failure; leukopenia occurs rarely, is
transient, and usually returns to normal during therapy; persistent
leukopenia, granulocytopenia, or thrombocytopenia warrants further
evaluation and may require discontinuation of drug | |
Drug Name
|
Ketoprofen (Oruvail, Orudis,
Actron) -- For relief of mild to moderately severe pain and
inflammation. Small dosages initially indicated in small and elderly
patients and in those with renal or liver disease. Doses over 75 mg
do not increase therapeutic effects. Administer high doses with
caution and closely observe patient for response.
|
| Adult Dose |
25-50 mg PO q6-8h prn; not to
exceed 300 mg/d
|
| Pediatric Dose |
3 months to 12 years: 0.1-1 mg/kg
PO q6-8h
>12 years: Administer as in adults
| Contraindications |
Documented hypersensitivity; third
trimester of pregnancy
|
| Interactions |
Aspirin increases risk of inducing
serious NSAID-related adverse effects; probenecid may increase
concentrations and, possibly, toxicity; may decrease effects of
hydralazine, captopril, and beta-blockers; may decrease diuretic
effects of furosemide and thiazides; may increase PT in patients
taking anticoagulants—monitor PT closely and instruct patients to
watch for signs of bleeding; may increase risk of methotrexate
toxicity; may increase phenytoin levels
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Category D in third trimester of
pregnancy; caution in congestive heart failure, hypertension, and
decreased renal and hepatic function; caution in coagulation
abnormalities or during anticoagulant therapy | |
Drug Name
|
Ketorolac (Toradol) -- Inhibits
prostaglandin synthesis by decreasing activity of enzyme
cyclooxygenase, which results in decreased formation of
prostaglandin precursors. PO form offers no advantage over other
less expensive PO NSAIDs.
|
| Adult Dose |
30 mg IV single dose; most common
route used in ED
>65 years, renal impairment, or <50
kg: 15 mg IV single dose
30-60 mg IM initially, followed by
15-30 mg q6h prn
Not to exceed 5 d of treatment; consider
only 1-2 days of treatment in elderly because of increased risk of
GI bleed
| Pediatric Dose |
Not established; suggested dose
0.4-1 mg/kg IM once
|
| Contraindications |
Documented hypersensitivity; peptic
ulcer disease; recent GI bleeding or perforation; renal
insufficiency; high risk of bleeding
Do not administer into CNS
|
| Interactions |
Aspirin increases risk of inducing
serious NSAID-related adverse effects; probenecid may increase
concentrations and, possibly, toxicity; may decrease effects of
hydralazine, captopril, and beta-blockers; may decrease diuretic
effects of furosemide and thiazides; may increase PT in patients
taking anticoagulants—monitor PT closely and instruct patients to
watch for signs of bleeding; may increase risk of methotrexate
toxicity; may increase phenytoin levels
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Category D in third trimester of
pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia,
interstitial nephritis, and renal papillary necrosis may occur;
increases risk of acute renal failure in patients with preexisting
renal disease or compromised renal perfusion; low WBC counts (rare)
usually return to normal during ongoing therapy; discontinue therapy
if persistent leukopenia, granulocytopenia, or thrombocytopenia
occurs | | Drug Category: Acetylsalicylic
acids -- These agents alleviate headache, possibly by
inhibiting prostaglandin synthesis.
Drug Name
|
Aspirin (Anacin, Ascriptin, Bayer
Aspirin, Bufferin) -- Treats mild to moderately severe pain.
Inhibits prostaglandin synthesis, which prevents formation of
platelet-aggregating thromboxane A2.
|
| Adult Dose |
325-650 mg PO q4-6h; not to exceed
4 g/d
|
| Pediatric Dose |
10-15 mg/kg/dose PO q4-6h; not to
exceed 60-80 mg/kg/d
|
| Contraindications |
Documented hypersensitivity; liver
damage; hypoprothrombinemia; vitamin K deficiency; bleeding
disorders; asthma
Because of association with Reye syndrome, do
not use in children (<16 y) with flu
|
| Interactions |
Antacids and urinary alkalinizers
may increase effects; corticosteroids decrease serum levels;
anticoagulants may cause additive hypoprothrombinemic effects and
increased bleeding time; may antagonize uricosuric effects of
probenecid and increase toxicity of phenytoin and valproic acid;
doses >2 g/d may potentiate glucose-lowering effect of
sulfonylurea drugs
|
| Pregnancy |
D - Unsafe in pregnancy
|
| Precautions |
May cause transient decrease in
renal function and aggravate chronic kidney disease; avoid use in
patients with severe anemia, with history of blood coagulation
defects, or taking anticoagulants | Drug
Category: Barbiturates -- These agents are used in
combination with aspirin and acetaminophen for pain relief and to induce
sleep. Caffeine is used to increase its GI absorption. However, butalbital
is associated with rebound headaches. Increasing use of these combination
preparations may fail to provide pain relief and worsen headache symptoms.
Drug Name
|
Acetaminophen, butalbital, and
caffeine (Fioricet) -- Drug combination used to relieve tension
headaches. Barbiturate component has generalized depressant effect
on CNS.
|
| Adult Dose |
1-2 tab PO at onset, repeat q4h;
not to exceed 6 doses in 24 h
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity
|
| Interactions |
Effects decreased by
phenothiazines, quinidine, tricyclic antidepressants, theophylline,
haloperidol, chloramphenicol, ethosuximide, corticosteroids,
warfarin, doxycycline, and beta-blockers; effects increased by CNS
depressants, methylphenidate, valproic acid, propoxyphene, and
benzodiazepines
|
| Pregnancy |
D - Unsafe in pregnancy
|
| Precautions |
Caution in patients with history of
substance abuse |
Drug Name
|
Butalbital, aspirin, caffeine
(Fiorinal) -- Drug combination used to relieve tension headaches.
Barbiturate component has generalized depressant effect on CNS.
|
| Adult Dose |
1-2 tab/cap PO q4h; not to exceed 6
tab/cap in 24 h
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity
|
| Interactions |
Effects decreased by
phenothiazines, quinidine, tricyclic antidepressants, theophylline,
haloperidol, chloramphenicol, ethosuximide, corticosteroids,
warfarin, doxycycline, and beta-blockers; effects increased by CNS
depressants, methylphenidate, valproic acid, propoxyphene, and
benzodiazepines
|
| Pregnancy |
D - Unsafe in pregnancy
|
| Precautions |
Caution in patients with history of
substance abuse | Drug Category:
Analgesics -- Patients with infrequent headaches can be
treated with simple analgesics initially.
Drug Name
|
Acetaminophen with codeine (Tylenol
#3) -- Indicated for treatment of mild to moderately severe
headache.
|
| Adult Dose |
30-60 mg/dose based on codeine
content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d; not to
exceed 4 g acetaminophen in 24 h
|
| Pediatric Dose |
0.5-1 mg/kg/dose based on codeine
content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content;
not to exceed 2.6 g/d of acetaminophen in 24 h
|
| Contraindications |
Documented hypersensitivity
|
| Interactions |
CNS depressants or tricyclic
antidepressants increase toxicity
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Caution in patients dependent on
opiates since this substitution may result in acute
opiate-withdrawal symptoms; caution in severe renal or hepatic
dysfunction |
Drug Name
|
Acetaminophen and oxycodone
(Percocet) -- Indicated for relief of moderately severe to severe
pain. DOC for aspirin-hypersensitive patients.
|
| Adult Dose |
1-2 tab/cap PO q4-6h prn headache
|
| Pediatric Dose |
0.05-0.15 mg/kg/dose oxycodone PO
q4-6h prn; not to exceed 5 mg/dose of oxycodone
|
| Contraindications |
Documented hypersensitivity
|
| Interactions |
Phenothiazines may decrease
analgesic effects; CNS depressants or tricyclic antidepressants
increase toxicity
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Duration of action may increase in
the elderly; be aware of total daily dose of acetaminophen patient
is receiving; do not exceed 4000 mg/24h of acetaminophen; higher
doses may cause liver toxicity |
Drug Name
|
Acetaminophen (Tylenol, Panadol,
Aspirin Free Anacin) -- DOC for pain in patients with documented
hypersensitivity to aspirin or NSAIDs or upper GI disease or taking
oral anticoagulants.
|
| Adult Dose |
325-650 mg PO q4-6h or 1000 mg
tid/qid; not to exceed 4 g/d
|
| Pediatric Dose |
<12 years: 10-15 mg/kg/dose PO
q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO
q4h; not to exceed 5 doses in 24 h
| Contraindications |
Documented hypersensitivity; G-6-P
deficiency
|
| Interactions |
Rifampin can reduce analgesic
effects; barbiturates, carbamazepine, hydantoins, and isoniazid may
increase hepatotoxicity
|
| Pregnancy |
B - Usually safe but benefits must
outweigh the risks.
|
| Precautions |
Hepatotoxicity possible in chronic
alcoholics who exceed 4000 mg/d; severe or recurrent pain or high or
continued fever may indicate serious illness; APAP contained in many
OTC products, and combined use with these products may result in
cumulative APAP doses exceeding safe daily
totals | | Drug Category:
Analgesic/antiemetic or sedatives -- These agents are
useful in aborting headache and treating emesis that results from acute
pain.
Drug Name
|
Prochlorperazine (Compazine) -- May
relieve nausea and vomiting by blocking postsynaptic mesolimbic
dopamine-receptors, through anticholinergic effects, and depressing
reticular activating system. In addition to antiemetic effects, has
advantage of augmenting hypoxic ventilatory response, acting as
respiratory stimulant at high altitude.
|
| Adult Dose |
5-10 mg PO/IM tid/qid; not to
exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10
mg/dose or 40 mg/d
25 mg PR bid
| Pediatric Dose |
2.5 mg PO/PR q8h or 5 mg q12h prn;
not to exceed 15 mg/d
IV dosing not recommended for
children
0.1-0.15 mg/kg/dose IM; change to PO as soon as
possible
| Contraindications |
Documented hypersensitivity; bone
marrow suppression; narrow-angle glaucoma; severe liver or cardiac
disease
|
| Interactions |
Other CNS depressants or
anticonvulsants may cause additive effects; with epinephrine may
cause hypotension
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Drug-induced Parkinson syndrome or
pseudoparkinsonism occurs quite frequently; akathisia is most common
extrapyramidal reaction in elderly; lowers seizure threshold;
caution in patients with history of seizures | | |
Drug Name
| Promethazine (Phenergan) --
Antidopaminergic agent effective in treating emesis. Blocks
postsynaptic mesolimbic dopaminergic receptors in brain and reduces
stimuli to brainstem reticular system.
|
| Adult Dose |
12.5 mg PO/PR tid and 25 mg
hs
25 mg IV/IM, repeat in 2 h prn; switch to PO as soon as
possible
| Pediatric Dose |
<2 years: Not
recommended
>2 years: 0.25-1 mg/kg PO/IV/IM/PR q4-6h prn
| Contraindications |
Documented hypersensitivity
|
| Interactions |
Other CNS depressants or
anticonvulsants may cause additive effects; with epinephrine may
cause hypotension
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Caution in cardiovascular disease,
impaired liver function, seizures, sleep apnea, and
asthma | | |
Further Outpatient Care:
- Physical therapy for patients with headache includes warm and cold
packs, ultrasound, and electrical stimulation.
- Regular exercise, stretching, balanced meals, and adequate sleep are
part of a headache prevention program.
- Trigger point injections, occipital nerve blocks, or changes that
improve posture may be used.
Deterrence/Prevention:
- Biofeedback and relaxation therapy
- Injection of trigger points
Complications:
- Undue reliance on nonprescription caffeine-containing
analgesics
- Dependence on/addiction to narcotic analgesics
- GI bleed from use of NSAIDs
- Risk of epilepsy 4 times greater than that of the general
population
Prognosis:
- Headache is usually chronic if life stressors are not
changed.
- Most cases are intermittent and do not interfere with work or normal
life span.
REFERENCES
- Arena JG, Bruno GM, Hannah SL, et al.: A comparison of frontal
electromyographic biofeedback training, trapezius electromyographic
biofeedback training, and progressive muscle relaxation therapy in the
treatment of tension headache. Headache 1995 Jul-Aug; 35(7): 411-9
- Bogaards MC, ter Kuile MM: Treatment of recurrent tension headache:
a meta-analytic review. ALYSIS 1994 Sep; 10(3): 174-90
- Carlsson J, Augustinsson LE, Blomstrand C, et al.: Health status in
patients with tension headache treated with acupuncture or
physiotherapy. Headache 1990 Sep; 30(9): 593-9
- DeBenedittis G, Lorenzetti A, Sina C: Magnetic resonance imaging in
migraine and tension-type headache. Headache 1995; 35: 264-268.
- Ficek SK, Wittrock DA: Subjective stress and coping in recurrent
tension-type headache. Headache 1995 Sep; 35(8): 455-60
- Iversen HK, Langemark M, Andersson PG, et al.: Clinical
characteristics of migraine and episodic tension-type headache in
relation to old and new diagnostic criteria. Headache 1990 Jul; 30(8): -
Hansen PE
- Silberstein SD: Tension-type headaches. Headache 1994 Sep; 34(8):
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