Tension headache
Definition
Epidemiology
Commonest type of
headache
Pathophysiology
Primary idiopathic
headache disorder
Pathology
Nil serious pathology; unclear cause
Peripheral pain mechanisms in episodic type, central
pain mechanisms in chronic type
Pericranial pain sensitivity plus triggers (stress, caffeine, disturbed sleep)
Classification
Infrequent episodic: <1d/m; little QoL impact, self managed
Frequent episodic: 10+ headaches on <15d/m, +/- disability
Chronic: 15+ d/m for 3+m, considerable disability
Most people at some point (80%)
F>M
Clinical
presentation
Diagnosis
Differentials
Management
Complications
Psychosocial
Reduced QoL, anxiety, depression
Medication overuse headache
Chronic analgesia use
Prognosis
Episodic often self limiting and
responds to simple analgesia
Can evolve from episodic to chronic,
with reduced QoL and disability
Headache
Bilateral temporal
Pressing/tightening
Lasts min-days
Investigations
Examination
History
DH
Current meds (analgesia?), allergies
FH
Headaches, neurological disorders
PMH
Children: growth and development, vaccinations
Known medical conditions, previous surgery
SH
Occupation/school, living arrangements,
smoking, alcohol, leisure activities
PC/HPC
Headache: SOCRATES (bilateral temporal,
pressing/tight band, mins-days, no aggrevators)
Associated symptoms: may have photophobia/phonophobia
Previous episodes
Neuro
Normal
May have some pericranial tenderness
Bedside
Obs (nil)
Classification
(International Classification
of Headache Disorders)
Frequent episodic
10+ headaches on 1-14d/m for >3m
Last 30m-7d
2+ of: pressing/tightening; mild-mod; not aggrevated by routine activity; no N+V; no photo AND phono
Not better accounted by another cause
Chronic
15+d/m for >3m
Last hr-days/unremitting
2+ of: pressing/tightening; mild-mod; not aggrevated by routine activity; no N+V; no photo AND phono
Not better accounted by another cause
Infrequent episodic
10+ headaches on <1d/m
Last 30m-7d
2+ of: billateral, pressing/tightening; mild-mod; not aggrevated by routine activity; no N+V; no photo AND phono
Not better accounted by another cause
Primary headache
Migraine
Cluster
Secondary
Vascular: SDH, ICH, CVST, pre-eclampsia
Infection: meningitis, encephalitis,
otitis media, sinusitis, optic neuritis
Trauma: head, neck
Autoimmune: GCA
Metabolic: hypoxia, hypercapnia, CO poisoning
Idiopathic: IIH, AACG, TMJ problems,
trigeminal neuralgia
Neoplastic: CNS cancer
Drugs: cocaine, alcohol, med overuse headache
Conservative
Information, advice, support
Identify and treat comorbidities
Self care (rest, fluids, avoid triggers, headache diary)
Refer to neurology if failure to respond to tx/unclear diagnosis
Medical
Simple analgesia
Indication: 1L episodic type
E.g. paracetamol, ibuprofen, aspirin
Acupuncture
Indication: prevention for chronic type
E.g. 10 sessions over 5-8w
TCAs
Indication: prevention for chronic type
E.g. amitryptilline
Imaging
CT head (if unclear diagnosis)