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)