Tension headache

Dimitris Papadopoulos MD Fellow Of Interventional Pain Practice (FIPP)

Updated 23 March, 2011

GENERAL

Tension headache is the most common type of headache. Episodes of tension headache occur frequently and are short in duration, not more than a few hours. The intensity of pain is moderate to severe. Patients describe headache episodes as “a strong pressure or tighening around their head, like a clamp”. The feeling of distress and tightening may start either from the neck region or from the scalp extending towards the neck.
Patients do not isolate in a dark room, as happens with migraine, but may even be able to go on working. Tension headache episodes are not associated with nausea or/and vomiting and there is no phonophobia and phogophobia, as opposed to migraine.

The main triggering factor is anxiety, even if there is no obvious reason for being anxious. Anxiety is believed to cause contraction (tension) of  head muscles. However, other triggering factors can also be acting, such as some sort of food, staying in the sun, intense fatigue, insomnia, the day following too much alcohol consumption etc.

The reason for which patients resort to a specialist is the high incidence of episodes and the difficulty of  treating them effectively. Tension headache is characterized as chronic when there are more than 15 episodes a month and sometimes it may even occur daily. The chronic form of tension headache needs special treatment for the acute episodes and prevention therapy for reducing the incidence and intensity of episodes.

TREATMENT

The first therapeutic measures aim at relaxation: physiotherapy and massage of the muscles of the back and neck, which are usually in contraction due to the style of life, type of work and body posture during walking and sitting.
Should the patient live under too much anxiety, stress and pressure, the initial measure is to manage anxiety with relaxation exercises for the spirit and body (yoga, music therapy, meditation etc).

PHARMACOTHERAPY

Over-The-Counter drugs/ OTC (non-prescribed) for treating acute episodes

• Aspirine (600-900mg)
• Ιbuprofen (400mg)

Anti-inflammatory drugs (prescribed)

• Ketoprofen (25-50mg)
• Νaproxen (250-500 mg)

Paracetamole (500-1000mg) seems to be less effective.
It is preferable for children and adolescents below 16 years old not to take aspirine.
In case of chronic tension headache, administration of Naproxen (250-500mg) twice daily for a period of three weeks (as long as there is no contraindication for long-term use of antiinflammatory drugs) can interrupt the circle of frequently repeated episodes. Should the regimen fail, it should not be repeated again.

PREVENTION THERAPY

The drug of choice is Amitriptyline. It belongs to the category of tricyclic antidepressants. Very often the drug is not easily tolerated and in this case the slow and gradual increase of the dose is recommended. The dose begins from 10-25mg at bedtime and may go up to 75-150mg.
The efficacy of the drug, regarding the reduction of frequency of episodes, should be assessed only after a satisfactory therapeutic dose has been achieved (with no significant drug side effects) and only if 6-8 weeks have elapsed from the beginning of treatment. The gradual discontinuation of the drug can be attempted after 4-6 months, as long as a steady and satisfactory condition has been achieved.
Although SSRIs have fewer side effects, they are not proven to be effective in preventing chronic tension headache.
B-blockers may aggravate depression, as long as it coexists with stress. Tranquillizers, like Venzodiazepines, should be avoided because, when taken for a long time, they may cause addiction.

DRUGS THAT SHOULD BE AVOIDED IN TENSION HEADACHE

• Codein
• Strong opioids
• Botulinum Toxin (BOTOX) is effective in tension headache.

MEDICAL INFORMATION SOURCES

BRITISH ASSOCIATION FOR THE STUDY OF HEADACHE