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• Managing Tension-Type Headaches
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Headaches - tension

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of common headaches.

Introduction

Most people are familiar with headaches, the all too common affliction marked by throbbing, piercing, or vise-like pain around much or a part of the head. There are many different kinds of headaches, and they range from being an infrequent annoyance to a persistent, severe, and disabling medical condition.

The brain itself is insensitive to pain, so that is not what hurts when a headache arises. The pain, instead, occurs in the following locations:

• The tissues covering the brain
• The attaching structures at the base of the brain
• Muscles and blood vessels around the scalp, face, and neck

Doctors categorize headaches as either primary or secondary, which helps to distinguish the many different kinds of headaches and to determine appropriate treatments for each.

Primary Headaches. A headache is considered primary when a disease or other medical condition does not cause it. Most primary headaches fall into three main types: Tension-type, migraine, and cluster headaches.

• Tension headache is the most common primary headache and accounts for 90% of all headaches.
• Neurovascular headaches are the second most frequently occurring primary headaches and include migraines (the more common) and cluster headaches. Such headaches are caused by an interaction between blood vessel and nerve abnormalities. [For more information, see In-Depth Report #97: Migraine headaches; and Report #11: Tension headaches.]

Symptoms of migraine and tension-type headaches often overlap, and a diagnosis is sometimes difficult.

Secondary Headaches. Secondary headaches are caused by other medical conditions, such as sinus infections, neck injuries, and strokes. About 2% of headaches are secondary to abnormalities or infections in the nasal or sinus passages, and they are commonly referred to as sinus headaches.

Chronic Daily Headaches. The International Headache Society's classification system includes a category called chronic daily headaches. They may originate as tension headaches, migraines, or a combination of these or other headache types. Chronic daily headaches affect 4 - 5% of the population.

Chronic daily headaches are defined as any benign headache that occurs at least 15 days a month and is not associated with a serious neurologic abnormality. Most people with these headaches have them daily, or almost daily, and they can be quite debilitating.

Chronic daily headaches are, in turn, subdivided into two categories:

• Short-duration headaches last less than 4 hours. The most common short-acting chronic headaches are cluster headaches.
• Long-duration headaches last more than 4 hours. Tension-type headaches are the most common type of long-duration chronic (recurring) headaches and, in fact, the most common type of chronic headaches in general.

Tension-Type Headaches

General Description. Tension-type headaches, also called muscle contraction headaches or simply tension headaches, are the most common of all headaches. Tension-type headaches can last minutes to days and have the following characteristics:

• The pain is commonly described as a tight feeling, as if the head were in a vise. It usually occurs on both sides of the head and is often experienced in the forehead, in the back of the head and neck, or in both regions. Soreness in the shoulders or neck is common.
• Depression, anxiety, and sleeping problems may accompany persistent headaches.
• Sufferers of tension-type headaches may also have migraine-like symptoms, including being sensitive to light or noise (but not both). Some patients also may suffer from visual disturbances. (Such symptoms in tension headaches, however, tend to be less severe than in migraine. Tension headaches also do not cause nausea or limit activities to the degree that migraines do.)

Types of Tension Headache . In 2004, the International Headache Society updated its original 1988 classification criteria. Tension-type headaches are now divided into the following four classifications:

• Frequent episodic tension-type headache. Headaches occur at least once but not more than 15 days per month for at least 3 months (a minimum of 12 days but not more than 180 days per year). Headaches last from at least 30 minutes to 7 days.
• Infrequent episodic tension-type headache. At least 10 episodes of headache that occur less than 1 day per month (12 days per year). Because these headaches occur infrequently, they do not impact a patient's quality of life as severely as frequent episodic headaches and may not require attention from a medical professional.
• Chronic tension-type headache. Headaches occur at least 15 days per month for at least 3 months (180 days per year). The headache persists for hours at a time and may be continuous.
• Probable tension-type headache. Probable tension headaches may be classified as probable frequent episodic, probable infrequent episodic, or probable chronic. They have most, but not all, of the symptoms of tension-type headaches and are not attributed to migraine without aura or other neurological disorders. Probable chronic tension-type headache may be related to medication overuse.

OTHER PRIMARY HEADACHES Migraine Headache: General Description of Its Course Migraine is now recognized as a chronic illness, not simply as a headache. These headaches are often classified by whether or not auras accompany them: Common migraine s are without auras. About 75% of migraines are the common type. Classic migraines are those with auras. A person may experience one or the other at different times. In general, there are four symptom phases to a migraine (although they may not all occur in every patient): the prodrome phase, auras, the attack, and the postdrome phase. Prodrome. The prodrome phase is a group of vague symptoms that may precede a migraine attack by several hours, or even a day or two. Prodrome symptoms include: Sensitivity to light or sound Changes in appetite Fatigue and yawning Malaise Mood changes Food cravings Auras. Auras are sensory disturbances that occur before the migraine attack in between 20 - 25% of patients. Visually, auras are referred to as being positive or negative: Positive auras include bright or shimmering light or shapes at the edge of their field of vision called scintillating scotoma . They can enlarge and fill the line of vision. Other positive aura experiences are zigzag lines or stars. Negative auras are dark holes, blind spots, or tunnel vision (inability to see to the side). Patients may have mixed positive and negative auras. This is a visual experience that is sometimes described as a fortress with sharp angles around a dark center. Other neurologic symptoms may occur at the same time as the aura, although they are less common. They include: Speech disturbances Tingling, numbness, or weakness in an arm or leg Perceptual disturbances such as space or size distortions Confusion Migraine Attack. If untreated, attacks usually last from four to 72 hours. A typical migraine attack produces the following symptoms: Throbbing pain on one side of the head. The word migraine, in fact, is derived from the Greek word hemikrania , meaning "half of the head" because the pain of migraine often occurs on one side. Pain also sometimes spreads to affect the entire head. Pain worsened by physical activity. Nausea, sometimes with vomiting. Visual symptoms. Facial tingling or numbness. Extreme sensitivity to light and noise. Looking pale and feeling cold. Less common symptoms include tearing and redness in one eye, swelling of the eyelid, and nasal congestion, including runny nose. (Such symptoms are more common in certain other headaches, notably cluster headaches. In one study, however, they occurred in over 40% of migraine sufferers.) Postdrome. After a migraine attack, there is usually a postdrome phase, in which patients may feel exhausted and mentally foggy for a while. Cluster Headache Cluster headaches are very painful events. Patients typically awaken a few hours after they go to sleep with the following symptoms: Very severe, stabbing pain centered in one eye. Excessive tearing, a drooping eyelid, and one stuffy or runny nostril, all on the same side as the pain. Feelings of intense restlessness are common. People in the throes of a cluster headache may pace the floor or may even bang their heads against the wall in an attempt to cope with the pain. Cluster headaches often have a cycle with the following pattern: Attacks themselves are usually brief, lasting 30 - 90 minutes, although they can persist for up to 3 hours. During an active period, sufferers can experience as few as one attack every other day to one or more daily. In a rare form of cluster headache, known as chronic paroxysmal hemicrania, as many as six attacks per day can occur. An active period of recurrent cluster attacks typically extends over 4 - 12 weeks. Headache-free periods last several months to even years. Hemicrania Continua Hemicrania continua is a rare form of chronic headache. Such headaches occur on one side of the face, mostly in women. The patient generally experiences continuous low-level headache with periodic attacks that can last days to weeks. (About 10% of patients experience remissions.) The actual attacks can be mild to severe, and may resemble migraines. The headaches can usually be treated successfully with NSAIDs such as indomethacin (Indocin). Migraine medications are typically not as helpful.

• Review Date: 10/3/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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