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Tension-Type headache


Tension-Type headache


Tension-type headache ( TTH ) is the most common primary headache disorder across all age groups worldwide.

Ill-defined heterogeneous syndrome – often diagnosed based on 
absence of features found in other headache types Term coined by International Headache Society to describe a new heading that underlies the uncertain pathogenesis but, nevertheless indicates that some form of mental or muscular tension may play a role Lifetime prevalence may vary from 30-78 % TTHA leads to considerable disability , decreased effectiveness from
 work , ↑↑ absenteeism and ↓↓ social engagement Features may overlap with a migraine ( may co-exist with other headache disorders) Females are affected slightly more Patients less likely to seek medical attention, in comparison to migraine

Exact cause – not known Psychological stress Peripheral pain mechanisms ( Episodic TTH ) Central pain mechanisms and Generalized increased pain sensitivity
( Chronic ) Possibly multifactorial ( factors involving CNS, PNS and environmental factors ) Genetic factors

episodic tension type headache

Infrequent episodic ,frequent episodic, chronic Duration 30 min to 7 days
 At least two of

♦ b/l location 
♦ pressing or tightening ( non-pulsatile ) quality
♦ mild or moderate intensity
♦ not aggravated by routine physical activity such as walking or climbing stairs
 No nausea or vomiting and no more than one of photophobia or phonophobia
 Not better accounted by any other cause

Presentation-B/L head pain of mild- moderate intensity with a pressing, tightening, squeezing quality ” Band round the head ” – constriction band Does not worsen with routine physical activity Commonly spreads into or arises from the neck Not associated with any significant autonomic symptoms Headache worsens as the day progresses Frontal and occipital region most commonly affected Headache not exacerbated by physical activity unlike migraine No nausea or vomiting 
( mild nausea may happen in chronic TTH ) Rarely incapacitating Pericranial tenderness Patients with chronic TTH are ↑↑ likely than those with an episodic type to seek help

Check- General history Neurological examination , mental 
Fundoscopy BP , temp , head injury ( elderly ) Temporal tenderness Manual palpation of pericranial muscles
Commonly tender muscles include
SCMastoid , trapezius, temporalis , lateral pterygoid and massater Neurological examination should be normal Lab tests should be unremarkable ( not helpful )
 CT of sinuses
MRI of brain
Lumbar puncture

Differential-Migraine – particular mild migraine without aura Giant cell arteritis Temperomandibular joint dysfunction Trigeminal autonomic cephalgias eg
○ cluster headache
○ paroxysmal hemicranias Significant cervical pathology Tumours (Pituitary, brain ) Medication overuse in chronic headaches Sinusitis Chronic subdural haematoma Idiopathic intracranial hypertension

Red flags-Thunderclap headache- sudden onset “worse headache of my life” 
( max intensity within 5 minutes ) New onset headache in a person over 50 ( r/o temporal arteritis ) Progressive or persistent headache that has changed dramatically Associated symptoms as
○ fever , impaired consciousness , seizure , neck pain/ stiffness or photophobia
○ papilloedema
○ new onset neurological deficit
○ atypical aura
○ dizziness
○ visual disturbance
○ vomiting Recent ( within 3 months ) head injury Headache triggered by cough , Valsalva or sneeze Headache that worsens on standing ( CSF leak ) Headache that worsens on lying down (SOL , CVS thrombosis ) Visual disturbance ( glaucoma ) Vomiting Contacts with similar symptoms ( eg carbon monoxide poisoning ) Immunosuppression Current or past malignancy

 Biofeedback Physical measures eg
Physiotherapy , acupuncture
spinal manipulation Myofascial trigger point focused massage CBT Lifestyle Exercise Relaxation training

Amitriptyline ( 10-75 mg ) Consider other tricyclics if one not effective SSRIs ( limited evidence ) Venlafaxine ,Mirtazepine 
small studies have suggest may be of some value Botulinium toxin not recommended ( SIGN ) 

Further study-research needed (10 )

References Tension -Type Headache : A Life-Course Review Karen E Waldie et al Review Article iMedPub Journals Tension-Type headache : current research and clinical managementAmaud Fumal, Jean Schoenen Lancet Neurology , The, 2008-01-01, Volume 7,, Issue 1, Pages 70-83 Primary Headache Disorders- Part 2 : Tension-type headache and medication overuse headache Gary w et al Disease-a-month, 2017-12-01 , Volume 63 , Issue 12, Pages 342-367 Headache- tension type CKS NHS Last revised November 2017 EFNS guideline on the treatment of tension-type-headache- Report of an EFNS task force European Journal of Neurology 2010 ,17 : 1318-1325 Tension Headache Medscape BMJ Best Practice Tension-type headache Tension-type headache BMJ 2008 336 ;88 Minor Emergencies Philip Buttaravoli et al Mosby Lack of benefit for prophylactic drugs of tension-type headache in adults DynaMed Plus Tension Type headache Diagnosis and management of headache in adults A national clinical guideline SIGN Nov 2008


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