History

Fact Explanation
Headache Tension type headache is the most commonest type of headache. Though the exact pathophysiology is not cleat yet, it is thought to be caused by multiracial means such as neurological, vascular, muscular and psychological. As it does not show any apparent underlying organic disease process, tension headache is classified as a primary headache. Patients often complains of a headache of mild or moderate in intensity. It is described as tightness, pressure, or a dull ache experienced as a band extending bilaterally back from the forehead. It may also extend across the sides of the head to the back of the head (occiput). Sometimes the pain may radiate from the back of the head to the posterior neck muscles. The frequency of the occurrence may vary. Some patients gets episodic headaches whereas some may complain of a chronic/ daily headache. Episodic type may last from 30 minutes to 7 days. It does not aggravate from walking stairs or similar routine activities and does not pulsatile as well. [1,2,3,4,5]
Neck/ jaw discomfort The characteristic headache may be accompanied by sense of discomfort in the neck or jaw. This is due to co-existing muscle contraction tension type headache that affects the neck muscles and temperomandibular joint spasms. Headache with a "cape like" distribution denotes the most extensive form of the disease. When it occursthe pain radiates along the medial and lateral trapezius muscles covering the shoulders, scapular, and interscapular areas. [1,2,3,4]
Important negative facts There are several important negative facts in the the history that must be evaluated. Most of them are helpful in differentiating the tension type headache from migraine. Patients usually does not complain of nausea or vomiting. Photophobia and phonophobia are usually absent, or only one is present. Patients with tension type headache do not typically report any form of aura, constant generalized pain, fever, stiff neck, recent trauma, or bruxism. [1,2,3,6]
past history of similar events Tension type headache is the most commonest type of primary headache which is recurring/ episodic or chronic in human. Therefore patients may give a past history of similar events. Most of them are usually same as the above and are usually self limiting. And they are usually associated with a stressful events. These patients may have either episodic, chronic tension-type headache or chronic daily headache. Chronic tension-type headache is the same as tension-type headache which occurs at least 15 days per month, for at least six months. It is named as Chronic daily headache when it occurs at least 6 days per week. When the frequency is less than 180 per year or 15 per month, it is called as episodic type of tension headache. [1,3,5]
Risk factors This headache may be exacerbated by inadequate rest, poor posture and emotional or mental stress, including depression. The most common sources of stress include family, social relationships, friends, work, and school. Females and adolescents are found to be slightly more predisposed to tension type headache than others. [1,2,4]
Complications Complications of the tension type headache is usually caused by the improper therapy. Undue reliance on nonprescription caffeine-containing analgesics, dependence on narcotic analgesics, gastrointestinal bleed caused by log term/ frequent use of NSAIDs are some of them. Additionally, It has been found that the risk of epilepsy in these patients is higher than that of the general population. Some patients with chronic or daily variant may progress in to migraine. [1,2,3,5]
References
  1. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia [online] December, 33(9):629-808 [viewed 09 September 2014] Available from: doi:10.1177/0333102413485658
  2. MERIKANGAS KR, CUI L, RICHARDSON AK, ISLER H, KHOROMI S, NAKAMURA E, LAMERS F, RöSSLER W, AJDACIC-GROSS V, GAMMA A, ANGST J. Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study BMJ [online] 2011:d5076 [viewed 09 September 2014] Available from: doi:10.1136/bmj.d5076
  3. TAVASOLI A, AGHAMOHAMMADPOOR M, TAGHIBEIGI M. Migraine and tension-type headache in children and adolescents presenting to neurology clinics. Iran J Pediatr [online] 2013 Oct, 23(5):536-40 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24800013
  4. SCHRAMM SH, OBERMANN M, KATSARAVA Z, DIENER HC, MOEBUS S, YOON MS. Epidemiological profiles of patients with chronic migraine and chronic tension-type headache. J Headache Pain [online] 2013 May 7, 14(1):40 [viewed 09 September 2014] Available from: doi:10.1186/1129-2377-14-40
  5. SJAASTAD O. Tension-type headache: one or more headaches? Funct Neurol [online] 2011 Jul-Sep, 26(3):165-70 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22152438
  6. CHOWDHURY D. Tension type headache. Ann Indian Acad Neurol [online] 2012 Aug, 15(Suppl 1):S83-8 [viewed 09 September 2014] Available from: doi:10.4103/0972-2327.100023

Examination

Fact Explanation
Tender spots Palpation of the scalp may cause tenderness. This is due to the involvement of the pericranial musculature and tension in the nuchal musculature or trapezius. [1,2,3]
Tender cervical muscles Upper cervical muscles are tender to palpate in some patients. This is more commonly found in those with occipital tension headaches, because of the extention of the disease or spasm towards the cervical musculature. [1,2,3]
Important negative signs Vital signs such as blood pressure should be normal. Hypertension is associated with a headache which has similar features. But its resolution with blood pressure control is differentiating. Neurological examination must be normal. Serious intracranial pathologies such as occult brain tumors, hemorrhage, or increased cerebrospinal fluid pressure has to be excluded. Patient does not show any sign suggetive of cranial nerve defects, cerebellar dysfunction, papilledema, fundal abnormalities or visual field defects. There are no motor or sensory deficits. Absence of the tenderness over the temporal arteries rule out temporal arteritis. [1,2,3]
References
  1. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia [online] December, 33(9):629-808 [viewed 09 September 2014] Available from: doi:10.1177/0333102413485658 2)
  2. MERIKANGAS KR, CUI L, RICHARDSON AK, ISLER H, KHOROMI S, NAKAMURA E, LAMERS F, RöSSLER W, AJDACIC-GROSS V, GAMMA A, ANGST J. Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study BMJ [online] 2011:d5076 [viewed 09 September 2014] Available from: doi:10.1136/bmj.d5076
  3. TAVASOLI A, AGHAMOHAMMADPOOR M, TAGHIBEIGI M. Migraine and tension-type headache in children and adolescents presenting to neurology clinics. Iran J Pediatr [online] 2013 Oct, 23(5):536-40 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24800013

Differential Diagnoses

Fact Explanation
Migraine Migraine is a chronic neurological disorder characterized by recurrent moderate to severe headache. This is usually associated with several other symptoms such as nausea, vomiting and sensitivity to light, sound, or smell. There are several other symptoms which are common to both migraine and sinusitis namely facial pain, sinus pressure, nasal congestion, rhinorrhoea and teary eyes. [1]
Cluster headache Cluster headache is a primary headache with a neurovascular origin. Patients present with symptoms usually over a period of several weeks. The headache is strictly unilateral and severe. Orbital, supraorbital, or temporal the pain is lasting for 15-180 minutes and occur in a range from once every other day to eight times a day. Ipsilateral conjunctival injection, nasal congestion lacrimation, rhinorrhea, forehead and facial sweating, miosis, eyelid edema or ptosis will be associated with the pain. [2]
Sinusitis Sinusitis is an infectious or non-infectious inflammation of one or more para nasal sinuses. The infection may be bacterial, viral or fungal. Non-infectious sinusitis is allergic in origin. Acute sinusitis is defined as the infection lasts less than 4 weeks and symptoms resolves completely with treatment. In sub acute cases, the infection lasts 4 - 12 weeks whereas in chronic sinusitis it lasts more than 12 weeks with or without treatment. The majority of cases follow a viral upper respiratiory tract infection which involves the whole upper respiratory epithelium including the para nasal sinuses. Such infections cause hyperaemia and edema of the mucosa which block the ostia. There will be a cellular infiltration and an increase in mucous production which blocks the nasal passage. Excessive mucous production causes initial watery nasal discharge. Stasis of secretion occurs due to paralyzed cilia. This leads to secondary bacterial infection which makes the nasal discharge purulent. [1,3]
Temporal Arteritis Temporal Arteritis (Giant-cell arteritis) is a form of vasculitis characterised by inflammation of the branches of the external carotid artery. The onset of the disease in either insidious or acute. Constitutional symptoms such as fever, malaise, anorexia, myalgia, weight loss and night sweats are followed by a headache usually localised to the temporal or occipital area. [4]
Meningitis Meningitis is the acute inflammation of the meninges covering the brain and spinal cord. Patients present with usually fever, vomiting, headache and feeling unwell. This may be followed by sleepiness confusion, irritability, delirium and coma. [5]
Somatoform Disorder Somatoform Disorder is a mental disorder characterized by physical symptoms that suggest physical illness or injury that can not be explained by any medical means. Patients can be presented with a wide range of severity. There may be mild symptoms such as stomachache and headache, to chronic disabling symptoms, such as seizures and paralysis. [6]
References
  1. AL-HASHEL JY, AHMED SF, ALROUGHANI R, GOADSBY PJ. Migraine misdiagnosis as a sinusitis, a delay that can last for many years. J Headache Pain [online] 2013 Dec 12:97 [viewed 26 May 2014] Available from: doi:10.1186/1129-2377-14-97
  2. MATHARU M. Cluster headache Clin Evid (Online) [online] :1212 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907610
  3. DESROSIERS M, EVANS GA, KEITH PK, WRIGHT ED, KAPLAN A, BOUCHARD J, CIAVARELLA A, DOYLE PW, JAVER AR, LEITH ES, MUKHERJI A, SCHELLENBERG RR, SMALL P, WITTERICK IJ. Canadian clinical practice guidelines for acute and chronic rhinosinusitis Allergy Asthma Clin Immunol [online] , 7(1):2 [viewed 27 May 2014] Available from: doi:10.1186/1710-1492-7-2
  4. NESS T, BLEY TA, SCHMIDT WA, LAMPRECHT P. The Diagnosis and Treatment of Giant Cell Arteritis Dtsch Arztebl Int [online] 2013 May, 110(21):376-386 [viewed 09 September 2014] Available from: doi:10.3238/arztebl.2013.0376
  5. DE FáTIMA MAGALHãES ACIOLY MENDIZABAL M, BEZERRA PC, GUEDES DL, CABRAL DB, DE BARROS MIRANDA-FILHO D. Prognostic indicators in bacterial meningitis: a case-control study. Braz J Infect Dis [online] 2013 Sep-Oct, 17(5):538-44 [viewed 10 September 2014] Available from: doi:10.1016/j.bjid.2013.01.016
  6. MAHARAJ R, ALEXANDER C, BRIDGLAL CH, EDWARDS A, MOHAMMED H, RAMPAUL T, SANCHEZ S, TANWING G, THOMAS K. Somatoform disorders among patients attending walk-in clinics in Trinidad: prevalence and association with depression and anxiety. Ment Health Fam Med [online] 2013 Jun, 10(2):81-8 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24427174

Investigations - for Diagnosis

Fact Explanation
CT scan/ MRI scan Neuroimaging is not needed except those who have abnormal findings on examination or the nature of the headache is changing recently. They are useful to exclude secondary causes of headache such as intracranial hemorrhages and tumors. Otherwise the diagnosis of the tension type headache is clinical. [1,2,3]
References
  1. SCHRAMM SH, OBERMANN M, KATSARAVA Z, DIENER HC, MOEBUS S, YOON MS. Epidemiological profiles of patients with chronic migraine and chronic tension-type headache. J Headache Pain [online] 2013 May 7, 14(1):40 [viewed 09 September 2014] Available from: doi:10.1186/1129-2377-14-40
  2. SJAASTAD O. Tension-type headache: one or more headaches? Funct Neurol [online] 2011 Jul-Sep, 26(3):165-70 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22152438
  3. CHOWDHURY D. Tension type headache. Ann Indian Acad Neurol [online] 2012 Aug, 15(Suppl 1):S83-8 [viewed 09 September 2014] Available from: doi:10.4103/0972-2327.100023

Management - General Measures

Fact Explanation
Counselling Recognizing and treating the underlying stress and tension that cause in the headache plays a major role in the management. Counseling helps the patient to identify the trigger for the headache that is helpful in further psychological interventions if needed. [1,2,3,4]
Patient education Patient should be educated regarding the disease and how it begins. Keeping a headache diary may help in detecting the triggering factors. Patients should be educated that the proper treatment by a doctor is very important though over the counter medications may relieve the pain. They must be told regarding the possibility of developing chronic headache , rebound headache or drug dependence due to improper use of the medications. [1,2,5]
Prevention Handling stress, cessation of smoking, balanced diet, adequate sleep, exercise, correct posture, resting in between while working on computer or watching TV are important in prevention. Treatment should be taken for depression or anxiety. [1,2,3]
Hot or cold packs In general, ice and heat can be used to lessen the pain of headaches by releaving muscle spasms. The choice of either cold or warm depends on the individual sufferer. Most of them prefer warm packs. Cautions must be taken as overly hot packs can sometimes cause the opposite effect such as muscle spasm and, in extreme cases, cause burns. [1,2,3,4]
Positioning Uncomfortable stressful position and/or bad posture may results in aggravating the disease. Proper positioning and a supportive pillow are helpful in reducing the pain. [2,3,4]
Stretching exercises Stretching exercises to the neck has found to be helpful in revealing the muscle spasms that cause in the neck pain. [1,3,4]
Massage Massage therapy is useful in chronic tension headache. The muscle-specific massage therapy technique is a potential nonpharmacological intervention to reduce the incidences. [1,2,5]
Acupuncture Aupuncture has a role in the treatment of recurrent headaches. It is often used for tension-type headache prophylaxis as well. but its effectiveness is still controversial. Acupuncture has been shown to decrease the severity and frequency of headaches. [2,3,6]
References
  1. he International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia [online] December, 33(9):629-808 [viewed 09 September 2014] Available from: doi:10.1177/0333102413485658
  2. TAVASOLI A, AGHAMOHAMMADPOOR M, TAGHIBEIGI M. Migraine and tension-type headache in children and adolescents presenting to neurology clinics. Iran J Pediatr [online] 2013 Oct, 23(5):536-40 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24800013
  3. MERIKANGAS KR, CUI L, RICHARDSON AK, ISLER H, KHOROMI S, NAKAMURA E, LAMERS F, RöSSLER W, AJDACIC-GROSS V, GAMMA A, ANGST J. Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study BMJ [online] 2011:d5076 [viewed 09 September 2014] Available from: doi:10.1136/bmj.d5076
  4. SCHRAMM SH, OBERMANN M, KATSARAVA Z, DIENER HC, MOEBUS S, YOON MS. Epidemiological profiles of patients with chronic migraine and chronic tension-type headache. J Headache Pain [online] 2013 May 7, 14(1):40 [viewed 09 September 2014] Available from: doi:10.1186/1129-2377-14-40
  5. QUINN C, CHANDLER C, MORASKA A. Massage Therapy and Frequency of Chronic Tension Headaches Am J Public Health [online] 2002 Oct, 92(10):1657-1661 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447303
  6. LINDE K, ALLAIS G, BRINKHAUS B, MANHEIMER E, VICKERS A, WHITE AR. Acupuncture for tension-type headache. Cochrane Database Syst Rev [online] 2009 Jan 21:CD007587 [viewed 09 September 2014] Available from: doi:10.1002/14651858.CD007587

Management - Specific Treatments

Fact Explanation
Simple analgesics Simple analgesics such as Acetylsalicylic acids (Aspirin) and acetaminophen gives symptomatic relief of episodic or chronic tension headaches. This is thought to be by inhibiting the synthesis of prostaglandin, the main pain mediator of the body. Analgesics can be augmented with a sedating antihistamine, or an antiemetic for better efficacy. Metoclopramide, prochlorperazine, promethazine and diphenhydramine are used in this purpose. [1,2,3,4]
Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs such as ibuprofen is the drug of choice in the initial therapy. NSAIDs may alleviate headache pain by inhibiting prostaglandin synthesis. [1,3,5]
Barbiturates Barbiturates along with simple analgesics has been found to relieve pain and induce sleep. The combination is usually quite effective, however, there is a risk of developing rebound headache/ chronic daily headache with long term use. Therefore, patients should be informed of this possibility before initiating regimen. They should be instructed to limit their use of the combination to twice weekly. [1,2,4,5]
Amitriptyline Tricyclic antidepressants (TCA) such as amitriptyline, imipramine and nortriptyline have been shown to prevent chronic daily headaches. Amitriptyline is the most effective drug for treating tension-type headaches. Initial 10 mg at bedtime and gradual titration is recommended. The efficacy of TCAs is higher when combined with stress management. [1,2,3,6]
Selective serotonine reuptake inhibitors (SSRIs) SSRIs may be helpful in patients with co-morbid depression. Some SSRIs (fluoxetine) have been shown to increase headache free days and decrease the intensity of the disease. [1,3,5]
Anticonvulsants Both gabapentin and topiramate have been shown to decrease headache frequency. [1,2]
References
  1. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia [online] December, 33(9):629-808 [viewed 09 September 2014] Available from: doi:10.1177/0333102413485658
  2. MERIKANGAS KR, CUI L, RICHARDSON AK, ISLER H, KHOROMI S, NAKAMURA E, LAMERS F, RöSSLER W, AJDACIC-GROSS V, GAMMA A, ANGST J. Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study BMJ [online] 2011:d5076 [viewed 09 September 2014] Available from: doi:10.1136/bmj.d5076
  3. TAVASOLI A, AGHAMOHAMMADPOOR M, TAGHIBEIGI M. Migraine and tension-type headache in children and adolescents presenting to neurology clinics. Iran J Pediatr [online] 2013 Oct, 23(5):536-40 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24800013
  4. CHOWDHURY D. Tension type headache. Ann Indian Acad Neurol [online] 2012 Aug, 15(Suppl 1):S83-8 [viewed 09 September 2014] Available from: doi:10.4103/0972-2327.100023
  5. SCHRAMM SH, OBERMANN M, KATSARAVA Z, DIENER HC, MOEBUS S, YOON MS. Epidemiological profiles of patients with chronic migraine and chronic tension-type headache. J Headache Pain [online] 2013 May 7, 14(1):40 [viewed 09 September 2014] Available from: doi:10.1186/1129-2377-14-40
  6. SJAASTAD O. Tension-type headache: one or more headaches? Funct Neurol [online] 2011 Jul-Sep, 26(3):165-70 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22152438