Tension-type headache -- american family physician

Tension-Type Headache
Medical College of Wisconsin, Milwaukee, Wisconsin
Tension-type headache typically causes pain that radiates in a band-like fashion bilater-
ally from the forehead to the occiput. Pain often radiates to the neck muscles and is

described as tightness, pressure, or dull ache. Migraine-type features (unilateral, throb-
tion handout on ten-sion headaches, writ- bing pain, nausea, photophobia) are not present. All patients with frequent or severe
headaches need careful evaluation to exclude any occult serious condition that may be
causing the headache. Neuroimaging is not needed in patients who have no worrisome
findings on examination. Treatment of tension-type headache typically involves the use
of over-the-counter analgesics. Use of pain relievers more than twice weekly places
patients at risk for progression to chronic daily headache. Sedating antihistamines or
antiemetics can potentiate the pain-relieving effects of standard analgesics. Analgesics
combined with butalbital or opiates are often useful for tension-type pain but have an
increased risk of causing chronic daily headache. Amitriptyline is the most widely
researched prophylactic agent for frequent headaches. No large trials with rigorous
methodologies have been conducted for most non-medication therapies. Among the
commonly employed modalities are biofeedback, relaxation training, self-hypnosis, and
cognitive therapy. (Am Fam Physician 2002;66:797-804,805. Copyright 2002 American
Academy of Family Physicians.)

matically, with the goal being relief andpreventing recurrence. Although sec- merly called tension head-ache or muscle contractionheadache, is a common con- tomatic relief, treatment of the underly- with over-the-counter (OTC) analgesics.
ing disease process is the focus of care.
aches vary among studies from 291 to 712percent of patients examined, because of tive pain of tension-type headaches has a by an underlying organic disease and are a family practice depart-ments develop articles symptom of a recognized disease process.
The International Headache Society’s crite- Family and CommunityMedicine at the Med- daily headache,5 are listed in Table 1.4 See editorial on page 728 and
definitions of strength-of-evidence
levels on page 893.
sion-type headache.7 Further research sug- Tension-type headache pain is usually experienced as a band gests that nitric oxide may be the local media-tor of tension-type headache. Infusion of a extending bilaterally back from the forehead across the sides nitric oxide donor reproduces tension-type of the head to the occiput and may extend to the posterior headache in patients previously diagnosed with chronic tension-type headache.8 [Evi-dence level B, lower quality randomized con-trolled trial (RCT)]. Also, blocking nitric oxide production with an investigative agent headache. A recent review article6 noted that the relationship between EMG level and pain is complex enough to warrant further investi- headache.9 [Evidence level B, lower quality gation. Muscle hardness (measured by exter- nal probing of resting muscle) has been foundto be increased in the pericranial muscles of Evaluation of the Headache Patient
patients with chronic tension-type headache.7 These findings indicate that muscle hardness was similar during periods with and without minutes to several days and can be continuous headache and that muscle hardness is “perma- in severe cases. The pain is mild or moderately nently altered” in patients with chronic ten- intense and is described as tightness, pressure,or a dull ache. The pain is usually experiencedas a band extending bilaterally back from the forehead across the sides of the head to the Diagnostic Criteria for Tension-Type, Chronic Tension-Type,
occiput.10 Patients often report that this ten- and Chronic Headache
sion radiates from the occiput to the posteriorneck muscles. In its most extensive form, the Tension-type headache
pain distribution is “cape like,” radiating along A. At least 10 previous headache episodes fulfilling criteria B through D; the medial and lateral trapezius muscles cov- number of days with such headaches: less than 180 per year or 15 per month ering the shoulders, scapular, and interscapu- B. Headaches lasting from 30 minutes to 7 days C. At least two of the following pain characteristics: 1. Pressing or tightening (nonpulsating) quality In addition to its characteristic distribution 2. Mild to moderate intensity (nonprohibitive) and intermittent nature, the history obtained from patients with tension-type headache dis- 4. No aggravation from walking stairs or similar routine activities closes an absence of signs of any serious underlying condition.11 Patients with tension- 1. No nausea or vomiting2. Photophobia and phonophobia absent, or only one is present type headache do not typically report any Chronic tension-type headache
visual disturbance, constant generalized pain, Same as tension-type headache, except number of days with such headaches: fever, stiff neck, recent trauma, or bruxism.
at least 15 days per month, for at least six months Table 24 lists disease processes that may have Chronic daily headache
include questions about the type, amount,effect, and duration of self-treatment strate- Adapted with permission from Classification and diagnostic criteria for headache gies. Patients typically self-treat their ten- disorders, cranial neuralgias and facial pain. Headache Classification Committeeof the International Headache Society. Cephalalgia 1988;8(suppl 7):1-96, with caffeinated products, massage or chiropractictherapy for symptom relief. A headache his- Tension Headache
tory should also include discussion of anylifestyle changes (e.g., smoking) that may Repeated use of analgesics, especially ones containing caf- have preceded or exacerbated the headache.11 feine or butalbital, can lead to “rebound” headaches. present with the typical pain characteristicsof tension-type headache but have symp-toms that occur daily or almost daily. A use are early morning awakening with head- careful history will generally reveal that the ache, poor appetite, nausea, restlessness, irri- tability, memory or concentration problems, Patients should be screened for psychiatric comorbidity, because anxiety, depression, and The progression of either migraine or ten- psychosocial stress can be prevalent in pa- sion-type headache into chronic daily head- ache can occur spontaneously but often occursin relation to frequent use of analgesic medica- PHYSICAL EXAMINATION
tion. Repeated use of analgesics, especially ones containing caffeine or butalbital, can lead hypertension may be similar to tension-type to “rebound” headaches as each dose wears off headaches. Although patients often attribute and patients then take another round of med- headaches to any degree of hypertension, only ication. Common features of chronic daily headache associated with frequent analgesic 200/120 mm Hg) is definitely associated with TABLE 2
Acute Secondary Headache Disorders
Headache associated with substance use or withdrawal Headache associated with vascular disorders Headache associated with noncephalic infection Headache associated with metabolic disorder Headache associated with nonvascular intracranial disorder Benign intracranial hypertension (pseudotumor cerebri) Low cerebrospinal fluid pressure (e.g., headache subsequent Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranialstructures Cranial neuralgias, nerve trunk pain, and deafferentation pain Adapted with permission from Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. HeadacheClassification Committee of the International Headache Society. Cephalalgia 1988;8(suppl 7):1-96. Patients with chronic tension-type headache should limit their use of analgesics to two times weekly to prevent the Indications for Neuroimaging
in Patients with Headache Symptoms

development of chronic daily headache. Focal neurologic finding on physical examinationHeadache starting after exertion or Valsalva’s pressure control confirms the diagnosis.11 Change in well-established headache pattern headache should include a neurologic evalua- New-onset headache in patient > 35 years of age tion to rule out any serious intracranial pathol- New-onset headache in patient who has HIV ogy. Specifically, cranial nerve defects, cerebel- lar dysfunction, papilledema or absent venouspulsations on fundal examination, visual field HIV = human immunodeficiency virus. defects, or motor or sensory deficits should be Information from references 14 and 15. considered. These findings may suggest occultbrain tumors, hemorrhage, or increased cere-brospinal fluid pressure.
may reveal tenderness in the pericranial mus- cles and tension in the nuchal musculature or screened for by palpating the temporalmandibular joints for tenderness and asking Treatment
the patient about habits such as bruxism and Treatment goals for patients with tension- gum chewing. If signs suggestive of secondary type headache should include recommending headache are present, appropriate diagnostic effective OTC analgesic agents and discover- studies should be done before making a defin- ing and ameliorating any circumstances that itive diagnosis of tension-type headache [Ref- may be triggering the headaches or causing erence 15—Evidence level C, expert opinion].
the patient concern. Tension-type headache is Table 314,15 lists indications for the use of neu- roimaging in patients with progressive or con- steroidal anti-inflammatory drugs (NSAIDs) tinuous headache symptoms. Palpation of the head in patients with tension-type headache found that 98 percent of responders with ten-sion-type headache reported using analgesics.
The most common agents used were aceta- minophen (56 percent), aspirin (15 percent),or other agents (17 percent).16 PAUL J. MILLEA, M.D., M.S., M.A., is assistant professor of family medicine at the MedicalCollege of Wisconsin, Milwaukee. Dr. Millea received his medical degree from the Medical College of Wisconsin, a master of science in addiction studies from the University of Ari- minophen are effective in reducing headache zona College of Medicine, Tucson, and a master of arts in bioethics from the Medical Col- symptoms; however, this research offers lim- lege of Wisconsin. He completed a residency in family practice at Baylor College of Medi-cine, Houston, and a fellowship in family therapy at Galveston Family Institute, Houston. ited guidance about which one to choose for JONATHAN J. BRODIE, M.D., is in private practice in Milwaukee, Wis. Dr. Brodie received individual patients. A large, randomized con- his medical degree from the University of Connecticut School of Medicine, Farmington.
trolled trial17 assigned patients with tension- He completed a faculty development fellowship at the Medical College of Wisconsin and a family practice residency at Texas Tech University, Lubbock.
placebo, 400 mg of ibuprofen, or 1,000 mg of Address correspondence to Paul J. Millea, M.D., Department of Family and Community acetaminophen. Both medications were well Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI53226-0509 (e-mail: [email protected]). Reprints are not available from the authors. tolerated and significantly more effective than Tension Headache
placebo at relieving the symptoms of head-ache. Ibuprofen was more effective than aceta- Amitriptyline (10 to 75 mg, one to two hours before bed- time) is the most researched of the prophylactic agents for A similar trial18 comparing 25 mg of keto- profen with 1,000 mg of acetaminophenreported that both agents were significantlymore effective than placebo at two hours afterdosing but no better than placebo in achieving chronic tension-type headache, and compre- total pain relief at four hours after dosing. This hensive reviews are available for interested result probably reflects the short duration and self-limiting nature of the episodic tension- chronic tension-type headache. It is typically headache, the treatment goals are to initiate effective prophylactic treatment and to man- hours before bedtime to minimize grogginess age any residual headaches in a manner that prevents the frequent use of analgesics and the controlled studies confirm its use in patients risk for progression to chronic daily headache with chronic tension-type headache.20 [Evi- effects (dry mouth, blurred vision, orthosta- ache should limit their use of analgesics to two sis) and weight gain can limit its usefulness in times weekly to prevent the development of chronic daily headache. If the patient requires analgesic medication more frequently, adjunc- (SSRIs) cause fewer side effects, and several of tive headache medications can be initiated.
these agents (paroxetine [Paxil], venlafaxine Analgesics can be augmented with a sedat- shown their efficacy in the prophylaxis of chronic tension-type headache in small stud- dryl), or an antiemetic, such as metoclopra- ies.21,22 One small study23 showed that 20 mg of citalopram (Celexa) had no beneficial effect pazine). If this regimen is inadequate, the small trial24 noted that amitriptyline and flu- combined with caffeine and butalbital. This oxetine were equally effective in reducing the combination is usually quite effective but is month. The beneficial effect of fluoxetine daily headache. Before initiating this regi- only manifested after two months of treat- ment and was slightly inferior to the effect of possibility of chronic daily headache and instructed to limit their use of the combina- tion to twice weekly. The physician should to address in patients with chronic tension- carefully monitor the patient’s progress and smoked has been “significantly related” to the headache index score and to the number ofdays with headache each week.25 Higher levels PROPHYLAXIS OF FREQUENT HEADACHES
of nicotine are also correlated with trends A wide variety of prophylactic agents have toward higher measures of anger, anxiety, and cluded. Participants immediately ceased all CHRONIC DAILY HEADACHE
analgesics and began a short course of taper- The first decision in treating patients who ing prednisone (60 mg for two days, 40 mg have chronic daily headache is to ascertain for two days, and 20 mg for two days), com- how often they are using OTC analgesics.
bined with ranitidine (300 mg once daily for “Rebound” headache is particularly com- six days). Amitriptyline was instituted on the mon with use of narcotics and combination day following the last dose of prednisone.
products containing butalbital and caffeine.
headache successfully withdrew from their prove if their daily analgesic medication can be withdrawn, although this is not easily ac- After stopping daily analgesic use, patients complished.26 The initial task is to assure often revert to the headache pattern that pre- patients that, although they will experience ceded the chronic daily headache (typically, increased discomfort during the analgesic sporadic migraine headache). If this does withdrawal period, their headache frequency occur, prophylactic treatment should con- and intensity will begin to reduce within two tinue, and migraine-specific treatment should weeks after their withdrawal is complete.
For nonpregnant patients using fewer than seven to 12 tablets or capsules of analgesic Nonmedication Therapies for Headache
daily, the simplest method is to abruptly stop the analgesic and initiate prophylaxis with monly used treatment for chronic tension- amitriptyline. Patients will typically experi- ence withdrawal symptoms for several days to have some evidence of efficacy. No large trials weeks. These symptoms include nervousness, with well-designed methodologies have been restlessness, increased headaches, nausea, conducted for most nonmedication therapies; vomiting, insomnia, diarrhea, and tremor.27 reports of beneficial effects need to be tem- Patients who cannot tolerate complete cessa- pered by the high rates of placebo effects for tion may taper the analgesic dosage over four to six weeks and begin amitriptyline prophy- laxis when they have completely stopped tak- treatments for headache are biofeedback, relax- ation training, self-hypnosis, and cognitive In patients using more than 12 tablets or therapy. One study31 showed improvement in capsules of analgesic daily, particularly those 39 percent of 94 patients with headache using containing butalbital, abrupt cessation is not relaxation training alone. Adding biofeedback appropriate because of the possibility of increased the portion of patients experiencing improvement to 56 percent.31 One small, long- cluding seizure or delirium.28 [Evidence level C, term study32 of relaxation and EMG biofeed- expert opinion] Pregnant patients may be at risk for miscarriage caused by withdrawal cognitive psychotherapy alone and in combi- analgesics using a short steroid taper has nation with other behavioral treatment for been reported from a large, open-label trial.29 chronic tension-type headache. Among these [Evidence level B, uncontrolled study] Only trials, at least 50 percent of patients had patients taking simple analgesics were stud- ied; persons dependent on barbiturates, ben- gressive relaxation, cognitive therapy, or a zodiazepines, or opiate medications were ex- combination of the two.33 This study33 com- Tension Headache
pared patients who self-administered treat- ments at home with patients receiving therapy 1. Gobel H, Petersen-Braun M, Soyka D. The epi- in the office and noted a trend toward greater demiology of headache in Germany: a nationwidesurvey of a representative sample on the basis of symptom reduction in patients receiving in- the headache classification of the International office treatment; however, this difference was Headache Society. Cephalalgia 1994;14:97-106.
2. Rasmussen BK. Epidemiology of headache. Cepha- A recent systematic review of acupuncture 3. Wober-Bingol C, Wober C, Karwautz A, Schnider P, Vesely C, Wagner-Ennsgraber C, et al. Tension-type ized controlled studies, but only one study headache in different age groups at two headachecenters. Pain 1996;67:53-8. was categorized as “rigorous.” In all of the 4. Classification and diagnostic criteria for headache trials of tension-type headache that were disorders, cranial neuralgias and facial pain.
Headache Classification Committee of the Interna-tional Headache Society. Cephalalgia 1988;8(suppl patients in the control groups. The authors 5. Solomon S, Lipton RB, Newman LC. Clinical fea- of the review concluded that, “overall, the tures of chronic daily headache. Headache 1992;32:325-9. existing evidence suggests that acupuncture 6. Jensen R. Pathophysiological mechanisms of ten- sion-type headache: a review of epidemiological and headaches”.34 [Evidence level A, systematic experimental studies. Cephalalgia 1999;19:602-21. 7. Ashina M, Bendtsen L, Jensen R, Sakai F, Olesen J.
Muscle hardness in patients with chronic tension- Studies have also been conducted investi- type headache: relation to actual headache state.
gating the role of spinal manipulation for 8. Ashina M, Bendtsen L, Jensen R, Olesen J. Nitric headache relief.35 [Evidence level A, RCTs] In oxide-induced headache in patients with chronic a trial comparing manipulation with the use tension-type headache. Brain 2000;123:1830-7.
9. Ashina M, Lassen LH, Bendtsen L, Jensen R, Olesen J. Effect of inhibition of nitric oxide synthase on chronic tension-type headache: a randomised crossover trial. Lancet 1999;353:287-9.
headache intensity was significantly less in the 10. Spira PJ. Tension headache. Aust Fam Physician amitriptyline group. Four weeks after cessa- 11. Marks DR, Rapoport AM. Practical evaluation and tion of therapy, patients in the spinal manipu- diagnosis of headache. Semin Neurol 1997;17: lation group continued to experience benefits 12. Rapoport A, Stang P, Gutterman DL, Cady R, Markley H, Weeks R, et al. Analgesic rebound The use of traditional physical therapy for headache in clinical practice: data from a physician 13. Puca F, Genco S, Prudenzano MP, Savarese M, Bus- domized controlled trial.36 [Evidence level sone G, D’Amico D, et al. Psychiatric comorbidity B, uncontrolled study] Study participants and psychosocial stress in patients with tension-type headache from headache centers in Italy. The ItalianCollaborative Group for the Study of Psycho- pathological Factors in Primary Headaches. Cepha- exercise program, and used ice packs, mas- sage, and “passive mobilization” of the cer- 14. Sutton CL, Weisberg LA. Which headache patients vical facets. Both headache frequency and 15. Masdeu JC, Drayer BP, Anderson RE, Braffman B, cantly in the group receiving physical ther- Davis PC, Deck MD, et al. Atraumatic isolatedheadache—when to image. American College of apy at the end of six weeks and at the 12- Radiology. ACR Appropriateness Criteria. Radiol- 16. Forward SP, McGrath PJ, MacKinnon D, Brown TL, Swann J, Currie EL. Medication patterns of recur- The authors indicate that they do not have any con- rent headache sufferers: a community study.
flicts of interest. Sources of funding: none reported. Tension Headache
17. Schachtel BP, Furey SA, Thoden WR. Nonprescrip- 27. Mathew NT, Kurman R, Perez F. Drug induced tion ibuprofen and acetaminophen in the treat- refractory headache–clinical features and manage- ment of tension-type headache. J Clin Pharmacol 28. McLean W, Boucher EA, Brennan M, Holbrook A, 18. Steiner TJ, Lange R. Ketoprofen (25 mg) in the Orser R, Peachey J, et al. Is there an indication for symptomatic treatment of episodic tension-type the use of barbiturate-containing analgesic agents headache: double-blind placebo-controlled com- in the treatment of pain? Guidelines for their safe parison with acetaminophen (1000 mg). Cephala- use and withdrawal management. Canadian Phar- macists Association. Can J Clin Pharmacol 2000; 19. Redillas C, Solomon S. Prophylactic pharmacologi- cal treatment of chronic daily headache. Headache 29. Krymchantowski AV, Barbosa JS. Prednisone as ini- tial treatment of analgesic-induced daily headache.
20. Gobel H, Hamouz V, Hansen C, Heininger K, Hirsch S, Lindner V, et al. Chronic tension-type headache: 30. Spierings EL, Ranke AH, Schroevers M, Honkoop amitriptyline reduces clinical headache-duration PC. Chronic daily headache: a time perspective.
and experimental pain sensitivity but does not alter pericranial muscle activity readings. Pain 1994;59: 31. Blanchard EB, et al. Behavioral treatment of 250 chronic headache patients: a clinical replication 21. Langemark M, Olesen J. Sulpiride and paroxetine in series. Behavior Therapy 1985;16:308-27. the treatment of chronic tension-type headache.
32. Blanchard EB, Appelbaum KA, Guarnieri P, Morrill An explanatory double-blind trial. Headache B, Dentinger MP. Five year prospective follow-up on the treatment of chronic headache with 22. Adelman LC, Adelman JU, Von Seggern R, Mannix biofeedback and/or relaxation. Headache 1987;27: LK. Venlafaxine extended release (XR) for the pro- phylaxis of migraine and tension-type headache: A 33. Attanasio V, Andrasik F, Blanchard EB. Cognitive retrospective study in a clinical setting. Headache therapy and relaxation training in muscle contrac- tion headache: efficacy and cost-effectiveness.
23. Bendtsen L, Jensen R, Olesen J. A non-selective (amitriptyline), but not a selective (citalopram), sero- 34. Melchart D, Linde K, Fischer P, White A, Allais G, tonin reuptake inhibitor is effective in the prophy- Vickers A, et al. Acupuncture for recurrent lactic treatment of chronic tension-type headache. J headaches: a systematic review of randomized Neurol Neurosurg Psychiatry 1996;61:285-90.
controlled trials. Cephalagia 1999;19:779-86.
24. Oguzhanoglu A, Sahiner T, Kurt T, Akalin O. Use of 35. Boline PD, Kassak K, Bronfort G, Nelson C, Ander- amitriptyline and fluoxetine in prophylaxis of son AV. Spinal manipulation vs. amitriptyline for migraine and tension-type headaches. Cephalalgia the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol 25. Payne TJ, Stetson B, Stevens VM, Johnson CA, Pen- zien DB, Van Dorsten B. The impact of cigarette 36. Hammill JM, Cook TM, Rosecrance JC. Effective- ness of a physical therapy regimen in the treatment of tension-type headache. Headache 1996;36: 26. Kudrow L. Paradoxical effects of frequent analgesic

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European Journal of Clinical Investigation (2005) 35 , 82– 92 Peroxisome proliferator-activated receptor γ : the more the merrier? C. A. Argmann*, T.-A. Cock* and J. Auwerx*† *Institut de Génétique et de Biologie Moléculaire et Cellulaire, CNRS/INSERM/Université Louis Pasteur, 67404 Illkirch, France; †Institut Clinique de la Souris, Génopole Strasbourg, 67404 Illkirch, Fra

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