Tension headache is a syndrome of uncertain pathogenesis and is one of the most common forms of headache. Although, much more common than migraine, the exact cause of this disease is not fully known and the symptoms are not as well shaped as in the case of migraine.
Tension headache is characterized by recurrent episodes of headache of moderate intensity, self-limited, and usually responsive to nonprescription drugs, episodes that are lasting from few minutes to several weeks. Usually vomiting is not typical for tension headache, but photophobia and phonophobia may be present. To be considered tension headache, cephalalgia should exclude the following causes: head trauma, cerebrovascular disorders, non-vascular brain disorders, non-encephalitis inflammatory process, the use of certain drugs, metabolic disorders, eye, neck, ears, nose, sinuses, teeth and mouth injuries or other facial or cranial injuries.
Tension Headache Causes
The International Headache Society (IHS) proposed in 1988 a classification of tension headache based on cephalalgia episodes in episodic and chronic form. In episodic tension headache, painful accesses occur for up to 15 days per month and a higher frequency of this episodes represents a diagnostic criterion for chronic tension headache. Clinical manifestations are similar to both forms of headache, but the treatment differs. Another criterion for classification of tension headache is the presence or the absence of pericranial muscle disorders, both in episodic and in chronic form. Pericranial muscle disorders are considered to be present when these muscles are under tension and are establish either by palpation or by electromyographic (EMG) testes. It is worth noting, that pericranial muscle tension occurs in most patients with tension headache, but can also occur in other situations such as fibromyalgia, migraine or low back pain.
A subdivision of tension headache can be done according to the possible etiologic factors, thus the disease may be associated with one of the following conditions: oromandibular dysfunction, psychosocial stress, anxiety, depression, psychogenic headache, drug overdose and muscle contraction.
Oromandibular dysfunction is often concomitant with tension headache, but is not exactly know if this condition may represent one of the causes of tension headache, because both diseases have a higher prevalence. Psychosocial stress may be incriminated as etiologic factor, but it was observed that represents a precipitating factor both for tension headache and migraine.
Although, in some cases of tension headache was observed a depressed mood, it was not a real depressive illness. Epidemiological studies have shown that depression and anxiety are frequently associated with migraine and less with tension headache.
Muscle contraction, especially of pericranial muscles seems to be an important cause of tension headache, especially in episodic forms. Menstruation appears to be a precipitating factor for tension headache.
Tension headache represents between 30% and 80% of all headaches cases. The disease may debuts in childhood, at the age of 10 years or later and females are more affected than males. It was observed that the prevalence of disease has a tendency to decrease with aging.
Tension Headache Symptoms
The main symptom of disease is headache and in 99% of patients has moderate intensity, but pain intensity may increase along with frequency in episodic form. In most cases, the headache does not interfere with normal daily activities. Pain is usually bilateral, occipitonuchal or bifrontal and approximately in 89% of cases the pain is localized fronto-temporal than fronto-occipital and is described as a dull ache, tightness/squeezing, pressure or “bandlike/viselike”(nonpulsatile quality). Although most patients have no symptoms associated, photophobia and phonophobia may be described, nausea and in very rare cases vomiting. As associated phenomena have been described anxiety, abdominal distension, left chest pain, lumbar or coccygeal pain and indigestion All these associated phenomena are considered to be psychosomatic symptoms. No focal neurological signs are present.
Headache is often precipitated by sleep deprivation. In general population, tension headache is common in people who have sleep disturbances, compared with migraine subjects. It was noted that sleep apnea is associated with a type of headache that mimic tension headache.
Headache onset usually occurs during the day and gradually increase in intensity in the second part of the day. In some cases, especially in forms of episodic tension headache, pain occurs in relation to a state of stress. In the chronic forms of tension headache, pain may begin early in the morning or shortly after this time and may persist throughout the day and is not influenced by the patient’s daily activities. Pain intensity varies depending on the type of individual behavior, being more severe in depressed patients. The duration of a painful access is variable, with a minimum of 30 minutes, up to 72 hours, but with a average of 12 hours.
Tension Headache Treatment
Medical treatment of tension headache can be divided into short-term, long-term and prophylactic therapy.
NSAIDs (nonsteroidal anti-inflammatory drugs) are drugs of first choice especially in short-term treatment regimens. The most effective NSAIDs are represented by ibuprofen and naproxen. Ketoprofen and indomethacin are also effective, but have been much less studied. In some cases, the combination of NSAIDs with caffeine, sedatives or tranquilizers was more effective than the combination of NSAIDs with analgesics such as acetaminophen. It is generally recommended to avoid long-term use of analgesics because they produce addiction and chronic headache. Muscle relaxant drugs, such as baclofen, diazepam and myolastam can be useful.
Tricyclic antidepressants are recommended as preventive therapy, amitriptyline is considered to be more effective than doxepin, mianserin and maprotiline. New generation antidepressants such as citalopram, which selectively blocks the serotonin reuptake are indicated especially in obese patients.
Refers to relaxation and biofeedback therapy or cognitive behavioral interventions such as stress control programs that have proven to be effective if were associated. The results of these therapies are less effective in patients who excessively use analgesics or ergotamine, in patients with continuing headache and in depressive patients or with other psychiatric disorders. This type of therapy produces slower improvement than drug therapy, improvements that are lasting longer.
Other methods of therapy are represented by physical therapy, ergonomics training and transcutaneous nerve electrical stimulation. In some patients the oromandibular treatment may be useful.