Abby Austin

Abby said that most days she had headaches, and that while they never kept her from going to work, she just felt worn out from them. “Doctor, my sleep is really messed up. I keep waking up around 4 AM with a headache brewing and I just can’t get back to sleep. I go ahead and get up, but by the end of the day, I feel pretty rough.”

I asked Abby how long she suffered from headaches and she said, “I’ve had headaches about as long as I can remember. My mom always had headaches, and I can remember her making my brother and me go outside and play because we were making her headache worse.” Abby denied any nausea, vomiting, or other neurologic symptoms associated with her headaches. She said, “By the end of the day, the brightness of my computer monitor seems to aggravate the headache, and I really just want my boss to shut up, but other than the tightness around my head and neck ache, I don’t have any other symptoms with my headaches.”

I asked Abby if she had identified anything that triggered her headache and she immediately answered, “My boss. I just can’t take the stress anymore.” I asked Abby if she knew whether she was going to get a headache before the headache actually started, and she said, “Not really.” She continued, “Often I wake up with a headache in the making, but it is just there. There are not really any warning signs.” I asked about her neck and she said, “By the end of the day, I just want someone to give me a neck massage. I thought it was my pillow, so I bought a MyPillow, and it only made it worse. I feel like the neck and headaches are one and the same.”

I asked her what made it better and she said, “I’ve tried all of the usual over-the-counter medications like Excedrin Migraine and Advil, but they really upset my stomach, so I can’t take them very often. A heating pad and a neck massage seems to help a little.”

I asked Abby to use one finger to point at the spot where it hurt the most, and she pointed to both her temples and then started rubbing her neck. I asked her what the pain was like: an ache, sharp, stabbing, burning. She immediately said, “It’s like my head is being squeezed in a vise. No throbbing, just a squeezing, achy feeling.” I asked whether the headache was on both sides or just one side, and she said it was always on both sides and in her neck. I asked Abby from the time that she knew she was going to get the headache until the time it was at its worst, whether it was a period of seconds, minutes, or hours. She said, “It is always at least hours to a day before it is at its worst.”

I asked Abby if I could examine her and she said, “That’s why I’m here. I just have to get rid of these headaches.” On physical examination, Abby was afebrile. Her respirations were 16 and her pulse was 78 and regular. Her blood pressure was 126/80. There were no cranial abnormalities and her head, eyes, ears, nose, throat (HEENT) examination was completely normal, as was her fundoscopic examination. Her cervical paraspinous muscles were tender to deep palpation, but no myofascial trigger points were identified. Her cardiopulmonary examination was normal, as was her thyroid. Her abdominal examination revealed no abnormal mass or organomegaly, and no rebound tenderness was present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and her deep tendon reflexes were normal. Abby’s mental status exam was within normal limits.

Key Clinical Points—What’s Important and What’s Not

What Tests Would You Like to Order?

The following test was ordered:

• ◼
  

  Magnetic resonance imaging (MRI) of the brain

Clinical Correlation—Putting It All Together

What is the diagnosis?

Tension-type headache

The Science Behind the Diagnosis

Signs and Symptoms

Tension-type headache is usually bilateral, but it can be unilateral; it often involves the frontotemporal, and occipital regions ( Fig. 3.1 ). It may present as a bandlike, nonpulsatile ache or tightness in the aforementioned anatomic areas ( Fig. 3.2 ). Associated neck symptoms are common. Tension-type headache evolves over a period of hours or days and then tends to remain constant, without progression. It has no associated aura, but significant sleep disturbance is usually present. This disturbance may manifest as difficulty falling asleep, frequent awakening at night, or early awakening. These headaches most frequently occur between 4 and 8 AM and 4 and 8 PM. Although both sexes are affected, female patients predominate. No hereditary pattern to tension-type headache is found, but this type of headache may occur in family clusters because children mimic and learn the pain behavior of their parents.

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