Abstract
Tension-type headache, formerly known as muscle contraction headache, is the most common type of headache that afflicts humankind. It can be episodic or chronic, and it may or may not be related to muscle contraction. Tension-type headache is usually bilateral but can be unilateral; it often involves the frontal, temporal, and occipital regions. It may present as a bandlike, nonpulsatile ache or tightness in the aforementioned anatomic areas. Although both sexes are affected, female patients predominate. Antidepressants are generally the drugs of choice for the prophylactic treatment of tension-type headache and can be used in combination with cervical epidural nerve blocks. The avoidance of addicting medications, coupled with the appropriate use of pharmacologic and nonpharmacologic therapies, should result in excellent palliation and long-term control of pain in most patients suffering from this headache syndrome.
Keywords
tension-type headache, headache, antidepressants, cervical epidural block, bilateral headache, muscle contraction headache, migraine headache, Arnold-Chiari malformation
ICD-10 CODE G44.009
The Clinical Syndrome
Cluster headache derives its name from the headache pattern—that is, headaches occur in clusters, followed by headache-free remission periods. Cluster headache is a primary headache that is included in the group of headaches known as the trigeminal autonomic cephalgias. Unlike other common headache disorders that affect primarily female patients, cluster headache is much more common in male patients, with a male-to-female ratio of 5 : 1. Much less common than tension-type headache or migraine headache, cluster headache is thought to affect approximately 0.5% of the male population. Cluster headache is most often confused with migraine by clinicians who are unfamiliar with the syndrome; however, a targeted headache history allows the clinician to distinguish between these two distinct headache types easily ( Table 4.1 ).
| Cluster Headache | Migraine Headache | |
|---|---|---|
| Gender | Male 5 : 1 | Female 2 : 1 |
| Age of onset | Late 30s to early 40s | Menarche to early 20s |
| Family history | No | Yes |
| Aura | Never | May be present (20% of the time) |
| Chronobiologic pattern | Yes | No |
| Onset-to-peak interval | Seconds to minutes | Minutes to 1 hr |
| Frequency | 2 or 3/day | Rarely >1/wk |
| Duration | 45 min | Usually <24 hr |
The onset of cluster headache occurs in the late third or early fourth decade of life, in contradistinction to migraine, which almost always manifests by the early second decade. Unlike migraine, cluster headache does not appear to run in families, and cluster headache sufferers do not experience auras. Attacks generally occur approximately 90 minutes after the patient falls asleep. This association with sleep is reportedly maintained when a shift worker changes from nighttime to daytime hours of sleep. Cluster headache also appears to follow a distinct chronobiologic pattern that coincides with seasonal changes in the length of the day. This pattern results in an increased frequency of cluster headache in the spring and fall.
During a cluster period, attacks occur two or three times a day and last for 45 minutes to 1 hour. Cluster periods usually last for 8 to 12 weeks, interrupted by remission periods of less than 2 years. In rare patients, the remission periods become shorter and shorter, and the frequency may increase up to 10-fold. This situation is termed chronic cluster headache and differs from the more common episodic cluster headache described earlier.
Signs and Symptoms
Cluster headache is characterized as a unilateral headache that is retro-orbital and temporal in location. The pain has a deep burning or boring quality. Physical findings during an attack of cluster headache may include Horner’s syndrome, consisting of ptosis, abnormal pupil constriction, facial flushing, and conjunctival injection ( Fig. 4.1 ). Additionally, profuse lacrimation and rhinorrhea are often present. The ocular changes may become permanent with repeated attacks. Peau d’orange skin over the malar region, deeply furrowed glabellar folds, and telangiectasia may be observed.
