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 G44.209
The Clinical Syndrome
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. Significant sleep disturbance usually occurs. Patients with tension-type headache are often characterized as having multiple unresolved conflicts surrounding work, marriage, and social relationships, and psychosexual difficulties. Testing with the Minnesota Multiphasic Personality Inventory in large groups of patients with tension-type headache revealed not only borderline depression but somatization as well. Most researchers believe that this somatization takes the form of abnormal muscle contraction in some patients; in others, it results in simple headache.
Signs and Symptoms
Tension-type headache is usually bilateral, but can be unilateral; it often involves the frontal, temporal, 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.
The triggering event for acute, episodic tension-type headache is invariably either physical or psychological stress. This may take the form of a fight with a coworker or spouse or an exceptionally heavy workload. Physical stress, such as a long drive, working with the neck in a strained position, acute cervical spine injury resulting from whiplash, or prolonged exposure to the glare from a cathode ray tube, may precipitate a headache. A worsening of preexisting degenerative cervical spine conditions, such as cervical spondylosis, can also trigger a tension-type headache. The pathologic process responsible for the development of tension-type headache can produce temporomandibular joint dysfunction as well.
Testing
No specific test exists for tension-type headache. Testing is aimed primarily at identifying an occult pathologic process or other diseases that may mimic tension-type headache (see “ Differential Diagnosis ”). All patients with a recent onset of headache that is thought to be tension type should undergo magnetic resonance imaging (MRI) of the brain and, if significant occipital or nuchal symptoms are present, of the cervical spine. MRI should also be performed in patients with previously stable tension-type headaches who have experienced a recent change in symptoms. Screening laboratory tests consisting of a complete blood count, erythrocyte sedimentation rate, and automated blood chemistry should be performed if the diagnosis of tension-type headache is in question.
Differential Diagnosis
Tension-type headache is usually diagnosed on clinical grounds by obtaining a targeted headache history. Despite their obvious differences, tension-type headache is often incorrectly diagnosed as migraine headache. Such misdiagnosis can lead to illogical treatment plans and poor control of headache symptoms. Table 3.1 helps distinguish tension-type headache from migraine headache and should aid the clinician in making the correct diagnosis.
