Symptoms
Sporadic, frequent, or chronic in onset:
- A bilateral pain originating in the forehead and extending along the sides of the head to the occipital bone at the back of the skull
- Pain quality: pulling, pressing, constricting, non-pulsating.
- Duration between 30 minutes and 7 days
- Mild to moderate pain, normal daily activities are possible
- Radiation into the neck muscles, tension.
Tension headache is the most common headache.
Causes
The causes are not precisely known. Central, psychological, and muscular factors are discussed.
Complications
A sporadic tension headache is relatively unproblematic and can be well self-treated with appropriate use of analgesics. Patients often do not seek medical treatment until the frequency of pain attacks increases. Chronic tension headache is less common and is characterized by very frequent pain (≥ 15 days per month), higher morbidity, and severe limitation of personal and professional activities. Psychological comorbidities such as stress, anxiety, and depression also occur. Frequent analgesic use can result in medication-induced headache and analgesic dependence. This is problematic because regular use of painkillers can lead to severe adverse effects, including gastrointestinal ulcers, liver damage, and kidney damage.
Trigger
In studies, these triggers were frequently cited:
- Physical or emotional stress, tension states, psychological problems, excessive demands.
- Irregular meals
- Smoking, high coffee or caffeine consumption.
- Dehydration
- Sleep disturbances
- Hormones (female cycle, hormone replacement therapy).
Risk factors
- Heredity
- Gender plays a lesser role than in migraine, which mainly affects women.
Diagnosis
Unlike migraine, tension headache does not cause visual disturbances, nausea or vomiting. Mild sensitivity to light or noise or nausea may occur. Migraine headache is usually unilateral and the pain quality is throbbing-pulsating. However, distinguishing it from migraine without aura is not always easy. Numerous diseases and conditions can trigger headaches. Many secondary headaches, such as those triggered by severely elevated blood pressure, manifest similarly to a tension headache and should be excluded at diagnosis. A valuable tool for diagnosis and follow-up is a headache diary. It allows estimation of frequency, can help identify triggers, and indicates medication overuse. In addition, it shows the effectiveness of treatment in comparison.
Nonpharmacologic prevention
Relaxation techniques and physical methods are considered effective for preventing chronic tension headaches. They are also used in combination with medications.
- Relaxation techniques: Autogenic training, meditative methods, hypnosis, biofeedback.
- Stress management
- Endurance training
- Acupuncture
- Heat or cold
- Massage
- Physiotherapy
- TENS
Drug prevention
Drug prevention should be considered for a chronic recurrent tension headache. Another indication is frequent headache that responds poorly to analgesics. Tricyclic antidepressants:
- Amitriptyline is most commonly used and is considered the 1st-line agent. The dosage range is 25-150 mg per day. Adverse effects such as constipation, dry mouth, weight gain, visual disturbances, and fatigue represent a disadvantage. To avoid fatigue during the day, the drug can be taken in the evening before bedtime. Alternatively, other antidepressants such as clomipramine, nortriptyline, doxepin, maprotiline, and mianserin are used. The effectiveness of SSRIs has not yet been reliably demonstrated.
More:
- Botulinum toxin is used for prevention and treatment, but its effectiveness has not yet been scientifically confirmed, so its use is not recommended so far.
- Topiramate has shown some efficacy in one study, but this has yet to be confirmed.
Drug treatment
Analgesics (NSAIDs and acetaminophen) have been shown to be effective. Ibuprofen and acetaminophen are often cited as first-line agents. However, which agent is most effective and tolerated by the patient must be determined and tried on an individual basis. It is recommended that analgesics for headache be taken on a maximum of 4-10 days per month to avoid the development of a drug-induced headache. Adverse effects occur mainly with regular use:
- Ibuprofen
- Naproxen
- Acetylsalicylic acid
- Diclofenac
- Other NSAIDs
- Paracetamol
Sedatives and caffeine enhance the effects of analgesics, but at the same time increase the risk of developing a drug-induced headache:
- Sedating antihistamines: chlorphenamine is approved in many countries in combination with acetaminophen and caffeine for the treatment of migraine. The drug can also be used off-label to treat tension headaches. Diphenhydramine is an alternative but is not commercially available in combination preparations for the treatment of headache in many countries.
- Barbiturates: preparations containing butalbital are no longer on the market in many countries. Cafergot-PB contained butalbital, belladonna alkaloids, ergotamine tartrate, and caffeine. It was used to treat migraine and has been off the market since 2007.
- Caffeine increases the effectiveness of analgesics and is included in some combination medications. The dosage range is 50-200 mg. Caffeine can also be ingested via a beverage containing caffeine, such as 1-2 cups of coffee. Black tea contains slightly less caffeine than coffee, cola drinks are another alternative.
Muscle relaxants and spasmolytics are controversial. Most authors advise against their use. Alternative therapeutics, such as homeopathics or anthroposophics, may provide relief for some patients.
Herbal preparations
- Headache oil with peppermint oil (see there).
- Caffeine drugs (see above).
- Heat treatment, for example, with warming ointments for tension.
- Willow bark
- Herbal sedatives such as valerian, lemon balm, hops and butterbur.
