TENSION TYPE

HEADACHE

Dr. Khairul P. Surbakti Sp.S

Departemen Neurologi
FK USU/RSUP H. ADAM MALIK
MEDAN

TENSION TYPE HEADACHE

Definition: An episodic or chronic headache

due to
sustained muscle contraction

Up to 88% of women and 69% of men

experience tension-type headache during their
lifetime
The word "tension" implies that this type of
headache can be attributed entirely to tension or
stress, which may make people with this type of
headache reluctant to consult a physician.

International Headache Society

diagnostic criteria for tension-type
headache

Primary diagnosis
1. Headache has at least two of the following
characteristics:
Bilateral pain
Pressure
Mild to moderate pain
No increased pain with physical exertion
2. And no more than one of the following:
Sensitivity to light
Sensitivity to sound
3. And neither of the following*:
Nausea
Vomiting
4. And duration of 30 minutes to 7 days

Classification of Tension
Type Headache (IHS 2004)

Tension Type Headache

2.1 Infrequent episodic tension-type headache

2.1.1 Infrequent episodic tension-type headache
associated with pericranial tenderness
2.1.2 Infrequent episodic tension-type headache not
associated with pericranial tenderness
2.2 Frequent episodic tension-type headache
2.2.1 Frequent episodic tension-type headache
associated with pericranial tenderness
2.2.2 Frequent episodic tension-type headache not
associated with pericranial tenderness

2.3 Chronic tension-type headache

2.3.1 Chronic tension-type headache
associated with
pericranial tenderness
2.3.2 Chronic tension-type headache not
associated with
pericranial tenderness
2.4 Probable tension-type headache
2.4.1 Probable infrequent episodic tensiontype
headache
2.4.2 Probable frequent episodic tensiontype
headache
2.4.3 Probable chronic tension-type
headache

Infrequent episodic tension-type

headache

Frequent episodic tension-type

headache

Chronic tension-type
headache

Subdivision diagnosis

1. Episodic (<15 days/mo) or chronic (>15

days/mo for >6 mo)
2. Associated with or not associated with
coexisting pericranial muscle tenderness**

*Chronic tension-type headache may include

one of these symptoms.

**Diagnosed by manual palpation or

electromyographic studies.

Adapted from Headache Classification

Committee of the International Headache
Society (2).

Potential triggers of tension-type

headache

Stress (eg, family crises, heavy

workloads, unpleasant work or social
situations)
Change in sleep regimen (eg, shift work,
oversleeping)
Certain foods (eg, caffeine, alcohol,
cheese,
chocolate)
Physical exertion

Potential triggers of tension-type

headache

Environmental factors (eg, sun glare, odors,

smoke, ambient noise, fluorescent lighting,
sustained postures at video terminals or while
driving)
Female hormonal changes (eg, menses,
menopause, pregnancy, exogenous hormone
use)
Medications -eg, nitrates, selective serotonin
reuptake inhibitors, antihypertensives)
Overuse of headache medication (eg, analgesic
and caffeine combinations, butalbital
compounds, opiates, ergot)

Pathophysiologic mechanisms

The cause of tension-type headache is

unknown,
Most research has focused on a
peripheral mechanism pertaining to
pericranial muscle tenderness, thus
explaining the previous term "muscle
contraction headache."

Pathophysiologic mechanisms

Another hypothesis, favored by

physicians who believe migraine and
tension- type headache are part of a
continuum of the same underlying
disorder, is that tension-type headache
has a purely central mechanism and that
muscle tension is an epiphenomenon

Pathophysiologic mechanisms

The cause of tension-type headache is most likely

multifactorial and best described by Olesen's
vascular-myogenic-supraspinal model
It is the convergence of multiple pain pathways-vascular, myogenic, supraspinal, or all of these-that enter the caudate nucleus of the
trigeminovascular system and, in combination with
other precipitating factors in a predisposed person,
determine whether the headache activation
threshold is met
A genetic predisposition has been suggested by
studies that found a threefold increased incidence
of chronic tension-type headache in families

 Difference from migraine:

Onset is more gradual & may persist for
days, weeks, months or even yrs.
Lacks the persistent throbbing quality.
Not associated with nausea, photophobia,
phonophobia.
Does not seriously interfere with daily
activities.
Sleep is usually undisturbed.

Nonpharmacologic approaches to
treatment of tension-type headache

Regulation of lifestyle
Maintain regular sleep schedule
Eat regular meals, Avoid known dietary triggers
Get regular aerobic exercise
Minimization of emotional stressors
Plan ahead and avoid stressful situations
Consider individual or family psychotherapy
Avoidance of environmental precipitants
Wear sunglasses
Avoid smoke, strong odors, and noisy areas
Maintain proper posture; limit sustained positions
Physical therapy techniques
Heat, ice, ultrasound, TENS
Massage or cervical traction
Stretching and strengthening exercises for cervical
musculature
Trigger point stretching, compression,

Pharmacologic
treatment of tensionAbortive
therapy
type
headache
Simple
analgesics : Aspirin , Acetaminophen
Simple analgesic combinations with caffeine :
Aspirin +
Caffein, Acetaminophen +
Caffein
NSAID : Naproxen, Ketoprofen, Ibuprofen,
Diclofenac
Prophylactic therapy
Tricyclic antidepressants : Amitriptiline
Sodium valproat
Venlafaxine
Topiramate

CLUSTER HEADACHE

CLUSTER HEADACHE

Synonym:
Raeders syndrome, Histamine cephalalgia,
Red migraine, paroxysmal nocturnal
cephalagia.
Age 20 to 50 yrs.
Sex men are affected 7 to 8 times more
than women.
The pain begins without warnings &
reaches a crescendo within 5 minutes. Each
attack last for 30 min to 2 hours.
1 3 short-lived attacks/day over a 4 8
weeks period, followed by a pain free interval
that average one year.

o Almost always the same orbit is involved

during attacks.
o The pain is excruciating in intensity &
deep, non-fluctuating and explosive in
quality.
o Associated with - homolateral lacrimation,
red eye, miosis, lid ptosis, nasal stuffiness
& nausea.
o Onset is nocturnal is about 50% of the
cases & then pain usually awakens the
patients within 2 hours of falling asleep.

Pathophysiology

A neurovascular disorder hypothesized to be

generated in the CNS in pacemaker or circdian
regions of the hypothalamic gray matter

The trigeminal/cervical nuclear overlap is also

central to the pathogenesis

Activation of trigeminovascular system (CGRP)

from peripheral terminals of trigeminal
nociceptive neuron which supply cephalic
blood vessels underlies symptoms of cluster
headache

Diagnostic Criteria for Cluster

Headache
A. At least five attacks fulfilling criteria B through D
B. Severe unilateral orbital, supraorbital and/or
temporal pain lasting 15 to 180 minutes
(untreated)
C. Headache associated with at least one of the
following signs on the pain side:

Conjunctival
sweating
injection
Miosis
Lacrimation
Ptosis
Nasal congestion
Eyelid edema
Rhinorrhea
D. Forehead
Frequency and
of attacks: one attack every other
day
to eight attacks per day
facial

Cluster headache

Male
Onset 1-2
hours after
falling
asleep
Strictly
unilateral
Avoid
recumbent
position

Cluster period usually last

between 2 weeks and 3 months

Difference from migraine

Male predominant.
Rapid evolution.
Non-throbbing.
Rhythmicity.
Flushing of the side of the face (pallor in case
of
migraine).
Temperature at the side of the pain (
temp. in
migraine).
IOP (IOP in migraine).

Treatment:
o Inhalation of 100% O2 7L/mnt for 10 15
minutes.
o Local anaestthetic : 1ml lidocaine intranasal
4% .
o Dihydroergotamine (DHE) : 0,5-1,5 mg i.v
o Sumatriptan s.c. 6 mg
o Indomethacin (rectal supp)
o Gabapentin or Topiramate
o Opioids (rectal, Stadol nasal spray)

Prophylaxis
- Verapamil 120-160 mg t.i.d

Lithium 300 to 1500 mg/day.

Methysergide 4-10 mg/day.
Divalproic sodiums
Neuroleptic (Chlorpromazine)
Indomethacin : 150 mg/day
Steroid
Opioid