AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Background

The International Headache Society (IHS) began developing a classification system for headaches in 1985. Finalized in 1988, this system includes a tension-type headache category, further defined as either episodic or chronic. Headache categories also are defined by whether they are associated with pericranial muscle disorders.

Episodic tension headache usually is associated with a stressful event. This headache type is of moderate intensity, self-limited, and usually responsive to nonprescription drugs.

Chronic tension headache often recurs daily and is associated with contracted muscles of the neck and scalp. This type of headache is bilateral and usually occipitofrontal.

Tension-type headache is the most common type of chronic recurring head pain. In the past, pain etiology was presumed to be the muscular contraction of pain-sensitive structures of the cranium, but the IHS intentionally abandoned the terms muscular contraction headache and tension headache because no research supports muscular contraction as the sole pain etiology.

Pathophysiology

Both muscular and psychogenic factors are believed to be associated with tension-type headache.

Frequency

United States

Headache is the ninth most common reason for a patient to consult a physician. Physicians classify 90% of headaches reported to them as muscle contraction or migraine headaches.

International

No literature suggests that headache frequency is different in other regions of the world.

Sex

A female preponderance exists.

Age

All ages are susceptible, but most patients are young adults.

• Approximately 60% of headache onset occurs in those older than 20 years.
• Headache onset is unusual in those older than 50 years.
• In elderly patients, the practicing physician should never assume that headache onset is due to benign causes, such as tension-type headaches, until pathologic etiologies are explored.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

History

Pain onset in tension-type headache can have a throbbing quality and is usually more gradual than onset in migraines. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.

• IHS diagnostic criteria for tension-type headaches states that 2 of the following characteristics must be present:
• • Pressing or tightening (nonpulsatile quality)
  • Frontal-occipital location
  • Bilateral - Mild/moderate intensity
  • Not aggravated by physical activity
• Tension-type headache history is as follows:
• • Duration of 30 minutes to 7 days
  • No nausea or vomiting (anorexia may occur)
  • Photophobia and/or phonophobia
  • Minimum of 10 previous headache episodes; fewer than 180 days per year with headache to be considered "infrequent"
  • Bilateral and occipitonuchal or bifrontal pain
  • Pain described as "fullness,tightness/squeezing,pressure," or "bandlike/viselike"
  • May occur acutely under emotional distress or intense worry
  • Insomnia
  • Often present upon rising or shortly thereafter
  • Muscular tightness or stiffness in neck, occipital, and frontal regions
  • Duration of more than 5 years in 75% of patients with chronic headaches
  • Difficulty concentrating
  • No prodrome
• New headache onset in elderly patients should suggest etiologies other than tension headache.

Physical

The physical examination serves mainly to exclude the possibility of other headache causes.

• Vital signs should be normal.
• Normal neurologic examination
• Tenderness may be elicited in the scalp or neck, but no other positive physical exam findings should be noted.
• Pain should not be elicited over temporal arteries or positive trigger zones.
• Some patients with occipital tension headaches may be very tender when upper cervical muscles are palpated.
• Pain associated with neck flexion and stretching of paracervical muscles must be distinguished from nuchal rigidity associated with meningeal irritation.

Causes

Stress may cause contraction of neck and scalp muscles, although no evidence confirms that the origin of pain is sustained muscle contraction.

• Stress and/or anxiety
• Poor posture
• Depression

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Problems to be Considered

Fever
Anoxia
Cervical spondylosis
Tumor
Caffeine dependency
Nonprescription analgesic dependency
Severe anemia or polycythemia
Uremia
Hepatic disorders
Toxic effects from drugs or fumes (carbon monoxide)
Dental disease
Paget disease of bone
Refractive error
Hypertension
Hypoxia
Lesions of the eye or middle ear
Lesions of the oral cavity

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Lab Studies

• Laboratory work should be unremarkable in cases of tension-type headache. Specific tests should be obtained if the history or physical examination suggests another diagnostic possibility.
• Head CT scan or MRI is necessary only when the headache pattern has changed recently or neurologic examination reveals abnormal findings. Such history or physical exam evidence would suggest an alternate cause of headache.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Prehospital Care

Most patients with severe headache should not receive opiate analgesics until the responsible physician can complete an appropriate history and neurologic examination.

Emergency Department Care

• Ascertain that the patient is not overusing medication, shows no evidence of drug dependency, and is not depressed.
• If headache cause includes dental pathology, sinus disease, trigger points, or CNS pathology, initiate care to treat the specific cause.

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

While the emergency physician must be able to identify patients with serious headache etiology, more than 90% of patients in the ED have migraine, tension, or mixed-type benign headache. Therefore, providing symptomatic relief should be a priority.

Various modalities are used in the treatment of tension headaches. These include hot or cold packs, ultrasound, electrical stimulation, improvement of posture, trigger point injections, and occipital nerve blocks.

Regular exercise, stretching, balanced meals, and adequate sleep may be part of a headache treatment program.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

These agents may alleviate headache pain by inhibiting prostaglandin synthesis, reducing serotonin release, and blocking platelet aggregation. Although the effects of NSAIDs in the treatment of headache pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include naproxen, ketoprofen, and ketorolac.

Drug Name	Naproxen (Naprosyn)
Description	For relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing enzyme cyclooxygenase activity, thus inhibiting prostaglandin synthesis.
Adult Dose	500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity
Interactions	Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Name	Ketoprofen (Oruvail, Orudis, Actron)
Description	For relief of mild to moderately severe pain and inflammation. Small dosages initially indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; third trimester of pregnancy
Interactions	Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Drug Name	Ketorolac (Toradol)
Description	Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors. PO form offers no advantage over other less expensive PO NSAIDs.
Adult Dose	30 mg IV single dose; most common route used in ED >65 years, renal impairment, or <50 kg: 15 mg IV single dose 30-60 mg IM initially, followed by 15-30 mg q6h prn Not to exceed 5 d of treatment; consider only 1-2 days of treatment in elderly because of increased risk of GI bleed
Pediatric Dose	Not established; suggested dose 0.4-1 mg/kg IM once
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding Do not administer into CNS
Interactions	Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs

Drug Name	Indomethacin (Indocin, Indochron E-R)
Description	Absorbed rapidly; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Useful in diagnosis as it helps other headache syndromes (eg, chronic paroxysmal hemicrania).
Adult Dose	Immediate release: 25-50 mg PO bid/tid Sustained release: 75 mg PO bid; not to exceed 200 mg/d
Pediatric Dose	1-2 mg/kg/d PO divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Contraindications	Documented hypersensitivity; GI bleeding or renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if leukopenia, granulocytopenia, or thrombocytopenia persists)

Drug Category: Acetylsalicylic acids

These agents alleviate headache, possibly by inhibiting prostaglandin synthesis.

Drug Category: Barbiturates

These agents are used in combination with aspirin and acetaminophen for pain relief and to induce sleep. Caffeine is used to increase its GI absorption. However, butalbital is associated with rebound headaches. Increasing use of these combination preparations may fail to provide pain relief and worsen headache symptoms.

Drug Name	Acetaminophen, butalbital, and caffeine (Fioricet)
Description	Drug combination used to relieve tension headaches. Barbiturate component has generalized depressant effect on CNS.
Adult Dose	1-2 tab PO at onset, repeat q4h; not to exceed 6 doses in 24 h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Effects decreased by phenothiazines, quinidine, tricyclic antidepressants, theophylline, haloperidol, chloramphenicol, ethosuximide, corticosteroids, warfarin, doxycycline, and beta-blockers; effects increased by CNS depressants, methylphenidate, valproic acid, propoxyphene, and benzodiazepines
Pregnancy	D - Unsafe in pregnancy
Precautions	Risk of rebound headache and overuse; caution in patients with history of substance abuse

Drug Category: Analgesics

Patients with infrequent headaches can be treated with simple analgesics initially.

Drug Name	Acetaminophen with codeine (Tylenol #3)
Description	Indicated for treatment of mild to moderately severe headache.
Adult Dose	30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d; not to exceed 4 g acetaminophen in 24 h
Pediatric Dose	0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen in 24 h
Contraindications	Documented hypersensitivity
Interactions	CNS depressants or tricyclic antidepressants increase toxicity
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Drug Name	Acetaminophen and oxycodone (Percocet)
Description	Indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult Dose	1-2 tab/cap PO q4-6h prn headache
Pediatric Dose	0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Contraindications	Documented hypersensitivity
Interactions	Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Duration of action may increase in the elderly; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24h of acetaminophen; higher doses may cause liver toxicity

Drug Category: Analgesic/antiemetic or sedatives

These agents are useful in aborting headache and treating emesis that results from acute pain.

Drug Name	Prochlorperazine (Compazine)
Description	May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine-receptors, through anticholinergic effects, and depressing reticular activating system. In addition to antiemetic effects, has advantage of augmenting hypoxic ventilatory response, acting as respiratory stimulant at high altitude. Metoclopramide (Reglan) can be used as an alternative to prochlorperazine. Studies show prochlorperazine is better.
Adult Dose	5-10 mg PO/IM tid/qid; not to exceed 40 mg/d 2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d 25 mg PR bid Metoclopramide: 10 mg IV
Pediatric Dose	2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d IV dosing not recommended for children 0.1-0.15 mg/kg/dose IM; change to PO as soon as possible
Contraindications	Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease
Interactions	Other CNS depressants or anticonvulsants may cause additive effects; with epinephrine may cause hypotension
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Drug-induced Parkinson syndrome or pseudoparkinsonism occurs quite frequently; akathisia is most common extrapyramidal reaction in elderly; lowers seizure threshold; caution in patients with history of seizures

Drug Category: Ergot alkaloids and derivatives

These are direct vasoconstrictors of smooth muscle in cranial blood vessels. Their activity depends on the CNS vascular tone at the time of administration.

Drug Name	Dihydroergotamine (D.H.E. 45, Migranal Nasal Spray)
Description	Alpha-adrenergic blocking agent with direct stimulating effect on smooth muscle of peripheral and cranial blood vessels; depresses central vasomotor centers. Mechanism of action is similar to ergotamine; nonselective 5HT1 agonist with wide spectrum of receptor affinities outside 5HT1 system; also binds to dopamine. Thus, has alpha-adrenergic antagonist and serotonin antagonist effect. Indicated to abort or prevent vascular headache when rapid control needed or when other routes of administration not feasible. Available in IV or intranasal preparations, tends to cause less arterial vasoconstriction than ergotamine tartrate.
Adult Dose	1 mg IM at first sign of headache, repeat q1 h; not to exceed 3 mg total dose 2 mg IV maximum dose for faster effect; most commonly given at 0.5-1 mg IV with antiemetic; not to exceed 6 mg/wk Intranasal: 1 spray into each nostril and repeat prn within 15 min; not to exceed 6 sprays/d or 8 sprays/wk
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; has used sumatriptan or zolmitriptan within previous 24 h; within 2 wk of discontinuing MAO inhibitors
Interactions	Increases effects of heparin and toxicity of nitroglycerin, propranolol, erythromycin, and clarithromycin
Pregnancy	X - Contraindicated in pregnancy
Precautions	Caution in angina, hypertension, impaired renal or hepatic function, or peripheral vascular disease

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Further Outpatient Care

• Physical therapy for patients with headache includes warm and cold packs, ultrasound, and electrical stimulation.
• Regular exercise, stretching, balanced meals, and adequate sleep are part of a headache prevention program.
• Trigger point injections, occipital nerve blocks, or changes that improve posture may be used.

Deterrence/Prevention

• Physical therapy
• Biofeedback and relaxation therapy
• Cervical traction
• Injection of trigger points

Complications

• Undue reliance on nonprescription caffeine-containing analgesics
• Dependence on/addiction to narcotic analgesics
• GI bleed from use of NSAIDs
• Risk of epilepsy 4 times greater than that of the general population

Prognosis

• Headache may become chronic if life stressors are not changed.
• Most cases are intermittent and do not interfere with work or normal life span.

Patient Education

• For excellent patient education resources, see eMedicine's Headache Center. Also, visit eMedicine's patient education articles, Causes and Treatments of Migraine and Related Headaches and Tension Headache.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

• Arena JG, Bruno GM, Hannah SL, et al. A comparison of frontal electromyographic biofeedback training, trapezius electromyographic biofeedback training, and progressive muscle relaxation therapy in the treatment of tension headache. Headache. Jul-Aug 1995;35(7):411-9. [Medline].
• Bogaards MC, ter Kuile MM. Treatment of recurrent tension headache: a meta-analytic review. ALYSIS. Sep 1994;10(3):174-90. [Medline].
• Carlsson J, Augustinsson LE, Blomstrand C, et al. Health status in patients with tension headache treated with acupuncture or physiotherapy. Headache. Sep 1990;30(9):593-9. [Medline].
• De Benedittis G, Lorenzetti A, Sina C, Bernasconi V. Magnetic resonance imaging in migraine and tension-type headache. Headache. May 1995;35(5):264-8. [Medline].
• Ficek SK, Wittrock DA. Subjective stress and coping in recurrent tension-type headache. Headache. Sep 1995;35(8):455-60. [Medline].
• Iversen HK, Langemark M, Andersson PG, et al. Clinical characteristics of migraine and episodic tension-type headache in relation to old and new diagnostic criteria. Headache. Jul 1990;30(8):514-9. [Medline].
• Landy S. Migraine throughout the life cycle: treatment through the ages. Neurology. Mar 9 2004;62(5 Suppl 2):S2-8. [Medline].
• Silberstein SD. Tension-type headaches. Headache. Sep 1994;34(8):S2-7. [Medline].
• Silberstein SD, Olesen J, Bousser MG, et al. The International Classification of Headache Disorders, 2nd Edition (ICHD-II)--revision of criteria for 8.2 Medication-overuse headache. Cephalalgia. Jun 2005;25(6):460-5. [Medline].

Article Last Updated: May 16, 2006