Muscle Contraction Tension Headache

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Background

Tension-type headache (TTH) represents one of the most costly diseases because of its very high prevalence. TTH is the most common type of headache, and it is classified as episodic (ETTH) or chronic (CTTH). It had various ill-defined names in the past including tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, and psychogenic headache. See Medscape's Headache Resource Center for more information.

The International Headache Society (IHS) defines TTH more precisely and differentiates between the episodic and the chronic types.

Episodic tension-type headache

The following is a modified outline of the IHS diagnostic criteria:

Chronic tension-type headache

See the list below:

Pathophysiology

Pathogenesis of TTH is complex and multifactorial, with contributions from both central and peripheral factors. In the past, various mechanisms including vascular, muscular (ie, constant overcontraction of scalp muscles), and psychogenic factors were suggested. The more likely cause of these headaches is believed now to be abnormal neuronal sensitivity and pain facilitation, not abnormal muscle contraction.

Various evidence suggests that, like migraine, TTH is associated with exteroceptive suppression (ES2), abnormal platelet serotonin, and decreased cerebrospinal fluid beta-endorphin. In one study, plasma levels of substance P, neuropeptide Y, and vasoactive intestinal peptide were found to be normal in patients with CTTH and unrelated to the headache state.

Several concurrent pathophysiologic mechanisms may be responsible for TTH; according to Jensen, extracranial myofascial nociception is one of them. Headache is not related directly to muscle contraction, and possible hypersensitivity of neurons in the trigeminal nucleus caudalis has been suggested.

Bendtsen described central sensitization at the level of the spinal dorsal horn/trigeminal nucleus due to prolonged nociceptive inputs from pericranial myofascial tissues.[1] The central neuroplastic changes may affect regulation of peripheral mechanisms and can lead to increased pericranial muscle activity or release of neurotransmitters in myofascial tissues. This central sensitization may be maintained even after the initial eliciting factors have been normalized, resulting in conversion of ETTH into CTTH.

Further research is necessary to understand and clarify the mechanisms of TTH. Research may lead to the development of more specific and effective management in the future.

Epidemiology

Frequency

TTH is the most common primary headache syndrome.

Rasmussen et al reported a lifetime prevalence of TTH of 69% in men and 88% in women in the Danish population.[2] The patient may experience more than one primary headache syndrome. In one study by Ulrich et al, the 1-year prevalence of TTH was the same among individuals with and without migraine.[3]

Sex

Women are slightly more likely to be affected than men.

Age

TTH can occur at any age, but onset during adolescence or young adulthood is common. It can begin in childhood.

History

Tension-type headaches (TTHs) are characterized by pain that is usually mild or moderate in severity and bilateral in distribution. Unilateral pain may be experienced by 10-20% of patients. Headache is a constant, tight, pressing, or bandlike sensation in the frontal, temporal, occipital, or parietal area (with frontal and temporal regions most common).

Physical

Patients with TTH have normal findings on general and neurologic examinations.

Some patients may have tender spots or taut bands in the pericranial or cervical muscles (trigger points).

Causes

Various precipitating factors may cause TTH in susceptible individuals. One half of patients with TTH identify stress or hunger as a precipitating factor.

Laboratory Studies

The diagnosis of tension-type headache (TTH) is clinical. As with the other primary headaches, no specific diagnostic test is available for TTH.

Occasionally, studies may be required to exclude secondary headache disorders.

Imaging Studies

Neuroimaging studies are important to rule out secondary causes of headache, including neoplasms and cerebral hemorrhage.

MRI imaging shows the greatest detail of cerebral structures and is especially useful in evaluating the posterior fossa.

CT scan with contrast is a viable alternative but is inferior to MRI for viewing structures in the posterior fossa.

Neuroimaging is indicated if the headaches are atypical in any way or if they are associated with abnormalities in the neurologic examination.

Other Tests

Consider CSF fluid analysis (lumbar puncture) if concerned about meningitis. 

Medical Care

Management of TTH consists of pharmacotherapy, psychophysiologic therapy, and physical therapy.

Pharmacotherapy consists of abortive therapy (to stop or reduce severity of the individual attack) and long-term preventive therapy. Preventive drugs are the main therapy for CTTH, but they seldom are needed for ETTH.

Consider preventive medications if the headaches are frequent (>2 attacks per wk), of long duration (>3-4 h), or severe enough to cause significant disability or overuse of abortive medication.

Physical therapy techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations.

Psychophysiologic therapy includes reassurance, counseling, relaxation therapy, stress management programs, and biofeedback techniques. With these modalities of treatment, both frequency and severity of chronic headache may be reduced.

Consultations

Psychiatry consultations: CTTH can mask or be associated with comorbid conditions such as depression, anxiety, or other serious emotional disorders.

Diet

Balanced meals

Activity

These nonpharmacologic methods have shown improvement of central nervous-system related symptoms:

Medication Summary

The goals of pharmacotherapy for tension-type headaches (TTHs) are to relieve the headache, reduce morbidity, and prevent complications.

Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall, Tempra)

Clinical Context:  First choice for treatment of headache, especially during pregnancy and breastfeeding.

Class Summary

These agents can be used for abortive therapy.

Ibuprofen (Motrin, Advil)

Clinical Context:  First choice for treatment of headache, especially during pregnancy and breastfeeding.

Naproxen sodium (Anaprox, Naprelan)

Clinical Context:  First choice for treatment of headache, especially during pregnancy and breastfeeding.

Class Summary

These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. They generally are used in mild to moderately severe headaches; however, they also may be effective for severe headaches.

Nortriptyline (Pamelor, Aventyl HCl)

Clinical Context:  Has demonstrated effectiveness in treatment of pain.

Amitriptyline (Elavil)

Clinical Context:  Has demonstrated effectiveness in treatment of pain.

Class Summary

These drugs increase the synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake by the presynaptic neuronal membrane.

Cymbalta can also be helpful for patients who have coexisting depression.

Fluoxetine (Prozac)

Clinical Context:  Has potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.

Sertraline (Zoloft)

Clinical Context:  Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Paroxetine (Paxil)

Clinical Context:  Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Class Summary

These agents specifically inhibit presynaptic reuptake of serotonin. May be considered as an alternative to TCAs.

Magnesium chloride (Slow-Mag, Mag-Delay)

Clinical Context:  Magnesium metabolism may have a significant role in both the etiology and the treatment of muscle contraction tension headache.

Class Summary

Electrolytes such as magnesium may help in the treatment of tension headache.

Follow-up

Patient Education

Advise the patient with tension-type headaches (TTHs) to take the following actions:

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

What is tension-type headache (TTH)?What are the HIS diagnostic criteria for episodic tension-type headache (TTH)?What are the HIS diagnostic criteria for chronic tension-type headache (TTH)?What is the pathophysiology of tension-type headache (TTH)?What is the prevalence of tension-type headache (TTH)?What are the sexual predilections of tension-type headache (TTH)?Which age groups have the highest prevalence of tension-type headache (TTH)?Which clinical history findings are characteristic of tension-type headache (TTH)?Which physical findings are characteristic of tension-type headache (TTH)?What causes tension-type headache (TTH)?What are the differential diagnoses for Muscle Contraction Tension Headache?What is the role of lab tests in the workup of tension-type headache (TTH)?What is the role of imaging studies in the workup of tension-type headache (TTH)?What is the role of lumbar puncture in the workup of tension-type headache (TTH)?What is the role of minimally invasive therapies in the treatment of tension-type headache (TTH)?How is tension-type headache (TTH) treated?What is the role of medications in the treatment of tension-type headache (TTH)?What is the role of physical therapy (PT) in the treatment of tension-type headache (TTH)?What is the role of behavioral therapies in the treatment of tension-type headache (TTH)?Which specialist consultations are beneficial to patients with tension-type headache (TTH)?Which activity modifications are used in the treatment of tension-type headache (TTH)?What is the role of medications in the treatment tension-type headache (TTH)?Which medications in the drug class Electrolyte supplements are used in the treatment of Muscle Contraction Tension Headache?Which medications in the drug class Serotonin reuptake inhibitors are used in the treatment of Muscle Contraction Tension Headache?Which medications in the drug class Antidepressants are used in the treatment of Muscle Contraction Tension Headache?Which medications in the drug class Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in the treatment of Muscle Contraction Tension Headache?Which medications in the drug class Analgesics are used in the treatment of Muscle Contraction Tension Headache?What is included in patient education about tension-type headache (TTH)?

Author

Syed M S Ahmed, MD, Neurologist and Sleep Specialist, Capital Neurology and Sleep Medicine; Staff Attending in Neurology and Sleep Medicine, Montgomery General Hospital; Staff Attending in Neurology and Sleep Medicine, Suburban Hospital

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS, Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Joseph Carcione, Jr, DO, MBA, Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans

Disclosure: Nothing to disclose.

Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

Disclosure: Nothing to disclose.

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