Disease: Tension Headache

Most headaches are tension headaches. These headaches tend to happen again and again, especially if you are under stress. They are not usually a sign of something serious. But they can be
very painful and hard to live with. Synonym: Muscle Contraction Headache
A tension-type headache is a recurrent headache that can last minutes to days. The pain often is described as pressing or tightening, of mild or moderate intensity, felt on both sides of the head, and does
NOT worsen with physical activity. Tension-type headache is usually not associated with nausea or sensitivity to light or noise.

Etiology
Experts once thought that tension or spasms in the muscles of your neck, face, and head played a role. Now they think a change in brain chemicals may also be a cause. It could be Emotional
or physical stress may cause contraction of the muscles in the neck and scalp.
• Stress
• Depression and anxiety

• Poor posture

• Working in awkward positions or holding one position for a long time

• Jaw clenching

Clinical Manifestations
Signs of tension headaches include:
• A headache that is constant, not throbbing. You usually feel the pain or pressure on both sides of your head.
• Pressure that makes you feel like your head is in a vise.
• Aching pain at your temples or the back of your head and neck.
• Steady, constant feeling of pressure that usually begins in the forehead, or the back of the neck.
• Tension headaches tend to come back, especially when you are under stress. They can last from 30 minutes to several days.
• Constant pain that does not throb or pulse. You usually feel the pain or pressure on both sides of your head.
• Tightness around your forehead that may feel like a “vise grip”
• Mild to moderate pain or pressure affecting the front, top or sides of the head
• Headache occurring later in the day
• Difficulty falling asleep and staying asleep
• Chronic fatigue
• Irritability
• Disturbed concentration
• Mild sensitivity to light or noise
• General muscle aching

Usually, pain from a tension headache is not severe and does not get in the way of your work or social life. But for some people the pain is very bad or lasts a long time. You have chronic tension
headaches if they occur at least 15 days a month.

Diagnostic Procedure/ Lab Works

• A lumbar puncture, a test in which your doctor uses a needle to remove a small amount of fluid from your spinal canal. The fluid is then looked at for signs of infection.
• An electroencephalogram (EEG), a test that measures and records the electrical activity of your brain by using sensors (electrodes) attached to your head and connected by wires to a computer.
• An MRI scans of your brain, a test that uses a magnetic field and pulses of radio wave energy to provide pictures of your brain.
• A CT scan of your head, a test in which a scanner directs a series of X-ray pulses through your head. This produces detailed pictures of structures inside the head.
Medical Management
Nonprescription drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, usually reduce the pain you get with a tension headache. But try to avoid taking
nonprescription drugs more than 3 times a week, because you may get rebound headaches. Rebound headaches are different from tension headaches. They are usually triggered after pain medicine has
worn off, prompting you to take another dose. Eventually, you get a headache whenever you stop taking the medicine.
Prescription drugs. If nonprescription drugs do not relieve your headache, your doctor may prescribe stronger medicine to treat your pain. You may be prescribed:

• Antidepressants such as mirtazapine (Remeron) and the tricyclic antidepressant amitriptyline. When taken daily, these medicines can help reduce how often tension headaches occur and how
long they last.
• Seizure medicines or anti anxiety drugs. These medicines are not often used to treat tension headaches.

Generic Name Brand Name Use Precautions Possible Side Effects

Acetaminophen Tylenol Pain relief Few side effects, if taken as directed, although they may include:
changes in blood counts and liver damage

Aspirin Bayer Bufferin Pain relief Do not use in children under age 20 years due to Heartburn, gastrointestinal bleeding, bronchospasm or constriction
Ecotrin the potential for Reye's syndrome (a life-threating that causes narrowing of the airways, anaphylaxis (life-threatening
neurological condition) allergic reaction), ulcers

Aspirin, acetaminophen, Excedrin Pain relief Do not use in children under 14 years of age due to Few side effects, if taken as directed, although they may include:
and caffeine Migraine the potential for Reyes syndrome changes in blood counts, liver damage

Fenoprofen Nalfon Prevention of tension headaches; Nausea, diarrhea, indigestion, dizziness, drowsiness
migraines; hormone headaches

Flurbiprofen Ansaid Prevention of tension headaches; Gastrointestinal upset, drowsiness, dizziness, vision problems,
migraines Treatment of tension ulcers
headache; migraines

Ibuprofen Advil Motrin IB Treatment of tension headache; Gastrointestinal upset, gastrointestinal bleeding, nausea, vomiting,
Nuprin migraines rash, liver damage

Ketaprofen Actron Orudis Prevention of tension headaches; Gastrointestinal upset, gastrointestinal bleeding, nausea, vomiting,
KT migraines Treatment of migraines rash, liver damage

Nabumetone Relafen Prevention of tension headaches; Constipation, heartburn, diarrhea, nausea, vomiting
migraines

Naproxen Aleve Prevention of tension headaches; Gastrointestinal upset, gastrointestinal bleeding, nausea, vomiting,
hormone headaches Treatment of rash, liver damage
migraines

Diclofenac Cataflam Treatment of tension headache; Stomach upset, bloating, dizziness, drowsiness, loss of appetite
migraines

Ketorolac Toradol Treatment of tension headache Gastrointestinal upset, drowsiness, dizziness, vision problems,
ulcers

Meclofenate Meclomen Treatment of tension headache Nausea, diarrhea, indigestion, dizziness, drowsiness

Carisoprodol Soma Treatment of tension headache Dizziness, drowsiness, nausea, headache, nervousness, skin rash,
bleeding

Orphenadrine citrate Norflex Treatment of tension headache Drowsiness, dizziness, headache, nervousness, blurred vision
Methocarbamol Robaxin Treatment of tension headache Dizziness, drowsiness, nausea, darkening of urine

Cyclobenzaprine HCL Flexeril Treatment of tension headache Dry mouth, drowsiness, dizziness

Metaxalone Skelaxin Treatment of tension headache Drowsiness, dizziness, headache, nervousness

Nursing Management
• Do relaxation exercises to reduce muscle tension and stress, which may help reduce the frequency and duration of tension headaches.
• Take medicine as prescribed by your doctor to prevent and treat your tension headaches. This will also help you to avoid getting rebound headaches, which can be caused by overusing pain
relievers.
• Identify your headache triggers and determine whether your headaches are becoming more severe, by keeping a headache diary
• Seek help if you think your tension headaches may be linked to depression or anxiety. Proper treatment of these conditions may reduce the frequency of your headaches, as well as relieve your
symptoms of anxiety or depression.

Lifestyle Changes

• Good health habits - including adequate sleep, healthy diet, regular exercise, and good stress management -- are important, along with the following specific measures for headache
management. Quitting smoking is essential in reducing the risks for all headaches.
Pressure, Heat, and Cold -An ancient and potentially effective remedy for tension headaches uses pressure applied to the head (such as a headband or a towel wrapped around the head) plus
either heat or cold. In one study, 87% of headache sufferers experienced significant relief, and the rest reported moderate relief while they were wearing special headbands that could be
tightened. They applied packs that were frozen or heated in a microwave. (Either heat or cold packs were useful, although people with tension headaches generally preferred cold packs.)
• Dietary Factors -A healthy diet rich in fresh fruits and vegetables and whole grains and low in saturated fats (animal fats) is important to everyone. Fish (particularly oily fish, such as salmon
and tuna) and soy are protein sources that may be a good alternative to red meats.
• Caffeine. In some people with headaches, caffeine appears to be an excellent companion to medications. One study found that the caffeine equivalent of two and a half of cups of coffee can
help treat a tension-type headache by itself. Many medications contain combinations of pain or anxiety relievers and caffeine, which boosts pain-relieving potency and counters drowsiness.
Taking ibuprofen along with caffeine is even more effective than either substance alone. (It should be noted that in some people with migraines, the tannin found in coffee or tea may be a trigger
for the headache. In addition, withdrawal from caffeine is a major cause of headache.)
• Treatment of Sleep Disorders -Headaches that occur during the night and early morning may be related to sleep disorders. One study reported that treating an underlying sleep disorder, such
as sleep apnea or insomnia, in patients who also had headaches resulted in headache cure or improvement in all patients except those who suffered from restless legs syndrome.

Pathogenesis
Tension headaches are one of the most common types of headaches. They can be triggered by stress, anxiety, depression, hunger, anger, fatigue, overexertion, poor posture, and muscle strain.
Tension headaches may come on suddenly or gradually. Prolonged sitting, having poor posture, or eyestrain can also trigger tension headaches. The headache may disappear after you relax or take a
nonprescription pain reliever, such as aspirin or ibuprofen.
Tension headaches can last anywhere from 30 minutes to 7 days. If you have at least 15 tension headaches a month over a 6-month period, you may have chronic tension headaches. Chronic
headaches can lead to stress and depression, which in turn can prolong the cycle of headaches. Treatment is available to reduce the frequency or stop the occurrence of chronic tension headaches.

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Cause and pathophysiology

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

• Stress - Usually occurs in the afternoon after long stressful work hours or after an exam
 • Sleep deprivation
• Uncomfortable stressful position and/or bad posture
• Irregular meal time (hunger)
• Eyestrain
• Caffeine withdrawal

Until recently it was believed that tension headaches were caused by muscle tension around the head and neck. One of the theories says that the main cause for tension type headaches and migraine is
teeth clenching which causes a chronic contraction of the temporalis muscle. Although muscle tension may be involved, many researchers now question this idea, and recent research has shown that
tension headache patients do not have increased muscle tension

Another theory is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information, for example from the temporal muscle
or other muscles, and interprets this signal as pain. One of the main neurotransmitters which is probably involved is serotonin. Evidence for this theory comes from the fact that chronic tension-type
headaches may be successfully treated with certain antidepressants such as amitriptyline. However, the analgesic effect of amitriptyline in chronic tension-type headache is not solely due to serotonin
reuptake inhibition, and likely other mechanisms are involved. Recent studies of nitric oxide (NO) mechanisms suggest that NO may play a key role in the pathophysiology of CTTH.[4]. The sensitization of
pain pathways may be caused by or associated with activation of nitric oxide synthase (NOS) and the generation of NO. Patients with chronic tension-type headache have increased muscle and skin pain
sensitivity, demonstrated by low mechanical, thermal and electrical pain thresholds. Hyperexcitability of central nociceptive neurons (in trigeminal spinal nucleus, thalamus, and cerebral cortex) is believed
to be involved in the pathophysiology of chronic tension-type headache. Recent evidence for generalized increased pain sensitivity or hyperalgesia in CTTH strongly suggests that pain processing in the
central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type headache

TENSION HEADACHES

Tension headaches occur as the muscles of the back of the neck closest to the spine and at the base of the head (occiput) get excessively tense. The tension of these muscles pulls upon the scalp
and, according to recent medical research, upon the inside lining of the skull (the dura mater). Pain results.

Tensions existing more on one side than the other create headaches more on one side than the other; tension near the base of the head in back
may cause pain in the temples, forehead, or eyes; tension at the base of the skull behind the nasal cavity and in the back of the throat causes sinus
headaches. In all cases, the sensation of heightened muscular tension is experienced as a headache.

As muscles relax and this tension eases, the tension headache decreases in size and intensity, then fades out.

Headache is the result of pain signals caused by interactions between the brain, blood vessels,
and surrounding nerves. During a headache, the pain does not come from the brain contrary to
what many sufferers believe. Rather, the pain comes from activated nerves surrounding the
skull, blood vessels, and head muscles. The reasons-why these nerves in the head are activated-
are not understood. However, activation of specific nerves in the head sends pain signals to the
brain that are interpreted as a "headache."