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.

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

Sex A female preponderance of migraine exists, 14-17%, compared with 5-6% in males. Age All ages are susceptible, but most patients are young adults.

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[4] :

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; Bilateral and occipitonuchal or bifrontal pain Pain described as "fullness, tightness/squeezing, pressure," or "bandlike"

Tension-type headache history is as follows: 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

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. Some patients with occipital tension headaches may be very tender when upper cervical muscles are palpated.

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

 Laboratory

work should be unremarkable in cases of tension-type headache. Head CT scan or MRI is necessary only when the headache pattern has changed recently or neurologic examination reveals abnormal findings.

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.

Ketorolac (Toradol) 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.

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

Acetaminophen

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.