​Kembara Xtra - Medicine - Tension Headache

​Kembara Xtra - Medicine - Tension Headache 
Introduction 
A mild to moderate, non-throbbing headache or pressure that is bilateral and unaccompanied by any other symptoms. Three different strain-type headaches (TTH) One day per month for infrequent episodic TTH; one day but fifteen days per month for frequent episodic TTH
- Chronic TTH: 15 days monthly for more than three months
The phrases muscle contraction headache, stress or tension headache, and psychogenic headache have been replaced by TTHs.


Epidemiology 

The most typical main headache and the second-most common condition worldwide
 Prevalence
In the United States, the fourth decade is when prevalence is at its highest. Men have a lifetime prevalence of 69% and women of 88%.

While the prevalence of chronic TTH rises with age, the prevalence of episodic TTH declines with age.

Pathophysiology and Etiology 

Multiple factors, including central and/or peripheral mechanisms
In episodic TTH, peripheral nociceptors' activation causes myofascial pain.
Chronic TTH is caused by chronic nociceptors being stimulated for an extended period of time, which sensitizes the central pain pathways.

Risk Elements 

Related to precipitating/triggering factors:

Stress (either mental or physical) is the most prevalent
Changing your sleep schedule, skipping meals, and consuming certain foods (caffeine, alcohol, and chocolate)
Dehydration, physical activity, and environmental conditions (such as brightness from the sun, smells, smoking, noise, and lighting)
Poor or persistent posture Changes in female hormone levels
Drugs (such as nitrates, SSRIs, and antihypertensives); Abortive headache drug abuse

Prevention 

• Recognize and prevent precipitating or triggering factors.
Reduce your level of mental and emotional tension.
Biofeedback, relaxation treatment, and physical therapy are all relaxation approaches.

Accompanying Conditions 
83 percent of migraine patients also experience TTHs.
Controversial: comorbid anxiety and depression are more common.

Diagnosis 
To rule out other headache diseases, obtain a full pain history that covers the pain's start, location, radiation, quality, severity, and related symptoms, as well as any existing medical problems, drugs being taken, recent trauma, or other procedures.
The diagnosis is made after a clinical evaluation.
There are numerous other ways to characterize pain, including "dull," "band-like," and pressure.
The International Headache Society's (ICHD-3) (1) diagnostic standards are as follows: - Episodic TTH: 10 or more headache episodes that satisfy each of the requirements below:  Pain that lasts for 30 minutes to 7 days
 Two or more of the following:
Bilateral placement

 Nonpulsating pressing/tightening quality

Mild to medium intensity
Not made worse by normal physical activities

 Dissociated from:

 Vomiting or nauseousness
No more than one person should be afraid of sound or light.
 No other cause of the headache diagnosis of ICHD-3
- Chronic TTH: More than three months of 15 days per month (on average) that satisfy all of the following requirements  Hours- to days-long or persistent headache At least two of the following
Bilateral placement
Nonpulsating pressing/tightening quality
Mild to medium intensity

Not made worse by regular exercise Both of the following:
No more than one of moderate nausea, phonophobia, or photophobia

No vomiting or mild to severe nausea


Clinical examination: Usually uneventful; Head and neck; palpation of myofascial tissues for pericranial muscle tenderness; Neurologic exam: mental status; pupillary responses; motor-strength testing; deep tendon reflexes; sensation; cerebellar function; gait testing; signs of meningeal irritation.


Differential diagnosis: Intracranial tumor, infection, or meningitis; Migraine headache; Cluster headache; Head trauma; Subarachnoid hemorrhage (SAH); subdural hematoma; unruptured vascular malformation; Ischemic cerebrovascular disease; cerebral venous thrombosis; Temporal arteritis; Arterial hypertension (HTN); benign intracranial HTN; Medication (nonprescription analgesic

Laboratory Results 
Most primary headaches with typical symptoms can be treated without lab work or imaging.
When a secondary cause is suspected, labs and neuroimaging (CT or MRI) should be taken into account: - An unusual pattern of headache (not a migraine, cluster headache, or tension headache). - An abrupt rise in frequency - Unaccounted-for focal neurologic findings
- First appearing after age 35 - Appearing suddenly or getting worse when exerted
MRI is the test of choice, both with and without contrast.
In emergency situations, head CT is favored, though.
Before doing a lumbar puncture, a head CT should be done if acute SAH is suspected.


Nonsteroidal anti-inflammatory medications (NSAIDs), aspirin, or acetaminophen are beneficial for relieving episodic TTH in the short term.

Amitriptyline ought to be the first option for treating chronic TTH.

General Actions 

Relieving activities include meditation, yoga, hot baths or showers, and massages of the back of the neck and temples.

Medication 

The selection of a simple analgesic is dependent on factors unique to the patient:
NSAIDs may be superior to acetaminophen in treating episodic TTH. Because they are better tolerated by the gastrointestinal system (GI), ibuprofen and naproxen may be recommended.
Patients who cannot tolerate NSAIDs or who are allergic to aspirin or NSAIDs might think about taking acetaminophen.


Initial Line

 For immediate care in episodic TTH:
The NSAIDs
Ibuprofen (Motrin, Advil): 200 to 400 mg; repeat as needed every 8 hours (maximum daily dose: 3.2 g)  Naproxen sodium (Naprosyn): 220 to 550 mg BID PRN, with a daily maximum of 1,250 mg. Drug interactions include antihypertensives, anticoagulants, antiplatelet drugs, aspirin, lithium, and methotrexate. Contraindications include aspirin or NSAID allergy or bronchospasm, renal disease, bleeding disorders, and an increased risk of cardiovascular events (myocardial infarction [MI], stroke, new onset or worsening of HTN).  Negative consequences include peptic ulcer and gastrointestinal distress
- Aspirin: 650–1,000 mg; repeat every six hours PRN (maximum 4 g/day):
Aspirin or NSAID allergy or bronchospasm, blood problems, and peptic ulcer are contraindications. Drug interactions include those with anticoagulants, antiplatelet medications, ACE inhibitors, beta-blockers, corticosteroids, NSAIDs, and sulfonylureas.  Negative consequences include thrombocytopenia and gastrointestinal bleeding.
- Acetaminophen (Tylenol): 1,000 mg; repeat as needed every six hours (maximum 3 to 4 g/day):
 Unfavorable consequences (rare): pancytopenia, liver damage, and rash
 Caution: Hepatic impairment, consuming three or less alcoholic beverages per day 
For prevention in frequently occurring episodic and persistent TTH: TCAs: Tricyclic antidepressants Amitriptyline [Elavil]: Start with 10 mg and increase dosage gradually to 100 mg QHS.
Chronic TTH is not approved by the U.S. Food and Drug Administration (FDA).
Assess the patient's level of anxiety, sleeplessness, or sadness.
Acute MI recovery period (within 30 days) and the use of monoamine oxidase inhibitors (MAOIs) within 14 days are contraindications. Clonidine, MAOIs, quinolone antibiotics, SSRIs, sympathomimetics, azole antifungals, and valproic acid are among the medications that interact with each other. Weight gain, sleepiness, dry mouth, tachycardia, heart block, blurred vision, urine retention, and seizure are some of the negative side effects. 

Next Line

 For immediate care in episodic TTH:
- Caffeine combinations: 500 mg of acetaminophen and/or 500 mg of aspirin q6h PRN (2)[C] and 130 mg of caffeine.
- 60 mg IM once for severe episodes of ketorolac
- Opioids (including codeine) and butalbital alone or in combination are not advised. Think about secondary headache causes or secondary gains such drug use for personal use, diversion, or sale.

- Mirtazapine: 15 to 30 mg/day (not FDA-approved for chronic TTH); for prevention in frequent episodic and chronic TTH.

Caution 
Use of abortion pills more than twice weekly may require medicine.-repeated headaches; diagnosing requires discontinuing immediate care

Further Treatments

The most successful treatment for chronic TTH may involve a TCA (amitriptyline) and stress management therapy.

 Topiramate: 100 mg/day (lack of FDA approval for chronic TTH; insufficient clinical evidence for prophylaxis)
Limited evidence of benefit for alternative TCAs (4)[B].
- Nortriptyline (Pamelor): 25 to 50 mg/day (slightly to moderately sedating, increases appetite) - Protriptyline, brand name Vivactil, 25 mg/day (nonsedating, induces weight reduction)

Tizanidine should not be used to treat chronic TTH due to inconsistent clinical evidence. 

Botulinum toxin injections: inconsistent clinical data for treatment in chronic TTH. Trigger point lidocaine injections: may reduce headache frequency in frequent episodic or chronic TTH.

Alternative Therapies 

Tiger Balm or peppermint oil, which are not FDA-approved for treating TTH, may work well for episodic TTH when applied directly to the forehead.

Cognitive behavioral treatment could be beneficial.

The effectiveness of electromyography (EMG) biofeedback may be increased when used in conjunction with relaxation training.

Physical treatment may be beneficial and may include exercises, ergonomic advice, massages, transcutaneous electrical nerve stimulation, and the use of heat and cold.
Chiropractic spine manipulation has conflicting research on its effectiveness in treating both episodic and chronic TTH.

When compared to standard care, acupuncture may reduce the frequency of symptoms; NNT = 3 indicates that the frequency of headaches will be reduced by at least 50%.


Admission 

Common symptoms are typically treated in an outpatient environment. Red flag symptoms, however, may call for urgent therapy (temporal arteritis, a relevant systemic illness, papilledema without focused indications, elderly patient with new headache and cognitive deficits), emergent evaluation (thunderclap onset, fever and meningismus, papilledema with focal signs), or both.

Follow-Up Keep a headache journal to track your progress, identify triggers, and avoid headache from taking too many medications.
Regular sleep and exercise routines

Diet: Establish a regular mealtime pattern, identify and avoid dietary triggers, etc.




When stressors in life are not adjusted, the prognosis is typically chronic. Most cases are intermittent and are less severe as people get older.

Complications include lost productivity and workdays (particularly so with chronic TTH), medication-induced headache, narcotic painkiller dependence or addiction, and GI bleeding from NSAID use.