Headaches: Tension-Type

Description

Diagnosis

Diagnosing the cause of persistent daily headache is difficult, even for expert physicians. Studies report that people who visit the emergency room with disabling headache are often misdiagnosed as tension-type headaches instead of migraines. It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.

Extensive testing may be advised for anyone with a chronic, daily headache. Tracking times of medications, withdrawal, and headache, using the headache diary, is usually very helpful in diagnosis.

Differentiating Medication-Overuse (Rebound) Headache from Tension-Type Headache. About a third of persistent headaches are actually the result of the rebound effect caused by the overuse of headache medications (formerly called rebound headaches).

Usually in such cases, medications have been taken on an ongoing basis for more than three days each week. If patients stop taking these drugs, the headaches come back. The patient then starts taking the drugs again. Eventually the headache simply persists and medications are no longer effective. Even after successful medication withdrawal, relapse is common, particularly with drugs that contain caffeine, so physicians should check for this type of headache even in patients who have previously been treated.

Medications implicated in medication-overuse headache include barbiturates, sedatives, narcotics, and migraine medications, particularly those that also contain caffeine. (Heavy caffeine use can also cause this condition.) Simple painkillers such as aspirin or ibuprofen are less likely causes of medication-overuse headaches.

Differentiating Tension Headaches from Chronic Migraines. It is often difficult to differentiate between chronic migraine and chronic tension-type headaches. Some experts report that a common questionnaire called the McGill Pain Questionnaire may be useful for ruling out migraine. According to a 2003 study, migraine sufferers who answer the questionnaire report significantly more severe specific symptoms (e.g., throbbing, stabbing, gnawing, hot, sickening, exhausting) than tension-type headaches. There is very little difference between them, however, in scores of overall severity of the pain.

Medical and Personal History

For an accurate diagnosis, the patient should describe the following:

• Duration and frequency of headaches.
• Recent changes in their character.
• The location of the pain.
• The type (e.g., throbbing or steady pressure).
• The intensity of the headache.
• Associated symptoms, such as visual disturbances or nausea and vomiting. (These are seen most often with migraines.)
• Behaviors during a headache. Different behaviors may help distinguish between migraine and tension headaches. People with tension headaches tend to relieve pain by massaging the scalp, temples, or the nape of the neck. The person with migraines is more apt to compress the forehead and (e.g., tying a scarf around the head) temples or to apply cold to the area. They also tend to isolate themselves, lie down, induce vomiting, and use more pillows than usual. (None of these maneuvers do much good in relieving either headache, unfortunately.)

Headache Diary to Identify Triggers

The patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is a useful way to identify triggers that bring on headaches. Some tips include the following:

Be sure to include all events preceding an attack. Often two or more triggers interact to produce a headache. Experts are investigating triggers of headaches to determine if certain ones are more likely to set off different primary headaches. In general, however, the same stimuli seem to trigger any of the primary headaches, although people with migraines may be more sensitive to some of them (e.g., weather, certain smells, light, and smoke) than people with tension headaches.

Tracking medications is an important way of identifying medication-overuse headache or transformed migraine.

Be sure to attempt to define the intensity of the headache. There are different scoring symptoms available that help communicate the severity of the pain to the physician. For instance, the following is a number system that can be helpful:

1 = mild, barely noticeable.

2 = noticeable, but does not interfere with work/activities.

3 = distracts from work/activities.

4 = makes work/activities very difficult.

5 = incapacitating.

Medical and Personal History

The patient should report any other conditions that might be associated with headache, including but not limited to the following:

• Any chronic or recent illness and their treatments.
• Any injuries, particularly head or back injuries.
• An uncharacteristic dietary changes.
• Any current medications or recent withdrawal from any drugs, including over-the-counter or so-called natural remedies.
• Any history of caffeine, alcohol, or drug abuse.
• Any serious stress, depression, and anxiety.
• The physician will also need the patient's general medical and family history, particularly concerning headaches or other diseases such as epilepsy. Migraine, in particular, tends to run in families.

Physical Examination

In order to diagnose a chronic headache, the physician will examine the head and neck and will usually perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The physician will also examine the eyes to rule out pressure build-up in the eye as a cause of headache. The physician may ask questions to test short-term memory and related aspects of mental function.

Imaging Tests

Imaging tests of the brain may be recommended under the following circumstances:

• If the results of the history and physical examination suggest neurologic problems.
• For patients with headache that wakes them at night.
• For new headaches in the elderly. In this age group, it is particularly important to first rule out age-related disorders, including stroke, hypoglycemia, hydrocephalus, and head injuries (usually from falls).
• For patients with worsening headache.

They are not recommended for patients with migraine and with no other abnormal indications.

The following tests may be used:

• A CT (computed tomography) scan may be ordered to rule out other conditions, particularly chronic sinusitis, which, in one study, occurred in 20% of patients with chronic headache. Other findings include aneurysms, benign or cancerous growths, and other abnormalities in the brain.
• X-rays and other tests may also be used if sinusitis is strongly suspected.
• A neck x-ray can reveal arthritis or spinal problems.
• Other tests include an MRI (magnetic resonance imaging), EEG (electroencephalogram), lumbar puncture, ultrasound testing, and cerebral angiography, which are only performed if there is reason to suspect an underlying disease.