Tension-type headache

Disease Description (Causes and Symptoms)

• Definition: Tension-type headache is the most common primary headache disorder and is characterized by dull, constricting bilateral pain that feels as though a band is wrapped around the head.
• Causes and pathophysiology:
  • Peripheral factors: Persistent contraction (muscle tension) of the scalp, neck, and shoulder muscles, causing pain in the fascia and soft tissues (peripheral muscular and myofascial pain).
  • Central factors: In chronic cases, central sensitization may occur, which can lower the pain threshold.
  • Triggers: Stress, fatigue, lack of sleep, anxiety or depression, persistently poor posture, teeth grinding (bruxism), caffeine or medication overuse, and others.
• Main symptoms:
  • Non-pulsating (not throbbing), with a feeling of pressure or constriction.
  • Usually bilateral, with mild to moderate pain.
  • Not aggravated by routine activities (distinguishing it from migraine, which tends to worsen with physical activity).
  • Nausea and vomiting are usually absent (rare even when present). Sensitivity to light or sound is usually absent, although one of them may occur.
  • May occur in episodic or chronic forms (persisting weekly or daily).

Treatment Methods

• Acute treatment (during an attack):
  • General analgesics: acetaminophen (Tylenol), nonsteroidal anti-inflammatory drugs (NSAIDs: ibuprofen, naproxen, etc.). Use for as short a period as possible and at the lowest effective dose.
  • Muscle relaxants and local treatment: Physical therapy, heat therapy, and other treatments that help relax the neck and shoulder muscles.
• Preventive treatment (for patients with chronic or frequent headaches):
  • Medication: The tricyclic antidepressant amitriptyline is the most widely used preventive medication. Selective serotonin reuptake inhibitors (SSRIs) have limited effectiveness. Other options, such as anticonvulsants or muscle relaxants, may be considered depending on the circumstances.
  • Nonmedication treatment: Cognitive behavioral therapy (CBT), relaxation therapy (deep breathing and muscle relaxation techniques), stress management, sleep hygiene, regular exercise, physical therapy (neck and shoulder-blade stretching and correction), posture correction, and improvement of the work environment.
• Procedures/surgery: Generally not necessary. In special cases, such as when another cause is present, nerve blocks may be considered, but they are not standard treatment.
• Precautions (risk of complications and self-care considerations):
  • Frequent overuse of analgesics to control pain (for example, on 10–15 or more days per month) can cause medication-overuse headache (medication-induced headache).
  • Depression or anxiety may accompany chronic headache, so mental health should be assessed.
  • Immediate emergency care is needed if the headache rapidly worsens, neurological deficits occur (visual disturbance, paralysis, or altered consciousness), a sudden and extremely severe headache occurs, or fever and neck stiffness develop.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items and records to prepare:
  • A list of all medications currently being taken, including prescription drugs, over-the-counter medications, supplements, and herbal medicines
  • Records of recent medical history, surgeries, and allergies
  • A headache diary, if possible for at least the past 4 weeks: date and time of onset, duration, pain intensity (0–10), characteristics of the pain (constricting, pressure, pulsating, etc.), location (bilateral or unilateral), accompanying symptoms (nausea or sensitivity to light and sound), triggers, and medications taken and response to them
  • Bring any previous imaging (brain CT/MRI) or neurology examination results, if available
• Examples of items healthcare professionals may ask about during the outpatient visit:
  • When the headaches began and their pattern (every day? Occasionally? Gradually worsening?)
  • The time required for the pain to reach its peak and its duration
  • The types of analgesics being taken and how frequently they are used
  • Sleep, stress, caffeine and alcohol consumption, and whether there are occupational or posture-related problems
  • Accompanying symptoms (vomiting, visual disturbance, sensory changes, fever, etc.)

Examples of General Questions to Ask the Doctor

• What effects and side effects can be expected from this medication?
• How long should I take the medication? What precautions should I take when stopping it?
• To prevent medication-overuse headache, how much analgesic use should I limit myself to?
• Which lifestyle habits should I focus on improving?
• What is the prognosis if the condition becomes chronic? What are the criteria for needing preventive treatment?

Examples of Condition-Specific Questions

• Is my headache episodic (occasional) or chronic (weekly/daily)? Do I need preventive medication depending on this?
• In addition to improving stress and sleep, do I need recommendations for physical therapy, an electromyography (EMG) test, or dental correction for teeth grinding?

Additional Brief Guidance

• If symptoms that are 'red flags' occur, such as rapid worsening, neurological abnormalities (language, visual, motor, or sensory changes), a sudden excruciating headache, fever, or neck stiffness, immediate evaluation in an emergency department is recommended.