1.07 Tension Headache

agk’s Library of Common Simple Emergencies

Presentation

The patient complains of a dull, steady pain, described as an ache, pressure, throb, or constricting band, located anywhere from eyes to occiput, perhaps including the neck or shoulders. Most commonly, the headache develops near the end of the day, or after some particular stress. The pain may improve with rest, aspirin, acetaminophen, or other medications. The physical exam will be unremarkable except for cranial or posterior muscle spasm or tenderness.

What to do:

Perform a complete general history (including environmental factors and foods which precede the headaches) and physical examination (including a neurological examination).
If the patient complains of sudden onset of the “worst headache of my life,” accompanied by any change in mental status, weakness, vomiting, seizures, stiff neck, or persistent neurologic abnormalities, suspect a cerebrovascular cause, especially a subarachnoid hemorrhage, intracranial hemorrhage, or arteriovenous malformation. The best initial diagnostic test for these is computed tomography, but when CT is not available and the patient does not have papilledema or other signs of increased intracranial pressure, rule out these problems with a lumbar puncture.
If the headache is accompanied by fever and stiff neck, or change in mental status, you need to rule out bacterial meningitis as soon as possible, again with lumbar puncture.
If the headache was preceded by ophthalmic or neurologic symptoms, now resolving, suggestive of a migraine headache, you may want to try sumatriptan or ergotamine therapy. If vasospastic symptoms persist into the headache phase, the etiology may still be a migraine, but it becomes more important to rule out other cerebrovascular causes.
If the headache follows prolonged reading, driving, or television watching, and decreased visual acuity is improved by viewing through a pinhole, the headache may be due to a defect in optical refraction, curable with new eyeglass lenses.
If the temples are tender, check for visual defects and myalgias that accompany temporal arteritis.
If there is a history of recent dental work or grinding of teeth, tenderness anterior to the tragus, or crepitus on motion of the jaw, suspect arthritis of the temperomandibular joint.
If there is fever, tenderness to percussion over the frontal or maxillary sinuses, purulent drainage visible in the nose, or facial pain exacerbated by lowering the head, consider sinusitis.
If pain radiates to the ear, be sure to inspect and palpate the teeth, which are a common site of referred pain.
Finally, after checking for all these other causes of headache, palpate the temporalis, occipitalis, and other muscles of the calvarium and neck, looking for areas of tenderness and spasm which usually accompany muscle tension headaches. Keep an eye out for especially tender trigger points which may resolve with gentle pressure or massage.
Prescribe anti-inflammatory analgesics (ibuprofen, naproxen), recommend rest, and have the patient try cool compresses and massage of any trigger points.
Explain the etiology and treatment of muscle spasm of the head and neck. Volunteer the information that you see no evidence of other serious disease (if this is true); especially that a brain tumor is unlikely. (Often this is a fear which is never voiced.)
Arrange for followup. Instruct the patient to return to the ED or contact his own physician if symptoms change or worsen.

What not to do:

Do not discharge without followup instructions. Many serious illnesses begin with a minor cephalgia, and patients may postpone urgent; care in the belief that they have been definitively diagnosed on the first visit.
Do not miss subarachnoid hemorrhage and meningitis. (If you are not obtaining a majority of negative CTs and LPs, you may not be looking hard enough.)

Discussion

Headaches are common and most are benign, but any headache brought to medical attention deserves a thorough evaluation. Screening tests are of little value – a laborious history and physical examination are required. Other causes of headache include carbon monoxide exposure from wood heaters, fevers and viral myalgias, caffeine withdrawal, hypertension, glaucoma, tic douloureux (trigeminal neuralgia) and intolerance of foods containing nitrite, tyramine, xanthine. Tension headache is not a wastebasket diagnosis of exclusion but a specific diagnosis, confirmed by palpating tenderness in craniocervical muscles. (“Tension” refers to muscle spasm more than life stress.) Tension headache is often dignified with the diagnosis of " migraine" without any evidence of a vascular etiology, and is often treated with minor tranquilizers, which may or may not help. Focal tenderness over the greater occipital nerves (C2, 3) can be associated with an occipital neuralgia or occipital headache, and be secondary to cervical radiculopathy from cervical spondylosis. These tend to occur in older patients and should not be confused with tension headache. Remember to probe for the patient’s hidden agenda. “Headache” may often be the justification for seeing a physician when some other physical, emotional, or social concern is actually the patient’s major problem.

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