October 15, 2022

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HEADACHE

Brain tissue does not experience sensations of pain.

Pain occurs in several locations:

The tissues covering the brain

The attaching structures at the base of the brain

Muscles and blood vessels around the scalp, face, and neck

The source of a headache is normally caused by muscle tension, or vascular problems.

The International Headache Society diagnostic criteria for classification of headache:

Primary classifications: Tension-type, Migraine, Cluster

Bilateral, band-like feeling of pressure around the head with a constant, squeezing and tightness

Most common type of headache is the Tension Headache

Classified into four types:

Frequent episodic tension-type headache

Infrequent episodic tension-type headache

Chronic tension-type headache

Probable tension-type headache

(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).

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Tension Headaches

According to research, tension headaches occur because of pain sensitivity, perception, and neurotransmitters.

Genetics are thought to be involved in chronic tension headache.

Environmental factors (stress) are involved in the physiologic processes experienced with episodic tension headache.

Abnormalities in the central nervous system, cause sensitivity to pain experienced in tension headaches.

Connective tissue and muscles in the neck and shoulders cause a tension headache by forming knots in the muscles.

Neurotransmitters cause the brain to experience pain when stimulated such as serotonin and nitric oxide.

Medication and Substance abuse cause about one third of all headaches.

Causes: Poor Posture, Work Conditions, Fatigue, Eyestrain, Physical Activity, Food, Stress Pharmacologic agents, Dental Problems, Physical Trauma, Hormonal Changes.

Symptoms of a tension headache: Constant, dull pain above the eyes and across the back of the head

Head pain that gets worse as the day progresses

Pain that may spread over your entire head and to your shoulders and neck

Muscles that are tight in the neck or shoulder area

Head pain that is made worse by bright lights or loud noises

(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).

Pathophysiology

78% of headache patients in population-based studies are from tension type headaches, it is the least distinct of all headache types. A clinical diagnosis is made mainly by on negative symptoms (Barbanti, Egeo, Aurilia, & Fofi, 2014).

Tension headache

Frequent episodic tension-type headache- ≥12 and <180 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.

Infrequent episodic tension-type headache- <12 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.

Chronic tension-type headache- ≥180 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.

Probable tension-type headache- Do not fulfill some of the above criteria.

(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).

DIAGNOSTIC CRITERIA

Tension headache

Questions

1. What is the most common side effect when taking NSAIDs, Acetaminophen and Aspirin?

A. Heartburn

B. Hypertension

C. Nausea

D. Insomnia

2. What is an indicator to do further testing in a patient with headaches?

A. Nausea and Vomiting

B. Blurred Vision

C. Recent head trauma

D. All of the above

3. What is the primary cause of a rebound headache?

A. Overuse of medication

B. Underuse of medication

C. Insomnia

D. All of the above

4. If a tension headache lasts ≥180 days per year, last from 30 minutes to 7 days what is the headache classification?

A. Frequent episodic tension-type headache

B. Infrequent episodic tension-type headache

C. Chronic tension-type headache

D. Probable tension-type headache

5. How long must preventive type drug that treats tension-type headaches be taken before the beginning to work?

A. Several weeks

B. Thirty minutes

C. Two days

D. None of the above

Answers: 1:C, 2:D, 3:A, 4:C, 5:A

Medical providers will perform physical and neurological exams to discover the type and cause of an individuals chronic or recurrent headaches. Pain characteristics: What type of pain pulsating, dull, sharp, or stabbing.

Pain intensity: Does the pain interfere with your average daily living?

Pain location: Where is the pain felt in your head?

Do you feel pain all over your head, one side of your head, or do you feel it in the forehead area or behind your eyes?

Tension headaches

Ibuprophen (Advil, Motrin, A-G Profen, Addaprin, Bufen, Genpril, Caldolor, Haltran), Analgesic NSAIDs

Dose-200 to 400 mg ORALLY every 4 to 6 hours as needed; MAX dose, 1200 mg in 24 hours

Side Effects-Heartburn, Nausea, Dizziness, Cardiac arrest, CHF, HTN, Hyperkalemia, GI bleeding.

MOA-a nonsteroidal anti-inflammatory drug (NSAID) that exhibits analgesic and antipyretic activities by inhibiting prostaglandin synthesis.

Contraindications-Asthma, urticaria, or other allergic-type reaction following aspirin or other NSAID administration, In the setting of coronary artery bypass graft (CABG) surgery, •Hypersensitivity to ibuprofen (Micromedex, n.d.a).

Aspirin (Ecotrin, Bayer, Ascriptin, Aspergum, Aspirtab, Easprin, Ecpirin, Entercote), Analgesic

Dose-500 mg to 1000 mg ORALLY every 4 to 6 hours; MAX: 4 g/24 hours.

Side Effects-GI ulcer, Hemorrhage, Exudative age-related macular degeneration, Tinnitus, Bronchospasm, Angioedema, Reye’s syndrome.

MOA-inhibitor of prostaglandin synthesis and platelet aggregation which irreversibly inactivates cyclooxygenase via acetylation which prevents the conversion of arachidonic acid to thromboxane A(2).

Contraindications-Hypersensitivity to NSAIDs, Syndrome of asthma, rhinitis, urticaria, angioedema, or bronchospas(Micromedex, n.d.b).

Over The Counter (OTC) Medications

There are many medications on the market that will treat a tension headache and reduce an individuals pain. Over the counter (OTC) medications for headaches are considered the first line of treatment such as aspirin, ibuprofen, and naproxen (Barbanti, Egeo, Aurilia, & Fofi, 2014).

Tension Headache OTC MEDICATIONS

Acetaminophen (Tylenol, Genapap, Feverall, Actamin Maximum Strength, Altenol, Aminofen, Ofirmev, Anacin Aspirin Free),

Dose-Adults: 650 to 1000 mg orally every 4 to 6 hours as needed (maximum 4 g/day)

Side effects-Constipation, Nausea, Vomiting, Headache, Insomnia,

Agitation, increased the risk of hepatic injury if taken with alcohol, Liver failure.

MOA-centrally acting analgesic and antipyretic with minimal anti-inflammatory properties and reduces fever by inhibiting the formulation and release of prostaglandins in the CNS and by inhibition endogenous pyrogens in the hypothalamic.

Contraindications-hepatic disease, allergy to acetaminophen or any other components of the product (Micromedex, n.d.c).

Naproxen (EC Naprosyn, Naprosyn)

Dose-500 mg orally initial dose, then 250 mg orally every 6 to 8 hours as needed or 500 mg orally every 12 hours as needed (maximum initial dose, 1250 mg/day, then 1000 mg/day)

Side effects-Abdominal pain, Constipation, Heartburn, Nausea, Dizziness Headache, Dyspnea, Body fluid retention, Congestive heart failure, Hypertension, Myocardial infarction, Hyperkalemia

MOA- a propionic acid derivative NSAID with analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action is unknown but involves inhibition of cyclooxygenase (COX-1 and COX-2), which reduces prostaglandin synthesis.

Contraindications-Asthma, urticaria, or allergic-type reaction following aspirin or other NSAID administration, Use in the setting of CABG surgery (Micromedex, n.d.d).

Headaches

Preventive medications

Amitriptyline (Elavil, Vanatrip) is an antidepressant agent that helps prevent tension headaches.

Dose-30–75 mg orally, may increase to MAX, 150 mg/day

Side Effects-Weight gain, Constipation, Dizziness, Headache, Somnolence, Blurred vision, Depression, and Hepatotoxicity

MOA-Amitriptyline hydrochloride is a tricyclic antidepressant (TCA) that has a sedative property. It promotes neuronal activity by blocking the membrane pump mechanism so that the absorption of serotonin and norepinephrine in serotonergic and adrenergic neurons does not occur.

Contraindications-Coadministration with cisapride; may cause QT interval prolongation and increase the risk of arrhythmia, Coadministration with an MAOI or use within 14 days of discontinuing an MAOI; may cause a hyperpyretic crisis, severe convulsions, death, and MI (Micromedex, n.d.g).

***Preventive medications must be taken for several weeks before there effects will be therapeutic to the individual..

***Overuse of OTC pain relievers may interfere with the effects of the preventive drugs.

Education about Medications

Over-the-counter (OTC) drugs have many side effects and contraindications with other medications and diseases that may cause serious harm.

According to the Beers Criteria, elderly patients should avoid chronic use of NSAIDS, Acetaminophen, and Aspirin (Micromedex, n.d.g).

Try not to take over-the-counter drugs more than 3 times a week, because you may get rebound headaches. Continually taking OTC medications for headache pain will cause a rebound headache to occur when you stop taking the medicine

According to Dreischulte & Guthrie (2012), the quality measures of drug prescribing include avoiding inappropriate medications by checking contraindications before prescribing or taking a medication. Use medications in proper dosage and purpose. Check for drug to drug interactions. Monitoring for side effects and drug levels.

Case Study

Jake, a 25-year-old male comes to the clinic for reoccurring headaches. He states that his symptoms started four days ago, and he gets no relief from Ibuprofen. He has previously been healthy. He does not smoke, but drinks 2-3 beers socially on weekends. He works out daily lifting weights and doing 30 minutes of cardio. He is currently taking a pharmacology class in college. He has no history of drug abuse. On physical examination, his blood pressure is 110/67 mm Hg, heart rate is 66/min, and he is afebrile. He describes the headache as dull and progressively get worse throughout the day, the pain ranges from 2 to 6 on scale of 1-10 (10 being worst pain). He has no previous medical history of headaches. When asked where it hurts Jake states; “it hurts over my entire head and to my shoulders and neck ”. He denies vomiting and nausea. He states that “sometimes light makes it worse”. He denies blurred vision, diplopia, tearing, rhinorrhea, numbness, or sensitivity to noise. He has taken Ibuprofen “a each day and at first it worked and now it will get a little better but then comes back”. When asked how much Ibuprofen he takes a day he states “I take eight a day trying to get rid of the pain”. When asked if working out makes it worse Jake states “no”. When asked if he feels like he is under stress he states “money and my pharmacology class both stress me out a lot, but that is why I work out daily”.

Surgeries; None

Hospitalizations; None

Current prescribed medications; None

Current Vitamins and supplements; Protein shake 2 x day, Multivitamin daily

Hours of sleep a day; 4-6

Meals a day; 2 (skips breakfast)

Poor Posture while working, fatigue from sleeping improperly, and eyestrain can all cause tension headaches. Intense physical activity or lack of activity can cause a tension headache, but the pain is not intensified by physical activity. Dental problems that cause a person to clench their jaw while sleeping may cause pain in the ear, cheek, temples, neck, or shoulders which lead to a tension headache. Physical trauma from a head or neck injury and hormonal changes may cause or increase the occurrence of tension headaches. Stress from writing a grand rounds presentation can also lead to a tension headache (Jensen, 2017)

Diagnosis

Jake has Infrequent episodic tension-type headache as evident by, bilateral dull mild to moderate pain that travels to his neck and shoulders and feels like a tight band around his head that last from 30 minutes to 7 days. He is able to continue his usual daily activities with the headaches and has no associated symptoms of nausea, vomiting, or phonophobia, although he does have some photophonia. He may also be having rebound headaches which are associated with frequent use of any analgesic medication being overused. Improvement of rebound headaches will not occur until the medication is discontinued. She should be screened for depression and anxiety as psychiatric co-morbidity is common in patients with tension type headaches.

DIFFERENTIAL DIAGNOSIS

Conditions that may cause symptoms similar to tension headaches include but are not limited to:

Brain tumor Dental/oral disease Caffeine dependency Encephalitis

Cluster Headache Cervical spine disease Chronic sinusitis Glaucoma

(Jensen, 2017).

After a complete assessment of the patient if the history or physical is unusual for an intracranial issue than a head CT or MRI scan may be indicated. Blood tests can include a complete blood count (CBC), and a complete chemistry panel. The spinal fluid analysis is needed only on rare occasions. Test that may be indicated by clinical findings may include an x-ray of the cervical spine (Jensen, 2017)

Barriers to effective care

The primary clinical barrier is due to the lack of knowledge of health-care providers. Medical education that focuses on headache disorders are usually given four hours in undergraduate school. Many people that have headache disorders are not diagnosed and treated: 40% of people with migraine or TTH are professionally diagnosed.

The public does not view headache disorders as a serious health issue because they are mainly episodic, are not contagious, and death does not occur. Many of the individuals that suffer from headaches are not aware that effective treatments exist. 50% of all individuals with headache disorders are self-treating.

Due to health-care costs constraints, governments do not acknowledge the profound burden of headaches on the public. The government may not be considering the loss of working days that individuals miss because of headaches compared to he small cost of treating headaches.

Infrequent episodic tension-type headache usually become chronic when life stressors or posture are not corrected. Most tension-type headaches are episodic or intermittent, allowing the individual to continue to work and live a normal life. Episodic tension-type headaches usually improve over time.

(Leonardi, 2015).

Treatment Plan

Treatment of a tension headache must start with lifestyle modifications. Jake needs adequate sleep (at least 8-10 hours per night), no caffeine, drink plenty of water, and do not skip meals. I will encourage Jake to include relaxation and stress relieving techniques in his daily activities. Non-pharmacological ways to reduce stress include massages, acupuncture, biofeedback and behavioral therapies. I will educated Jake of the importance of avoiding any identified triggers that may cause his tension headaches (ihs.org, 2013). OTC medications such as NSAIDs are first-line treatment for tension headaches, however, Jake reports that Ibuprofen does not relieve his headache anymore. At this time labs are not indicated. I will have Jake stop taking the Ibuprophen. I will inform him it may take 2 to 10 days for his sign and symptoms from the rebound headaches to be relieved. I will have him make an appointment for one week from now to evaluate his need for a preventive drug for the treatment of his tension headaches, such as Venlafaxine hydrochloride, Amitriptyline, or Mirtazapine.

I will educate Jake about the signs and symptoms of using OTC medications and to try not to take over-the-counter drugs more than 3 times a week, because you may get rebound headaches. Continually taking OTC will cause a rebound headache to occur when you stop taking the medicine prompting you to take more of the medication (Barbanti, Egeo, Aurilia, & Fofi, 2014).

Reference

Barbanti, P., Egeo, G., Aurilia, C., & Fofi, L. (2014). Treatment of tension-type headache: from old myths to modern concepts. Neurological Sciences, 3517-21. doi:10.1007/s10072-014-1735-3

Jensen, R. H. (2017), Tension-Type Headache – The Normal and Most Prevalent Headache. Headache: The Journal of Head and Face Pain. doi:10.1111/head.13067

Micromedex. (n.d.a). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/56E151/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/A4B146/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Ibuprofen&fromInterSaltBase=true&false=null&=null#

Micromedex. (n.d.b). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/E4A67E/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E91CDB/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=asa&UserSearchTerm=asa&SearchFilter=filterNone&navitem=searchGlobal#

Reference

Barbanti, P., Egeo, G., Aurilia, C., & Fofi, L. (2014). Treatment of tension-type headache: from old myths to modern concepts. Neurological Sciences, 3517-21. doi:10.1007/s10072-014-1735-3

Dreischulte, T., & Guthrie, B. (2012). High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved? Therapeutic Advances in Drug Safety, 3(4), 175–184. http://doi.org/10.1177/2042098612444867

Jensen, R. H. (2017), Tension-type headache – The normal and most prevalent headache. Headache: The Journal of Head and Face Pain. doi:10.1111/head.13067

Leonardi, M. (2015). Burden of migraine: what should we say more?. Neurological Sciences, 361-3. doi:10.1007/s10072-015-2188-z

ICHD-3 The International Classification of Headache Disorders 3rd edition. (n.d.). Retrieved from https://www.ichd-3.org/

Reference Continued

Micromedex. (n.d.c). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/74FE35/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/20B80A/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Acetaminophen&UserSearchTerm=Acetaminophen&SearchFilter=filterNone&navitem=searchGlobal#

Micromedex. (n.d.d). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/8F54A3/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/03B8AF/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Naproxen&fromInterSaltBase=true&false=null&=null#

Reference Continued

Micromedex. (n.d.e). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/98DD5B/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/CAC700/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFAction/evidencexpert.DoIntegratedSearch?SearchTerm=Mirtazapine&UserSearchTerm=Mirtazapine&SearchFilter=filterNone&navitem=searchALL#

Micromedex. (n.d.f). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/EE6205/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/6DE827/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Venlafaxine hydrochloride &UserSearchTerm=Venlafaxine hydrochloride &SearchFilter=filterNone&navitem=searchALL#

Micromedex. (n.d.g). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/DAEAF8/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E63695/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Amitriptyline&UserSearchTerm=Amitriptyline&SearchFilter=filterNone&navitem=searchGlobal#

Reference Continued

Micromedex. ( n.d.h). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/441CEC/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/33BB65/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.IntermediateToDocumentLink?docId=1172&contentSetId=50&title=Beers%2BCriteria%2B-%2BA%2BSummary%2Bof%2BPotentially%2BInappropriate%2BMedication%2BUse%2BAmong%2Bthe%2BElderly&servicesTitle=Beers%2BCriteria%2B-%2BA%2BSummary%2Bof%2BPotentially%2BInappropriate%2BMedication%2BUse%2BAmong%2Bthe%2BElderly

Society, I. (2006, January 25). ICHD-II Full Text Search. Retrieved from http://www.ihs-klassifikation.de/en/02_klassifikation/02_teil1/02.00.00_tension.html

The International Classification of Headache Disorders, 3rd edition (2013). Cephalalgia,

33(9), 629–808. doi:10.1177/03331024134856

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Grand Rounds Power Point

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Tension Headaches

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