9: Headaches

CHAPTER 9 Headaches


Headaches are one of the most common pain conditions for which medical attention is sought. Headaches are typically classified as primary or secondary. Primary headache disorders include migraine (see Chapter 10), tension-type headache, and cluster headache. Secondary headaches result from other organic disturbances such as infections and metabolic disorders.


Although most headaches are not serious, some signal dangerous medical conditions such as cerebral aneurysm, brain tumor, stroke, meningitis, or encephalitis. A severe headache that comes on suddenly—especially if it is accompanied by numbness, loss of consciousness, dizziness, slurred speech, seizures, or fever—must be evaluated immediately by an appropriately trained medical professional.



TENSION-TYPE HEADACHES


An estimated 88% of women and 69% of men experience a tension-type headache sometime during their lifetimes.1 Approximately 820 workdays are lost annually for every 1000 persons as a result of tension-type headaches,2 compared with 270 days lost annually per 1000 persons as a result of migraines. More than 45 million Americans live with chronic recurrent headaches. For some, these headaches are simply a nuisance; for others, tension-type headaches create a significant reduction in their quality of life.


It is estimated that only 15% of people who experience tension-type headaches seek medical attention (see “Self-Help Ideas for Handling Headaches”). This may be due in part to the very nature of the name tension-type headache. This term has fostered the widely held belief that this type of headache is purely psychological in nature. This chapter provides a discussion of the physiologic basis, diagnosis, and treatment of tension-type headaches.




SELF-HELP IDEAS FOR HANDLING HEADACHES


During times of heightened stress, the number and severity of headaches may increase. Several self-care strategies are useful in obtaining relief from headache pain.


image Relax with 5 minutes of deep abdominal breathing. If possible, lie down, close your eyes, and place one hand on your abdomen. Focus on the rise and fall of your hand as you breathe deeply.

image Stretch the muscles of the back, shoulders, and neck. While sitting in a chair, gently drop your chin toward your chest and hold for a count of 10. Slowly raise your head. Now reach your right hand around the back of the chair and look over your right shoulder. Hold for a count of 10. Slowly release the right hand and repeat the same movement on the left. Now lift your shoulders up toward your ears, hold for a count of three, and then relax the shoulders. Perform this movement twice and repeat the entire routine two or three times. Make sure to take deep, slow breaths throughout.

image If you are having problems sleeping, you may want to try valerian (Valeriana officinalis), one of the most widely used herbal sleep aids in the world. German health authorities recognize the use of valerian for restlessness and sleep problems caused by stress or nervous conditions. Valerian is not habit-forming and appears to be quite safe when used appropriately. Don’t take it with prescription sleeping medications, however.

image Take a 5-minute walk to help relieve a tension headache. Exercise releases endorphins, the body’s natural painkillers, thereby relieving head pain.

image Peppermint compresses are an old and effective treatment for tension headaches. Add two to four drops of peppermint oil to a cup of cold water. Dip a cloth into the fragrant water and apply it to the painful area for 10 to 15 minutes.

image Limit your intake of monosodium glutamate (a.k.a. MSG), alcohol, and caffeine. However, don’t just suddenly stop drinking caffeine-containing drinks, or you might experience “rebound” headaches. Wean yourself off caffeine slowly.

image Calcium and magnesium, 1,000 and 500 mg/day, respectively, may help reduce muscle tension. Take these supplements in divided doses, morning and night.

image Warm baths relax tense muscles and can ease aches and pains. Add some essential oils to further enhance the medicinal effects of the bath. Eucalyptus, mint, rosemary, ginger and sage are all excellent for relaxing tight muscles. Enhance the effect by turning down the lights and putting on some soft music.

image Add 2 T of dried ginger to a saucepan of water and simmer for 10 minutes. Put the warm water in a small tub big enough for your feet. Soak your feet in while drinking a cup of chamomile tea in a quiet room for 10 to 15 minutes.

image During stressful periods, it is extremely important to schedule personal time for exercise and relaxation. Try a yoga or Pilates class. Ever dream of signing up for martial arts? Grab a friend (two- or four-legged) and go for a 30-minute walk. Whatever you do, just remember to move on a regular basis.


Physiologic Basis


Although the tension-type headache is the most common type of head pain, its physiologic basis remains unclear. It is been thought for many years that tension-type headaches are muscular in origin because myofascial pain tends to be dull and achy, poorly localized, and radiating, whereas pain originating from cutaneous structures is normally sharp, localized, and nonradiating. Increased myofascial tenderness and muscle firmness are two of the most prominent abnormal findings in patients with chronic tension-type headache.3,4 What causes and sustains this muscle firmness and myofascial tendernesshas become a matter of debate. From the findings of experimental research and clinical studies it appears that myofascial nociception is a key component of episodic tension-type headache; however, central sensitization appears to predominate in the chronic form.5 (Nociception refers to the detection of noxious stimuli by the nervous sytem. The receptors involved in pain detection are referred to as nociceptors.) Central sensitization is best described as an increased excitability of central nervous system neurons that results from prolonged nociceptive input from the periphery. Central sensitization has been shown to play a significant role in chronic myofascial pain.6 Increased tenderness in patients with chronic tension-type headaches may be a result of sensitization of spinal dorsal-horn neurons induced by prolonged sensory input from pericranial myofascial tissues.7



Role of nitric oxide.


Nitric oxide (NO) is involved in the development of central sensitization8 and nitric oxide synthase (NOS) inhibitors, which reduce the level of NO, also have been shown to reduce central sensitization in animal studies of persistent pain.9,10 In light of these data, the role of NO as a mediator in tension-type headaches is being explored. Inhibition of NO was found to effectively reduce both pain and muscle firmness in a small randomized double-blind crossover study of 16 patients with chronic tension-type headaches. Patients were administered intravenous infusions of 6 mg/kg L-NMMA (NG-monomethyl-L-arginine hydrochloride, an inhibitor of NOS) or placebo for 2 days, separated by at least 1 week, in a randomized fashion. Headache intensity was measured on a 100-mm visual-analog scale at baseline and 30, 60, and 120 minutes after start of treatment. L-NMMA reduced pain intensity significantly more than did placebo (P = 0.01).11,12



Medications


In addition to NOS inhibitors, established medications for chronic myofascial pain and tension-type headache may be effective, partly because they reduce sensitivity.13 The documented analgesic effect of the tricyclic antidepressant amitriptyline in patients with chronic myofascial pain is thought to be due to a reduction in the transmission of painful stimuli from myofascial tissue, rather than a reduction in overall pain sensitivity.14


Practitioners should always inquire about long-term use of nonsteroidal antiinflammatory drugs (NSAIDs) by patients who have chronic headaches as the frequent use of these medications may lead to persistent headaches. Studies indicate that an increase in NOS activity is associated with a hyposerotonergic state. This state may contribute to central sensitization in chronic tension-type headache patients, particularly in those who engage in analgesic abuse.15


Additional basic scientific research is necessary to more accurately clarify the mechanism underlying both episodic and chronic tension-type headaches. This information is essential for the design and tailoring of effective treatments for the millions of patients who continue to suffer from episodic and chronic tension-type headaches.



Evaluation and Diagnosis


A thorough history and physical examination should be undertaken for the evaluation of headache. The history should include appropriate exploration of secondary causes of headache, including depression, medication (prescription and over-the-counter [OTC]), substance abuse, and neurological disorders. It is essential that the provider determine whether the headaches are episodic or chronic because the clinical management will differ accordingly.


The physical examination should include a comprehensive neurologic evaluation that includes observation for cranial nerve defects, cerebellar dysfunction, papilledema, absence of venous pulsation on fundoscopic examination, visual-field defects, and motor and sensory deficits. Abnormal findings could indicate intracranial irregularitis, and appropriate diagnostic studies should be performed before a definitive diagnosis of tension-type headache is made. The following recommendations were proposed as diagnostic criteria for neuroimaging: focal neurologic finding on physical examination, headache starting after exertion or Valsalva’s maneuver, acute onset of severe headache, headache awakens patient at night, change in well-established headache pattern, new-onset headache in a patient older than 35 years, and new-onset headache in a patient who has human immunodeficiency virus infection or a previously diagnosed cancer.16


Careful palpation of the head in a patient with tension-type headache often reveals tenderness in the pericranial muscles, the occipital region, and the trapezius. Palpation of the temporomandibular joint should also be performed, as this joint is often involved in the development of headaches.




PRIMARY DIAGNOSTIC CRITERIA FOR TENSION-TYPE HEADACHE



1. Headache features at least two of the following characteristics:
image Bilateral pain

image Pressure

image Mild to moderate pain

image No increase in pain on physical exertion

2. And no more than one of the following:
image Sensitivity to light

image Sensitivity to sound

3. And neither of the following*:
image Nausea

image Vomiting

4. And a duration of 30 minutes to 7 days


Subdivision Diagnosis


Episodic (<15 days/mo) or chronic (>15 days/mo for >6 mo)



2. Associated or not associated with coexisting pericranial muscle tenderness†


* Chronic tension-type headache may include one of these symptoms.


† Diagnosed on the basis of manual palpation or electromyographic studies.

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Nov 4, 2016 | Posted by in OBSTETRICS | Comments Off on 9: Headaches

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