Tension headache - tension headache: symptoms, causes, diagnosis and treatment

Some statistics

Headache is the most common nonspecific symptom worldwide. Almost every person on earth has at least once experienced a feeling associated with a headache, and on an ongoing basis this symptom occurs in more than 60% of the world's population, which makes the introduction of the latest laboratory diagnostic and therapeutic measures an urgent problem in modern healthcare in the largest countries of the world.

Most people simply complain of headaches and do not realize that in 75-80% of cases they suffer from tension-type headaches - the main type of cephalgia in neurological practice.

Treatment of chronic tension headache

If a tension headache occurs in a chronic form, then it is forbidden to take classical drugs with an analgesic effect! Not only will they not relieve pain, but they will also complicate the process of full treatment. Doctors prescribe antidepressants, which must be taken for six months according to a specially developed individual regimen. It is also possible to prescribe other medications from the group of antidepressants; the course of therapy is at least 60 days.

This treatment tactic involves not only getting rid of pain, but also eliminating the cause of tension headaches - for example, antidepressants solve the problem of dysfunction of the autonomic nervous system. Physiotherapeutic procedures (the same as in the case of therapy for episodic pathology) will also have an additional therapeutic effect.

Tension headaches require a professional approach to treatment. If symptoms of this disease appear, it is advisable to contact specialists at CELT - all necessary diagnostic measures will be carried out and treatment will be prescribed.

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What is a tension headache?

Headache or cephalgia is a complex symptom of a nonspecific nature that occurs under the influence of a developing pathological condition in the patient’s body. When you feel a headache, you might think that the nerve tissue of the brain itself is hurting, but this is not the case. There are no pain receptors in the nervous tissue of the brain, and the patient experiences the entire range of pain sensations arising from cephalgia due to receptors located in the periosteum of the skull, cerebral arteries, muscles of the head and neck, peripheral sensory nerves, subcutaneous tissue, eyes and mucous membranes. The entire spectrum of sensations is formed precisely as a result of overstimulation of the nerve receptors of the above-described areas, which directly forms cephalalgia itself.

From this we can conclude that depending on the tissue involved in the occurrence of pain, the nature of cephalgia will change, which is why in neurological practice it is convenient to distinguish several types of cephalgia, including tension headache.

Drugs for drug therapy

Treatment is prescribed by a doctor in the form of the complex use of various means (medicinal, relaxation, etc.). The main place in it is given to bringing the patient’s psycho-emotional state back to normal. Antidepressants are prescribed for the treatment of depression, phobias, and anxiety. Muscle relaxants are used to relieve muscle tension and spasms. Rapid-acting NSAIDs help cope with illnesses that develop under the influence of stress. There is no single recipe for getting rid of the disease; each patient requires a personal selection of medications.

To stop an attack and relieve acute symptoms of the disease, the following are most often used:

ibuprofen;
paracetamol;
diclofenac;
acetylsalicylic acid (aspirin);
flupirtine.

To prevent an attack, take:

amitriptyline;
tizanidine;
nortiptyline;
baclofen.

You should be careful when taking medications when treating TTH. Using a painkiller for too long can have the opposite effect and cause another headache - a headache.

Classification

In the International Classification of Diseases, 10th revision, headache is coded under R51 and refers to typical disorders of the nervous system.

It is customary to distinguish two main variants of cephalgia, according to the etiological principle:

Primary headache. This type of headache includes tension headache or tension headache, as well as migraine.
Secondary headache. It does not arise independently, i.e. is formed under the influence of any pathological process occurring in the nervous tissue. For example, a secondary headache may occur as a result of oncological damage to the central nervous system or due to atherosclerotic damage to the cerebral vessels.

In addition to the etiological classification, there is also a pathogenetic classification of cephalgia, which includes types such as:

Vascular headache. Vascular pain occurs as a result of spasm of the smooth muscles of the vascular walls, which leads to an increase in blood pressure in the cerebral basin and ischemia of brain tissue. In the opposite case, headache can also occur due to dilatation of the vascular bed or as a result of a violation of the rheological properties of the blood, which also leads to tissue hypoxia and ischemic damage.
Muscle tension pain. In this case, overstimulation of the neuromuscular synapses occurs, which leads to excessive muscle tension and spasticity.
Liquorodynamic pain. This type occurs as a result of changes in intracranial pressure, regardless of whether an increase or decrease in intracranial pressure occurred. Changes in pressure in the ventricles of the brain can lead to dislocation of brain structures, which ultimately creates pain.
Neuralgic cephalgia. It is formed as a result of irritation of peripheral nerve fibers as a result of an extraneural or endoneurial pathological process. In this case, the mechanism of cephalgia is associated with the formation of a focus of pathological activity in the nociceptive system of the brain.
Psychogenic. With this type, there are no pathological changes in tissues anatomically close to the nervous tissue. In this case, a malfunction occurs in the antinociceptive system of the brain, which leads to various disorders in the neurotransmitter dopaminergic system of the brain and the occurrence of pain. The main mechanism is disruption of the production of endogenous opiates.
Mixed genesis. It occurs under the influence of the combined influence of the pathological process on the tissues surrounding the brain. The pathological effect can be either simultaneous or sequential.

Types of HDN

First of all, it is worth identifying the subspecies.

Episodic pain occurs no more often than about 18 times a month, and a single attack lasts no more than half an hour. The severity of pain is usually low.
Another type, chronic tension headache, is noticeably high in intensity. Patients have attacks more than 20 times a month, or more than 180 cases per year. Often this type of pain is accompanied by the appearance of depression.

At a neurological appointment, headache ranks second after complaints of pain in the lower back. 85% of the population experiences it periodically. About 40% have reduced social and work activity and require qualified treatment.

Relevance

In only 5–6% of patients, the cause of headaches (HT) is severe organic diseases: tumor, traumatic brain injury, infection, vascular pathology, etc. In other cases, we are talking about benign primary headaches, among which headache is the most common voltage (GBN). Its lifetime prevalence ranges from 30% to 78%.

According to a population study (2009–2011), in one year this figure was 30.8%. Women are affected more often than men (ratio 5:4). The average age of onset of tension-type headache is higher than that for migraine—25–30 years. Recent analysis of various forms of headache has shown that the degree of maladjustment and socioeconomic harm associated with tension headache is greater than that of migraine. But there is no data confirming the involvement of genetic mechanisms in the origin of HDN.

Classification

TTH refers to primary (benign) cephalgia, which is not associated with organic damage to the brain and other structures located in the head and neck area.

There are infrequent episodic tension-type headache (EGTH) - 1 day or less per month, frequent EGTH - from 1 to 14 days per month, chronic tension-type headache (CHTH) - more than 15 days per month (or more than 180 days during the year). In addition, depending on the presence or absence of muscle dysfunction, a distinction is made between EGTH and CGTH with and without tension in the pericranial muscles. The latter is determined by palpation of the muscles of the craniocervical zone. If one or more diagnostic criteria for TTH are not met, a diagnosis of “possible TTH” may be made.

The most common occurrence is EGTH, which does not require treatment. In 24-37% of the population, episodes of tension-type headache occur several times a month, in 10% - weekly, and in 2-3% they are chronic. Mostly, patients with CGTH or frequent EGTH (more than 8–10 days per month) consult a doctor.

Risk factors and triggers

The main risk factors for tension-type headache are the inability to psychologically and muscularly relax, and insufficient night sleep. The most common causes are emotional stress (acute or chronic) and postural tension (prolonged stay of the head and neck in a forced, uncomfortable position). With distraction or positive emotions, the pain may weaken or disappear completely, and with the resumption of emotional stress and/or muscle/postural tension, it may intensify again. The main risk factors for increased frequency (chronicity) of painful episodes of tension-type headache include drug abuse (excessive use of painkillers) and mental disorders, primarily depression, anxiety and somatoform disorders.

Diagnostics

It is carried out in accordance with the criteria of the International Classification of Headaches (3rd edition, beta version) and is clinical, that is, based on an analysis of complaints, medical history and neurological examination. Additional studies are not required, since they do not reveal changes specific to TTH. They are carried out only according to indications, the main of which are the presence of danger signals and suspicion of the symptomatic nature of cephalalgia (doubt about the probable clinical diagnosis of tension-type headache).

Diagnostic criteria for tension-type headache

A. The duration of the headache is from 30 minutes to 7 days.

B. The headache has at least 2 of the following characteristics:

two-way localization,

pressing/squeezing/non-pulsating character like a “hoop” or “helmet”,

mild or moderate intensity (no more than 6–7 points on the visual analog pain scale),

the pain is not worsened by normal physical activity (walking, climbing stairs).

C. Both of the following symptoms:

no nausea or vomiting,

only one of two symptoms: photophobia or phonophobia.

D. The headache is not associated with other causes.

As a rule, the neurological status of patients does not reveal organic disorders. During the examination, signs of increased anxiety, vegetative dystonia, and the patient’s inability to psychological and muscular relaxation may be revealed. Due to frequent complaints of tension and pain in the neck and back of the head, it is important to assess the condition of the pericranial muscles. Palpation should be carried out with small rotational movements with the 2nd and 3rd fingers while applying pressure in the area of the temporal, masticatory, sternocleidomastoid, trapezius, as well as the posterior group of neck muscles (belt muscles, inferior obliques). The diagnosis of “cervical muscular-tonic syndrome” or “pericranial muscle tension” is made in the presence of severe pain up to the “jumping symptom” (due to muscle pain, the patient actively resists palpation) in two or more muscle groups.

To determine the form of HDN, you need to set the number of days with HDH per month. The diary helps the patient and the doctor determine the frequency of headaches, the number of dosages of painkillers taken to relieve it, and confirm or, conversely, exclude drug abuse.

The patient should also be asked about comorbid disorders that may further impair quality of life and require therapeutic correction. Among the most common of them, patients with TTH are found to have depression, anxiety disorders, including panic attacks, somatoform and senesto-hypochondriacal disorders, night sleep disorders, and other pain syndromes, including fibromyalgia. Emotional and personality disorders maintain muscle tension and pain, lead to serious maladjustment and are one of the main factors in the chronicity of tension-type headache.

Treatment

Involves relief of painful episodes and preventive treatment. Before choosing a tactic, you should conduct behavioral therapy, which includes:

explaining to the patient the benign nature of HDN and the mechanisms of its occurrence,

dissuading the presence of an organic cause of headache,

justification for the inappropriateness of additional studies (except for cases of suspected symptomatic HDN),

substantiation of the role of muscle tension during prolonged stay in a monotonous position, emotional disorders (anxiety and depression),

substantiation of the role of chronic emotional stress in maintaining pain and muscle tension,

explaining the need for relaxation training.

Based on the basic mechanisms of the formation of tension-type headache, treatment should be comprehensive and aimed primarily at normalizing the patient’s emotional state and eliminating muscle tension, and, if necessary, at correcting other comorbid disorders and drug abuse.

Relief of painful episodes

Is the key point in the treatment of headache. When stopping attacks of tension-type headache, the most effective are: simple analgesics and NSAIDs (ibuprofen, ketoprofen, acetylsalicylic acid, naproxen, diclofenac, paracetamol). Treatment with them can be used in patients with episodic tension-type headache with a frequency of attacks no more than 2 times a week (no more than 8 days per month). With a higher frequency of pain episodes, there is a risk of drug abuse and the development of drug-induced headache.

Preventive tactics

The main goals are:

1. Reducing the frequency, duration, intensity of headaches.

2. Improving the effectiveness of symptomatic analgesic therapy.

3. Restoring the patient’s daily activity and quality of life.

Before starting preventive pharmacotherapy, it is necessary to make sure that non-drug treatment methods are insufficiently effective. These include:

1. Sleep hygiene.

2. Regular health-improving sports activity (preference to aerobic activity, about 20–30 minutes a day).

3. Regular diet (avoid skipping meals, have a full breakfast).

4. Limit intake of caffeine and stimulants.

5. Identifying and eliminating triggers.

6. Behavioral therapy, psychotherapeutic correction:

relaxation methods (progressive muscle relaxation, self-hypnosis, breathing-relaxation training, autogenic training),

cognitive behavioral therapy.

7. Alternative approaches (acupuncture, herbal medicine, aromatherapy, Chinese traditional therapy).

Preventive therapy is indicated for patients with chronic TTH and frequent episodic TTH. Before starting it, it is necessary to explain to the patient the mechanism of action and possible side effects of the prescribed drugs (primarily antidepressants, which also have an analgesic effect). For better tolerability, the minimum dosage is initially prescribed, followed by a slow increase in dose to an adequately tolerated dose. Prevention that seems ineffective should not be interrupted quickly: 2–3 months is the minimum period to achieve a therapeutic effect. The duration of therapy is from 6 months to 1 year. To assess effectiveness and improve compliance, keeping a diary is recommended.

Muscle relaxants are used as additional therapy, especially in patients with severe tension in the pericranial muscles (tizanidine, tolperisone). The average duration of treatment is 2 months. Since the clinical effect of muscle relaxants occurs more quickly than that of antidepressants, the administration of combination therapy (antidepressant + muscle relaxant) may improve the effectiveness of treatment.

Treatment and prevention of tension-type headache is a complex multidisciplinary task, fraught with certain difficulties and requiring the formation of strategies for changing daily activities, interpersonal relationships, and psychological correction.

Non-drug therapy methods are of high importance.

An integrated approach is the key to reducing the frequency and intensity of headaches and normalizing daily activity.

It is important to take into account the individual characteristics of patients when drawing up a treatment program: age, gender, concomitant somatic and endocrine pathology, abuse factor, characteristics of interpersonal relationships.

Features of tension headaches

Tension headache or tension cephalgia, as mentioned above, is the most common option among all types of cephalgia. This type of headache is usually functional in nature and does not have a high degree of intensity or duration. Tension headache should not be confused with migraine, despite similar pathogenetic mechanisms of formation; with migraine, the pain syndrome is much more pronounced and manifests itself as localized pain mainly in one of the hemispheres of the brain. Unlike migraines, tension headaches cause diffuse pain.

Consequences

Often, due to the mild severity of the symptoms of tension-type headache, a person gets used to it and simply does not pay attention to the pain. Meanwhile, tension within the body increases, ultimately leading to depression, nervousness, aggressive behavior, and psychosis. If TTH becomes pronounced, the patient cannot relax, feels weak, gets irritated for no apparent reason, and gets tired quickly.

When you try to cope on your own, without the use of professional complex therapy, the situation quickly worsens. Episodic attacks turn into systematic ones, which leads to a decrease in the level of performance, disorder of behavior and character of a person.

Clinical picture

Tension headaches have the following characteristic symptoms:

Painful sensations of a diffuse nature.
Pain can come from the parietal part of the head, forehead, temples, but the entire head is necessarily included in the pain process.
Patients describe the nature of the sensation as squeezing, pressing or twisting.
The intensity of pain can vary from mild to moderate intensity. With tension headaches, the pain is never too intense or severe.
The duration of pain can vary significantly, from a few minutes to several days.

It is important to note that a small proportion of people with tension headaches may experience additional symptoms, such as photophobia.

The symptom of head compression in neurological practice is sometimes called the “neurotic helmet”, since many patients complain of a feeling of head compression in all areas. In most patients, tension-type headaches are symmetrical, but asymmetrical headaches may also occur.

Two thirds of patients experience episodic headaches, i.e. they occur only with any functional impairment, but approximately 30% of patients are diagnosed with chronic tension-type headache. The main criterion is the frequency of occurrence of attacks; to establish a chronic form, headaches must occur at least 15 episodes of headaches within a month and over a period of three months.

The Clinical Institute of the Brain is actively studying the processes of formation and manifestation of tension headaches, which makes it possible to introduce new original, and most importantly, effective treatment regimens into medical practice.

Prevention of tension-type headache

For prevention purposes, it is proposed to use non-medicinal methods:

Sleep at least 7-8 hours.
Eat well and often (3-6 times a day), drink 2 liters of water.
Avoid coffee, which contains caffeine, which dilates blood vessels and causes an increase in blood pressure.
Reduce consumption or completely eliminate alcohol, after which oxygen starvation occurs, which has a destructive effect on brain cells.
Choose the most optimal rest and work regime for your health.
Organize breaks at work more often, during which it is recommended to perform exercises for the eye muscles and do physical warm-up.
Move actively, take long walks in the air every day.
Do exercise therapy, water procedures, use massage, acupuncture, manual therapy.
Follow your doctor's instructions.

Causes

The etiological factor leading to the development of tension headaches can be a large number of pathological conditions occurring in the body. The main causes of tension headaches include:

Frequent stressful situations. After studies conducted to study the clinical course of tension headaches, it was concluded that pain most often develops in the second half of the working day after significant stressful situations or as a result of prolonged hard work.
Violation of rest and wakefulness. One of the most common causes of cephalgia. Constant lack of sleep or poor quality of night sleep leads to insufficient restoration of the central nervous system, which causes overstrain and headaches.
Starvation. Malnutrition, rare or monotonous nutrition leads to insufficient supply of nutrients to brain tissue and dystrophic manifestations in neurons, primarily manifested in the form of cephalgia. A special case of fasting is the development of a hypoglycemic state, in which the brain lacks glucose.
Hypertension or isolated arterial hypertension. An increase in systolic pressure leads, or less commonly, a decrease, which can cause the development of tension cephalgia of a vascular nature.
Premenstrual syndrome is a common cause for women. It has been observed that tension headaches occur more often in females, especially during premenstrual syndrome.

Causes

TTH is a neurological disease that occurs as a result of:

psycho-emotional stress, depression, prolonged stress of a negative or positive nature;
long-term stay of the muscle fibers of the neck, upper back, eyes in a tense static state;
increased fixation of attention, strong concentration;
long-term unsystematic use of analgesics, tranquilizers;
sleeping in an uncomfortable position.

Diagnostics

As a rule, establishing a diagnosis of tension headache is not difficult, but confirming the diagnosis is a labor-intensive process. To confirm the diagnosis, the patient must undergo a series of diagnostic studies, which allow not only to confirm the disease, but also to find out the degree of its severity, as well as the main cause, which qualitatively improves the further treatment of the patient.

On the basis of the Clinical Institute of the Brain there is a powerful diagnostic center that has the most advanced diagnostic tools. At the clinic, the following is used to verify tension headaches:

Ultrasound Dopplerography of the vessels of the head and neck to exclude or confirm atherosclerotic changes in the vascular wall.

For a more detailed and in-depth study of cerebral lesions, an X-ray examination - angiography - can be performed.

Angiography of cerebral arteries followed by contrast allows one to accurately determine the location of vascular pathology.
Tomographic research methods: computed tomography and magnetic resonance imaging allow detailed visualization of the tissues and structures of the brain, which has significant information weight in the diagnosis of headaches.
Electroencephalography is a classic method and the gold standard for diagnostic studies of the brain. EEG allows us to determine the functional activity of the brain and headache-related disorders.

Physiotherapy methods

With frequent attacks of tension-type headache, taking painkillers does not always solve the problem. In some cases, this may, on the contrary, worsen the situation. Most often, patients are prescribed complex preventive treatment, the purpose of which is to reduce pain sensitivity and prevent further development of the disease.

The therapy uses stress-reducing, muscle relaxing, non-drug treatment methods that reduce the electrical activity of the brain, among which the most effective are:

manual therapy;
exercise therapy;
physiotherapy for the head and neck area;
carboxytherapy;
ILBI;
mesotherapy;
acupuncture;
blood ozonation;
multimag (Headache program);
MDM therapy;
myorhythm;
micropolarization of the cerebral hemispheres;
cutaneous electrical neurostimulation.