Tension-type Headache (TTHA)

Question 1

Most common
type of
headache
* Over –% of adults experience TTHA periodically
* Also common in children and adolescents

Answer 1

80

Question 2

Presents in
two forms
(4)

Answer 2

Episodic
* Chronic- (frequency > 15 days/month for 6 months)
* Most patients who suffer TTHA do not seek specific
medical treatment
* Use OTC medications to combat symptoms

Question 3

2.1 Infrequent episodic TTH: ICHD
Diganostic Criteria
(A-E)

Answer 3

A. At least 10 episodes of headache occurring on
<1 d/mo. (<12 d/yr.) and fulfilling criteria B-D
B. Lasting from 30 min to 7 days
C. 2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3
diagnosis

Question 4

Tension-Type Headache
 Symptoms begin before the age 20 years in –% of patients.
 No predilection for any particular cranial location-may involve the (4) areas alone, or in combination
 Associated with pericranial/cervical muscle tenderness-Studies have shown that
patients with chronic TTH have a higher incidence of active TrPs in the (3), as well as the — and other posterior
cervical muscles than in controls.
 Occurs in relation to — conflict

Answer 4

40
frontal,
temporal, parietal, or occipital
upper
trapezius, SCM, temporalis
suboccipitals
emotional

Question 5

Tension-Type Headache
 Most patients with TTH experience occasional very painful headaches
often accompanied by — symptoms.
 Epidemiological characteristics of TTH patients not significantly
different from migraine patients-
 Migraine and TTH also share common triggers (5)
 Suggests that these disorders are

Answer 5

migrainous
(stress, mental tension,
fatigue, lack of sleep, and menstruation)
at two ends of a continuum and many
people will experience both types over a lifetime

Question 6

Non-pharmacological Management
 Decrease intake of caffeine and alcohol as well as any medications that have
been chronically used by the patient for the headache
 May at first increase the frequency and intensity of headaches
 After – weeks the withdrawal should subside
 Decrease Caffeine use by –% every week so caffeine withdrawal headache should not occur

Answer 6

1-2
25

Question 7

Non-pharmacological Management
(8)

Answer 7

 Strategies for coping with stress and muscular pain:
 Relaxation therapy with EMG biofeedback
 Hypnotherapy
 Massage therapy and physical therapy
 Increase physical activity especially outdoors
 Deep breathing exercises
 1 minute headspace mini breathing meditation:
https://www.youtube.com/watch?v=cEqZthCaMpo
 Calm app teaches mindfulness and meditation in 10 minute daily presentations
 Psychotherapy for cognitive therapy and mindfulness exercises

Question 8

 ANALGESICS:

Answer 8

aspirin, acetaminophen

Question 9

 NSAIDs:

Answer 9

indomethacin, ibuprofen, naproxen,
ketoprofen

Question 10

 COMBINATION:

Answer 10

aspirin &/or acetaminophen with
caffeine (i.e. Excedrin Migraine)

Question 11

skipped
 MUSCLE RELAXANTS:

Answer 11

diazepam, methocarbamol
(Robaxin), cyclobenzaprine (Flexeril), carisoprodol,
baclofen
 Usage is on an as needed basis but typically limited
time use

Question 12

Pharmacological Management
Tension-type Headache
 Judicious use of mild analgesics may be needed
 No more than – days per week
 Low dosages of a — can be helpful in managing
the headache
 Best taken before bedtime because of their — effects
 Examples:
 Amitriptyline (Elavil),Nortriptyline (Pamelor), Doxepin, Desipramine

Answer 12

2
tricyclic antidepressant
sedative

Question 13

3. Trigeminal autonomic cephalalgias (TACs)
   *All TACs are unilateral headaches accompanied by autonomic
   features
   (5)
   RULE OUT SECONDARY CAUSE!

Answer 13

3.1 Cluster headache
3.2 Paroxysmal hemicrania
3.3 Short-lasting unilateral neuralgiform headache attacks
3.4 Hemicrania continua
3.5 Probable trigeminal autonomic cephalalgia

Question 14

skipped
3.1 Cluster headache
(A-E)

Answer 14

A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 min (when
untreated)
C. Either or both of the following:
1. 1 of the following ipsilateral symptoms or signs:
a) conjunctival injection and/or lacrimation; b) nasal congestion and/or rhinorrhea; c)
eyelid oedema; d) fore-head and facial sweating; e) forehead and facial flushing;
f) sensation of fullness in the ear; g) miosis and/or ptosis
2. a sense of restlessness or agitation
D. Frequency from 1-2x/ d to 8x/d for > half the time when
active
E. Not better accounted for by another ICHD-3 diagnosis

Question 15

skipped
3.1 Cluster headache
3.1.1 Episodic cluster headache

Answer 15

A. Attacks fulfilling criteria for 3.1 Cluster headache and occurring in bouts (cluster
periods)
B. 2 cluster periods lasting 7 d to 1 y (when untreated) and separated by pain-
free remission periods of 1 month.

Question 16

3.1.2 Chronic cluster headache

Answer 16

A. Attacks fulfilling criteria for 3.1 Cluster headache and criterion B below
B. Occurring without a remission period, or with remissions lasting <1 mo, for 1
year

Question 17

Cluster Headache
 Brief attacks are:
(3)
 Primarily affects men — males: females ratio
 Age of onset between —

Answer 17

 Provoked by alcohol
 Frequently occurs during sleep or napping times.
 During an attack, patients will characteristically pace, cry,
scream, or pound their fists.

(4:1)

20-40

Question 18

Cluster Headache
 –% of the patients have chronic symptoms.
 HAs occur for years before termination
or remission.
 Chronic form may evolve from the
episodic form or may have a chronic
pattern from its onset.
 Etiology and pathogenesis are unknown-
possible dysfunction of hypothalamus
 Pain is usually centered behind or around
the orbit or in the temporal area, BUT
…

Answer 18

10

radiation to the teeth and jaws is common-
some patients may seek dental treatment
for the pain

Question 19

Cluster Headache
Abortive Treatment
(5)

Answer 19

100% Oxygen at 7-10 l./min. for 15 min. using face mask is
effective within 10-15 minutes in 60-70% of cases
Sumatriptan (6 mg S.C. or nasal spray)
DHE-45 (1.0 mg I.M. or I.V. or Migranol (intranasal)
Intranasal administration of 1 ml of 4% topical Lidocaine
Indomethacin (oral or rectal suppositories)- cluster
headache MAY respond

Question 20

skipped
Cluster Headache Treatment
(Prophylactic Treatment)
 Episodic Cluster:
(6)
 Chronic Cluster:
(4)

Answer 20

 Calcium channel blockers
i.e. Verapamil
 Ergotamine
 Lithium carbonate
 Methysergide
 Valproate
 Prednisone

 Verapamil
 Lithium carbonate
 Methysergide
 Gabapentin

Question 21

Hemicrania
Continua
 Common in —
 — pain is most
common
 Throbbing, aching, sharp, stabbing
 Age: 10-77 y.o. (mean range= —
years)
 A daily, continuous, strictly —
primary headache
 The intensity of the pain may fluctuate
but the headache never remits
 Treatment: By definition, hemicrania
continua remits with —
medication

Answer 21

women
Temporal or frontal
35-49
unilateral
indomethacin

Question 22

3.4 Hemicrania continua
(A-E)

Answer 22

A. Unilateral headache fulfilling criteria B-D
B. Present >3 mo, with exacerbations of moderate or
greater intensity
C. Either or both of the following:
1. 1 of the following ipsilateral autonomic symptoms:
a) conjunctival injection and/or lacrimation; b) nasal congestion and/or rhinorrhea;
c) eyelid oedema; d) fore-head and facial sweating; e) forehead and facial flushing;
f) sensation of fullness in the ear; g) miosis and/or ptosis
2. a sense of restlessness or agitation, or aggravation of pain by movement
D. Responds absolutely to indomethacin
E. Not better accounted for by another ICHD-3 diagnosis

Question 23

CPH Clinical
Characteristics
 Many consider CPH a variant of
— headache
 Occurs primarily in — 2:1
 Age range is 37-42 (mean age = –
years)
 Attacks may be precipitated by
— and occasionally by
— of the neck.
 Pain is — and
localized to the … regions.

Answer 23

cluster
women
34
flexion, rotation
Chronic, unilateral
temple, forehead,
ear, eye, or occipital

Question 24

CPH Clinical
Characteristics
 …pain
 Severe to very severe pain in
—%
 — is common during
attacks

Answer 24

Throbbing, stabbing or boring
88-93
Restlessness

Question 25

3.2 Paroxysmal hemicrania
(A-F)

Answer 25

A. At least 20 attacks fulfilling criteria B-E
B. Severe unilateral orbital, supraorbital and/or temporal
pain lasting 2-30 min
C. 1 of the following ipsilateral symptoms or signs:
1. conjunctival injection and/or lacrimation
2. nasal congestion and/or rhinorrhoea
3. eyelid oedema
4. forehead and facial sweating
5. forehead and facial flushing
6. sensation of fullness in the ear
7. miosis and/or ptosis
D. Frequency >5/d for > half the time
E. Prevented absolutely by therapeutic doses of
indomethacin
F. Not better accounted for by another ICHD-3 diagnosis

Question 26

3.2.1 Episodic paroxysmal
hemicrania
(2)

Answer 26

• A. Attacks fulfilling criteria
  for 3.2 Paroxysmal
  hemicrania and occurring
  in bouts
• B. 2 bouts lasting 7d to 1
  yr. (when untreated) and
  separated by pain-free
  remission periods of 1 mo

Question 27

3.2.2 Chronic paroxysmal
hemicrania (66-88%)
(2)

Answer 27

• A. Attacks fulfilling criteria
  for 3.2 Paroxysmal
  hemicrania
• B. Occurring without a
  remission period, or with
  remission periods lasting <1
  mo, for 1 yr.

Question 28

Paroxysmal Hemicrania Treatment
Absolute responsiveness of CPH to indomethacin is part of
the diagnostic criteria:

Long lasting remissions have been observed

Answer 28

25mg 3x/day up to 50mg 3x/day

Question 29

3.3 Short-lasting unilateral
neuralgiform headache attacks
(A-E)

Answer 29

A. At least 20 attacks fulfilling criteria B-D
B. Moderate or severe unilateral head pain, with
orbital, supraorbital, temporal and/or other
trigeminal distribution, lasting 1-600 sec and
occurring as single stabs, series of stabs or in a saw-
tooth pattern
C. 1 of the following ipsilateral cranial autonomic
symptoms or signs: 1. conjunctival injection and/or
lacrimation; 2. nasal congestion and/or rhinorrhoea;
3. eyelid oedema; 4. forehead and facial sweating;
5. forehead and facial flushing; 6. sensation of
fullness in the ear; 7. miosis and/or ptosis
D. Frequency 1/d for > half the time when active
E. Not better accounted for by another ICHD-3 diagnosis

Question 30

3.3.1 Short-lasting unilateral neuralgiform
headache attacks with conjunctival injection
and tearing (SUNCT)
(2)

Answer 30

A. Attacks fulfilling criteria for 3.3 Short-lasting
unilateral neuralgiform headache attacks
B. Both of conjunctival injection and lacrimation
(tearing)

Question 31

SUNCT VS
Trigeminal
Neuralgia (TN)
 TN more common in —,
SUNCT in —
 Autonomic features
(Conjunctival injection/tearing)
MUST be present in —, less
common in —
 Pain Location: Typically —
area in SUNCT; V1 TN is very
rare
 TN has a — PERIOD

Answer 31

females
Males
SUNCT,TN
ocular
REFRACTORY

Question 32

SUNCT
Treatment
(4)

Answer 32

 Lamotrigine
 Gabapentin
 Topiramate
 IV Lidocaine

Question 33

Referral to Specialists for Diagnosis
& Headache Management
1. PRIMARY REFERRALS:
(5)
6. You SHOULD REFER your patient with facial pain and headache within 2
weeks of your initial treatment if the pain is not being managed and to get a
proper diagnosis and treatment

Answer 33

2. Family doctor or Neurologist (American Headache Society website)
3. Orofacial Pain Specialist or Pain Management Medical Team
4. Secondary referral for pain management once diagnosis is made:
5. Psychotherapist
6. Acupuncturist