Neurology · Headache Disorders
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Tension-type headaches present as a bilateral, non-pulsatile, band-like pressure or tightness around the head.
The pain associated with tension headaches is typically mild to moderate in intensity and does not worsen with routine physical activity.
Tension headaches lack the nausea, vomiting, photophobia, or phonophobia that are characteristic of migraine headaches.
Physical examination often reveals pericranial muscle tenderness or myofascial trigger points in the neck and scalp.
First-line abortive therapy for acute tension headaches is NSAIDs or acetaminophen.
Chronic tension-type headaches are defined as occurring on 15 or more days per month for at least three months.
Amitriptyline is the most evidence-based medication for the prophylactic management of chronic tension-type headaches.
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A 32-year-old office worker presents to the clinic complaining of a persistent, dull headache that has occurred 18 days per month for the last four months. She describes the pain as a bilateral, tight band-like sensation around her forehead and occiput. She denies any nausea, vomiting, or visual disturbances, and states that her symptoms do not interfere with her ability to walk to work. On physical exam, there is notable tenderness to palpation of the trapezius and suboccipital muscles. Neurological examination is entirely normal.
What is the most appropriate first-line prophylactic pharmacotherapy for this patient?
Amitriptyline
The patient's presentation of frequent, bilateral, non-pulsatile, band-like pain without migraine features is diagnostic of chronic tension-type headache, for which tricyclic antidepressants like amitriptyline are the gold-standard prophylactic treatment.
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High yield triage
Etiology / Epidemiology
Most common primary headache; stress and musculoskeletal tension are primary triggers.
Clinical Manifestations
Bilateral, band-like pressure; no focal neurological deficits or nausea.
Diagnosis
A clinical diagnosis of exclusion; no imaging required for classic presentation.
Treatment
NSAIDs (e.g., ibuprofen) are first-line; avoid overuse to prevent medication overuse headache.
Prognosis
Benign, self-limiting course; chronic cases (>15 days/month) require prophylactic management.
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Epidemiology & Etiology
Prevalence peaks in the 30s-40s, affecting women more frequently than men. Triggers include emotional stress, poor posture, and sleep deprivation. It is the most common type of primary headache encountered in primary care.
Pertinent Anatomy
Involves the pericranial muscles and myofascial structures. Pain is often referred from the trapezius and sternocleidomastoid muscles to the scalp and forehead.
Pathophysiology
Previously attributed solely to muscle contraction, current models suggest a combination of peripheral sensitization of myofascial nociceptors and central sensitization. Chronic tension-type headaches involve increased excitability of the trigeminocervical complex. There is no evidence of vascular involvement, distinguishing it from migraines.
Clinical Manifestations
Patients describe a tight band or vice-like pressure around the head. Pain is typically bilateral, non-pulsatile, and mild-to-moderate in intensity. Red flags requiring neuroimaging include sudden onset (thunderclap), fever, weight loss, or new-onset headache in patients >50 years old.
Diagnosis
Diagnosis is clinical based on the International Headache Society criteria. No gold standard laboratory or imaging test exists. Imaging is reserved for patients with focal neurological deficits or atypical features to rule out secondary causes.
Treatment
NSAIDs or acetaminophen are the first-line abortive therapies. Medication overuse headache is a significant risk with frequent use of analgesics. For chronic cases, amitriptyline is the first-line prophylactic agent. Non-pharmacological interventions like cognitive behavioral therapy and physical therapy are highly effective.
Prognosis
Generally excellent with no long-term neurological sequelae. Chronic tension-type headache is defined as occurring >15 days per month for >3 months. Monitoring for medication dependence is essential to prevent rebound headaches.
Differential Diagnosis
Migraine: unilateral, pulsatile, associated with photophobia/phonophobia
Cluster headache: severe, unilateral, orbital pain with autonomic symptoms
Giant cell arteritis: elevated ESR/CRP, jaw claudication, age >50
Brain tumor: progressive, worse in the morning, associated with vomiting
Sinusitis: facial tenderness, purulent discharge, fever