Tension Type Headache Cluster headache Dr. walter amberger

Tension type headache

Diagnostic criteria At least 10 episodes fulfilling following criteria Headache lasting 30 mins to 7 days At least 2 of the following Bilateral location Pressing/tightening (non-pulsating) quality Mild or moderate intensity Not aggravated by physical activity such as walking or climbing stairs No nausea or vomiting < 2 episodes of photophobia or phonophobia Not attributable to another disorder

Categories Infrequent episodic tension type headache Occurs < 1 day per month ( < 12 days/year) Frequent episodic tension type headache Occurs > 1 and < 15 days/month ( > 12 and <180 days/year) Chronic tension type headache Occurs > 15 days/month ( 180 or more days/year)

Causes Uncertain Activation of hyper excitable peripheral afferent neurons from head and neck muscles Associated with and aggravated by muscle tenderness and psychological tension but do not cause it Abnormalities in central pain processing and generalised increased pain sensitivity are found in some individuals Genetic factors

People at risk Prevalence peaks at age 40-49 in both sexes Mean life time prevalence is 46% Chronic tension type headache affects 3% of general population Female to male ratio is 4:5 Prevalence increases with educational level Can occur in children

Presentation Mild to moderate bilateral pain Sensation of muscle tightness or pressure Lasts hours to days Not associated with constitutional or neurological symptoms People with chronic tension headache more likely to seek help often have a history of episodic headache but delayed until frequency and disability are high

Differential diagnosis Migraine – in chronic form characteristic features disappear and pain is less severe Neck problems – muscle tenderness of tension type headache may involve the neck Medication overuse headache – consider in patients taking opioid or combination analgesics for an average of 10 days/month

Examination and investigation Neurological examination Manual palpation of pericranial muscles ( frontal, temporal, masseter, pterygoid, sternomastoid, splenius and trapezius. Fundoscopy for papilloedema Investigations If neuro examination normal none needed

Investigation Neuroimaging should be arranged if Atypical pattern of headache History of seizures Neurological signs or symptoms Symptomatic illness – acquired immunodeficiency syndrome, tumours or neurofibromatosis

Treatment Infrequent headache Good results from non prescription medication May need reassurance If require drugs on more than 2-3 days/week then medical treatment is indicated to prevent medication misuse headache

Treatment Acute therapy for individual attacks Simple analgesia Aspirin 500 – 1000mg NSAIDS Paracetamol more effective than placebo less effective than NSAIDS Combination drugs containing simple analgesics and caffeine are helpful Opioids or sedatives should not be used as impair alertness and can cause overuse and dependence

Treatment Preventive treatment Consider when headaches are frequent or acute attacks don’t respond to abortive treatment Best evidence is for Amitriptyline 75- 150mg/day. It helps both pain and muscle tenderness. Works best when started at low dose and increased weekly Mirtazipine 15-30mg/day Venlafaxine (NARI) Unhelpful SSRI’s Botulinium toxin

Treatment Preventive treatment Should be considered when at least 2 headaches/month as risk of chronic headache goes up exponentially when frequency reaches 1/week as does severity of pain Benefit or preventive treatment is diminished when patients are simultaneously overusing abortive treatments. Withdrawal of medication is advised before starting preventative therapy

Treatment Education, lifestyle and non-pharmacological treatment Little evidence exists to support or refute most dietary or lifestyle recommendations for tension type headache.

Treatment Referral Diagnosis is unclear Does not respond to treatment Complicated by medication overuse Require neuroimaging

Prognosis 45% of adults with frequent or chronic tension type headache will go into remission 39% will carry on with frequent headaches 16% will carry on with chronic headache

Poor prognosis Associated with Presence of chronic headache at baseline Co-existing migraine Not being married Sleep problems

Good prognosis Associated with Older age Absence of chronic tension type headache at baseline Important message: intervene early before headaches become chronic

Cluster headache

3.1 Cluster headache IHS 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 if untreated C. Headache is accompanied by 1 of the following: 1. ipsilateral conjunctival injection and/or lacrimation 2. ipsilateral nasal congestion and/or rhinorrhoea 3. ipsilateral eyelid oedema 4. ipsilateral forehead and facial sweating 5. ipsilateral miosis and/or ptosis 6. a sense of restlessness or agitation D. Attacks have a frequency from 1/d to 8/d E. Not attributed to another disorder

3.1 Cluster headache IHS 3.1.1 Episodic cluster headache A. Attacks fulfilling criteria A-E for 3.1 Cluster headache B. At least two cluster periods lasting 7-365 d and separated by pain-free remission periods of 1 mo 3.1.2 Chronic cluster headache B. Attacks recur over >1 y without remission periods or with remission periods lasting <1 mo

Cyclical recurrence and regular timing Cluster headaches are occasionally referred to as "alarm clock headaches", because of the regularity of its timing and its ability to wake a person from sleep. Thus it has been known to strike at the same time each night or morning, often at precisely the same time during the day a week later. This has prompted researchers to speculate an involvement of the brain's "biological clock" or circadian rhythm. In some cases, cluster headaches remain "steady" without cyclical ups and downs for days.

Prevalence While migraines are diagnosed more often in women, cluster headaches are diagnosed more often in men. The male-to-female ratio in cluster headache ranges from 4:1 to 7:1. It primarily occurs between the ages of 20 to 50 years. prevalence rates of between 56 and 326 people per 100,000

Pathophysiology Cluster headaches are classified as vascular headaches. The intense pain is caused by the dilation of blood vessels which creates pressure on the trigeminal nerve. While this process is the immediate cause of the pain, the etiology (underlying cause or causes) is not fully understood. Among the most widely accepted theories is that cluster headaches are due to an abnormality in the hypothalamus This can explain why cluster headaches frequently strike around the same time each day, and during a particular season, since one of the functions the hypothalamus performs is regulation of the biological clock. Metabolic abnormalities have also been reported in patients.

Triggers Nitroglycerin (glyceryl trinitrate) can sometimes induce cluster headaches in sufferers in a manner similar to spontaneous attacks. Ingestion of alcohol or chocolate is recognized as a common trigger of cluster headaches when a person is in cycle or susceptible. Exposure to hydrocarbons (petroleum solvents, perfume) is also recognized as a trigger for cluster headaches

Triggers Smoking Nicotine may trigger cluster headaches, and the affliction is often found in people with a heavy addiction to cigarette smoking. Some sufferers report that quitting smoking has brought about an end to their cluster headaches.

Treatment Cluster headaches often go undiagnosed for many years, being confused with migraine or other causes of headache. Over-the-counter pain medications (such as aspirin, paracetamol, and ibuprofen) typically have no effect on the pain from a cluster headache. Medications to treat cluster headaches are classified as either abortives or prophylactics.

Abortive treatment During the onset of a cluster headache, some patients respond to rapid inhalation of pure oxygen (12-15 liters per minute with a mask). When used at the onset this can abort the attack in as little as 5 minutes. Alternative first-line treatment is subcutaneous administration of sumatriptan 0r nasal zolmitriptan

Prophylactic treatment A wide variety of prophylactic medicines are in use, and patient response to these is highly variable. Current European guidelines suggest the use of the calcium channel blocker verapamil at a dose of at least 240 mg daily. Steroids, such as prednisolone, are also effective, with a high dose given for the first five days before tapering down. Lithium and the anticonvulsant Topiramate are recommended as alternative treatments.