Headache Lawrence Pike

Tension headache Chronic daily headache Analgesic overuse / rebound headaches Rare causes

Tension headache Tension - type headache is most commonly episodic (occurs less than 15 times per month). It is defined as chronic when it occurs 15 or more times per month for a minimum of 6 months. Chronic tension headache is the commonest form of chronic and recurrent headache and often associated with a sustained contraction of skeletal muscle of the scalp, jaw and neck. This is sometimes associated with anxiety and emotional stress. Precipitating factors for tension headache include psychological, social and emotional factors, minor head injury and CNS infection (e.g. post viral meningitis).

Chronic daily headache Chronic daily headache (overlaps with chronic tension headache) is a descriptive term used when there is headache occurring on more days than not or for more than 50% of the time. There is often association with sleep disturbance, anxiety and analgesic overuse. Family history is positive in 90% of patients. The cause is often analgesic overuse.

Analgesic overuse / rebound headaches Usually result from analgesic overuse in chronic headache sufferers, most commonly with the use of opioids or ergotamine for the management of migraine or chronic tension headache. It may also occur when other analgesics are used over-frequently for headache. A chronic daily headache develops after long term continuous or overuse of the offending drug and cessation of treatment leads to withdrawal symptoms (primarily headache).

Rare Causes Benign cough headache ‘Ice-cream' headache Benign Exertional Headache Headache associated with sexual activity.

Incidence Over 95 % of the population suffer from occasional headache. A much smaller proportion consult their GP with headache. Tension headache and chronic daily headache are more common in women and those with a positive family history 3% of the population suffer from chronic daily headache. Up to 1 in 50 people suffer from analgesic overuse / rebound headache. Headache has a significant functional impact at work, home and school.

Examination CNS examination including cranial nerves and mental state is likely to be normal in tension and other non-serious headache, but is essential in order to exclude more serious causes. Fundoscopy should always be performed to exclude hypertension (also check blood pressure) and papilloedema. [Steiner 1997] Palpation of the face and neck to exclude local causes. Exclude meningeal irritation (neck stiffness and Kernig's sign).

Management Identification and exclusion of precipitating factors Headache calendar has been found effective in identifying possible aetiological factors Cognitive behavioural therapy with a view to improving coping strategies is sometimes effective Discussion with regard to lifestyle changes in order to reduce stress and anxiety, may be of value. Relaxation therapies and postural advice are effective if used appropriately.

Drug Management Paracetamol, aspirin and other NSAIDs are effective in the treatment of headache. Codeine should be used with caution because of the increased chance of causing analgesic rebound headache. Low dose combination codeine preparations have been shown to be of no greater efficacy than paracetamol alone. High dose codeine (30mg) may be used for patients with severe headache as it is an effective painkiller for severe pain but this must be short term (less than one week) only.

Management cont. Analgesic overuse rebound headache is treated by stopping the analgesic. An alternative analgesic used at recommended frequencies and doses can be helpful In severe, chronic tension headache, prophylaxis with tricyclic antidepressants and betablockers if there are migraine-like symptoms may be used Acupuncture: there is little supportive evidence of its benefit