1. Tension Type Headache Cluster headache
Dr. walter amberger

2. Tension type headache

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Treatment Preventive treatment
Consider when headaches are frequent or acute attacks don’t respond to abortive treatment
Best evidence is for Amitriptyline mg/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

14. 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

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

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

17. 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

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

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

20. Cluster headache

21. 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 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

22. 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 d and separated by pain-free remission periods of 1 mo
Chronic cluster headache
B. Attacks recur over >1 y without remission periods or with remission periods lasting <1 mo

23. 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.

24. 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

25. 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.

26. 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

27. 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.

28. 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.

29. 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

30. 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.