Talking about Tension-type headaches

Starting this month, I am going to move on from migraine and start to review another primary headache, tension-type headache (TTH), commonly seen in children and teens. In earlier blog posts I discussed lifestyle factors for good headache hygiene.  All of those recommendations can be applied to any headache type, including TTH, and I refer you to those earlier posts for specific recommendations.

Tension-type headaches are the most common type of headache, but generally less disabling than migraine or some other headaches. The pain can be mild to moderate, often described as being like a band around the head, pressure, dull and aching, and involving both sides of the head. Tension-type headaches usually come on slowly and can sometimes last for days. The headache is caused by muscle tension in the scalp, neck and upper back which tightens the blood vessels and causes pain. There is also irritation and changes in the blood vessels that make the pain feel worse and more severe than you would expect from muscle tension.

Some teens also have neck stiffness and signs of occipital neuralgia, which is described as sharp, shooting or burning pain which travels from the occiput to frontalis. The tight muscles squeeze the occipital nerve, leading to neuralgia. The neuralgic pain can be felt along the pathway of the occipital nerve and can be felt even behind the eyes. Occipital neuralgia has been described to me as a sudden and severe electric shock-like pain, brief, and can knock you off your feet.  The episodes of neuralgia can be infrequent or several times/day.  The pathophysiology of TTH is not completely clear; nociceptive input from cranial and cervical myofascial components will trigger TTH and if this noxious input is sustained, the pattern becomes chronic.  As a result, frequent TTH with/without neuralgia can lead to central sensitization, scalp allodynia, and chronic tension-type headache.

Common triggers are similar to migraine and include anxiety, depression, life and school stress, poor diet, lack of sleep, dehydration, lack of exercise and movement, poor posture, neck and upper back muscle spasms and strains, and general illness. Along with pain, kids with TTH can experience a few other symptoms such as lightheadedness or dizziness, mild nausea and fatigue. They do not usually have the array of associated symptoms that someone with migraine would experience. And while the pain is usually not as severe, TTH can also be debilitating when it becomes chronic, when there is occipital neuralgia, or when the underlying issues are not addressed.

Significant contributing factors are stress and mental health issues, such as anxiety and depression. Oftentimes, headache is the major presenting symptom, and on further investigation, environmental stress (home, school, peer bullying) and mental health challenges are revealed, either at the PCP or frequently at the school nurse’s office.  Getting to the bottom of these issues and intervening can lead to an improvement in TTH.

Learning to manage stress is the key to preventing or minimizing the suffering from TTH. When you think about your stress, where do you usually feel it in your body? Some people feel it in their gut- nausea, butterflies, GERD, abdominal pain, diarrhea/irritable bowel. Some people get short of breath, hyperventilate, feel chest tightness or even trigger an asthma or panic attack. Maybe you have emotional eating or stop eating altogether. For many people, it is in the muscles- muscle tightness or even muscle spasm.  This tightness can be in the back, such as low back pain in adults, or for many, in the upper back and neck, which can lead to headache.

So it makes sense to understand how we respond to stress and also how to decrease the habitual physical reactions to stress. We all can experience these reactions and our bodies respond instinctually ‘the way it always does’.  When stress is experienced in the musculoskeletal system and causes pain, this is often described as muscle memory. Say you have a minor low back injury and have a back spasm; the next time you feel stressed, you may respond by having a back spasm/pain.  Over time, this area of your body has become a point of weakness and susceptible to having a stress reaction. It happens differently for everybody.  This is often what happens with TTH: there is stress, then upper back and neck muscles get tight, squeeze around the skull and trigger headache.  What is important is making the connection, recognizing what stress does in our bodies, and then figuring out what to do to decrease the automatic response.  You can help your patients figure this out.

If you have diagnosed your patient with tension-type headaches, the next steps include how to prevent and treat them. The same questions apply to TTH as to migraine: Does this patient need a preventive or daily medication? What is the rescue plan? And even more importantly, what about the lifestyle factors that can trigger TTH? The questions are the same, sometimes the interventions are the same but there are some differences. We will cover this topic in my next post.

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