So you have diagnosed your teenaged patient with tension-type headaches, what are the next steps 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?
Again, deciding on a preventive or daily medication depends on how much impact the TTHs are having on your teen patient’s life. Anything more than once per week deserves this conversation. And your choices for medication can be different than for migraine. When you think about the main causes for TTH, you think about muscular tension which can lead to muscle spasm and occipital neuralgia, and stress and anxiety.
For muscle tightness and/or spasm: Oftentimes patient with TTH will awaken with a stiff neck and back or headache. Muscle relaxants given at bedtime can reduce neck tightness overnight, leading to less tension overall. The most typical muscle relaxant we use is tizanidine (Zanaflex), an alpha2-adrenergic agonist, used for muscle spasticity. Usual dosage is 2-4 mg at bedtime. Main side effects are drowsiness, dry mouth, and weakness. It is used with caution for patient with impaired renal function and not advised for patients with impaired hepatic function. If your patient has difficulty with sleep, tizanidine can also help with this. Cyclobenzaprine (Flexiril) is also a musculoskeletal relaxant, with a similar side effect profile and precautions. This medication is not recommended to be used for more than 2-3 weeks, and we do not generally use it. Another option is diazepam (Valium), a benzodiazepine, but we almost never use it due to the risk of dependence and CNS depression. It is not a good choice.
What else can be done besides medications for tight muscles in the neck and upper back? The many different options of body work, such as massage, cranial sacral massage, chiropractic, yoga and Physical Therapy are very useful. I especially like PT, as there is a component and need for self-care required. Sending your patient for PT for head and neck stretching and strengthening is a very useful therapeutic option. PT is usually easy to find locally, though does require co-pay every time you go. The patient needs to do their home exercise program as well for it to be effective.
A few years ago I recognized that for some families, doing PT was difficult- either because of the co-pay or the time commitment/hours of operation of the PT center. It just wasn’t happening and it needed to. With my yoga teacher, I developed a home head and neck stretching program to supplement or replace PT (for patients who were not going anyway). I taught the exercises in the office, gave the family written instructions and a firm ball to use. We collected data in follow up and the results were great. We surveyed 43 patients, 36 of whom did the exercises at least once/week or more. Results revealed that 78% had reduced muscle tension, 22% had reduced headache and 30% just felt better. The more the kids actually did the exercises, the more benefit they reported. I demonstrate the exercises, give out instructions and balls regularly for those who would benefit, and for those who actually do the exercises, it is very helpful. The balls we used are called ‘Pinky’ balls, firm like a lacrosse ball, inexpensive, and can be found easily. Here’s a link to the instructions: Pinky ball Head and Neck exercises
For TTH with occipital neuralgia: Of all the previously discussed medications useful for headache, Gabapentin (Neurontin) is the one I use most often. It is an anticonvulsant and is quite effective in dealing with neuropathic pain anywhere in the body. So it makes sense that it would help with occipital neuralgia. Gabapentin does cause sedation and mental clouding, may lead to weight gain. Dosing is at bedtime to start, though depending on toleration, it can be given up to TID. At most I will use BID dosing (bigger dose at bedtime), as that midday dose is often missed. It comes in capsule form, smallest dosing is 100mg, though it does come as a liquid, helpful for younger children. Pregabalin (Lyrica) can be used as well, but there is abuse potential so it is controlled substance. Generally the insurance companies require failure with gabapentin before approving Lyrica. It can be hard to obtain and I do not use it often.
In a specialty headache or pain program, there is the option of occipital nerve and trigger point injections, done with local anesthetic (lidocaine and bupivacaine +/- steroids). IN TTH, the occipital nerve may be inflamed. Trigger points (areas within muscles that are very irritable) will contribute to tension-type headaches and myofascial pain. The areas around the greater occipital nerve, as well as any trigger points in the upper cervical, trapezius muscles are infiltrated with local anesthetic. Initially, patients feel ‘heavy-headed’ or numb, which passes by the next day or so. The anesthetic medication blocks pain receptors within the nerves surrounding the muscle, thus reducing the pain signals sent to the brain. Your patient may feel immediate relief of pain, and then (hopefully) a reduction in neuralgia and headache. This procedure is done in a series of 3, spaced 4-8 weeks apart. I usually encourage them to try it at least twice to evaluate whether it is helpful. Some patients have significant improvement with this procedure; some have no benefit at all. It is generally well tolerated.
I am actually amazed at how well the teens do with this procedure. They are in my office with a parent, we do a breathing exercise throughout the procedure, and only do as many injections as they can tolerate. Even my most needle-phobic kids can do it, mainly because they cannot see what I am doing and are distracted by the breathing exercise. After we complete the injections, I insist they go to the ‘spa room’, lay down on our Biomat (like a large heating pad) in dim lighting for 15-20 minutes with relaxing ambient sounds and aromatherapy, and drink a Gatorade. Many fall asleep and are very relaxed when they leave. I know we are very lucky to be able to offer this kind of experience. I think it actually increases the therapeutic benefit of the procedure.
In my next post, I’ll talk about appropriate rescue medications and treatment for underlying anxiety, which often needs to be addressed for kids with tension-type headaches.