Tension headache

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Tension headache
ICD-10 code G44.2
IHS / ICHD-II code 2.0

Tension headaches are mild to moderate headaches that affect the entire head. Of the approximately 5% of the population who, according to epidemiological estimates, suffer from daily headaches, approximately 40% have a tension headache. A distinction is made between episodic (eSK) and chronic tension headache (cSK) according to the duration of the disease (see below). A genetic component can be assumed, since cSK occurs approximately three times more often in families with cSK than in cSK-free families.

As with any form of prolonged headache, the sufferer should keep a headache diary in which a. the following is to be noted:

  • the headache attacks with a subjective assessment of their intensity , e.g. B. on the basis of a numerical rating scale in points from 0 to 10 (0 = no pain, 10 = strongest / unbearable pain)
  • Any other abnormalities (nausea, vomiting, photophobia, etc.)
  • the respective duration and impairment of the quality of life for the day concerned.

This documentation makes it easier for the attending physician, on the one hand, to make the correct diagnosis and , on the other, to work out an adequate therapy .

Symptoms

According to the IHS criteria of 1998, a tension headache can then be spoken of if the headache is pain in the area of ​​the entire head ( bilateral / holocephalic) that is pushing-pulling but not pulsating. In terms of intensity, it is mild to moderate pain that does not increase with physical activity. The individual headache attack lasts between 30 minutes and 7 days. Vegetative accompanying symptoms such as photophobia and excessive sensitivity to noise, nausea, vomiting and loss of appetite usually do not occur and, if they do, only very rarely appear. The distinction between eSK and cSK is made - as already mentioned above - on the basis of the period of existence: One speaks of eSK if the SK has occurred at least ten times, but there are fewer than 180 headache days per year; One speaks of cSK as soon as the headache occurred on at least 15 days a month for more than 6 consecutive months. The headache, which is caused by tense chewing muscles in the head, must be differentiated from this. It is also a dull, pressing pain that seems to wander around in the head. However, it is always there.

Psycho- vegetative abnormalities such as anxiety, depressed mood, sleep disorders and drug overuse are more common in people with cSK . Other symptoms that frequently correlate with cSK include hair loss and trichodynia (itching, burning, tension, pain in the scalp), which are also partially derived from tension in the head, chewing and neck muscles and can occur at the same time.

Pathogenesis

The exact pathophysiology has not yet been clarified. A multifactorial event is suspected: On the one hand, an unphysiological spasm of the neck muscles activates pain receptors, which results in a central sensitization, which makes pain easier to perceive. On the other hand, feverish infections and stress are seen as triggers or intensifying factors. Another cause can be tense masseter muscles in the head. These cramp up due to the grinding of teeth at night ( bruxism ), which in turn has psychological causes.

Diagnosis

The diagnosis must rule out all other possible primary and secondary causes of headache. With SK, there are typically no abnormalities in the general examination findings or in the cerebral imaging (CCT, cMRT). As part of the differential diagnosis , an exact internal investigation must take place (exclusion of arterial hypertension, which can also lead to bilateral, dull-pressing headaches) and side effects of drugs must be considered (e.g. with calcium antagonists, nitro preparations, caffeine, certain hormones) . The exact history of the use of painkillers (analgesics) is of essential differential diagnostic importance for the differentiation from non-analgesic-induced headache. It is relatively easy to determine whether the affected patient suffers from cramped mastication muscles in the head. By pressing the corresponding muscles with the index finger, the affected patient immediately feels a painful stimulus.

therapy

Since the exact causes are still in the dark, only symptomatic therapy and preventive treatment can be carried out.

Episodic tension headache

According to the guidelines of the German Society for Neurology, the effectiveness of the following drugs for the treatment of episodic tension headache has been proven in studies: acetylsalicylic acid (ASA), paracetamol , ibuprofen , naproxen , metamizole and the fixed active ingredient combination of acetylsalicylic acid, paracetamol and caffeine . However, pain relievers should not be taken more than ten times a month, otherwise drug-induced headache can occur. The extensive application of peppermint oil to the temples and neck is considered a comparable therapeutic alternative. It also offers the advantage that no analgesic-induced headache can occur. Non-drug procedures such as acupuncture can also be used for episodic tension headache. The use of acupuncture has no influence on the frequency of episodic tension headaches.

Chronic tension headache

General measures include Jacobson's relaxation exercises , biofeedback , regular endurance sports, stress management training and a pain diary. The acute therapy corresponds to the therapy for episodic tension headache. Due to the risk of drug-induced headaches , the above-mentioned analgesics should be used for a maximum of 10 days per month.

In contrast to episodic tension headache, the benefit of prophylactic therapy for chronic tension headache has been well studied. Tricyclic antidepressants such as B. Amitriptyline 25–150 mg / d are the first choice for prophylaxis. Alternatives are doxepin , imipramine or clomipramine . All the preparations mentioned must be added slowly. The full effect may only take place after 4–8 weeks. Mirtazapine , venlafaxine , valproic acid , moclobemide , fluoxetine , sulpiride and topiramate can be used for prophylaxis as the second choice preparations, the effectiveness of which has not been clearly or insufficiently proven . No final assessment is available for the muscle relaxant tizanidine and the anticonvulsant gabapentin .

Without accompanying measures, the effectiveness of prophylactic drug therapy is only up to 40–45%. For example, a combination of antidepressants and stress management training can reduce pain in around 65% of cases. Affected patients also seem to benefit well from the use of physiotherapy with training of the cervical and shoulder muscles, stretching exercises and massage, as well as relaxation exercises. Performing acupuncture is also effective. The way the acupuncture is performed has no influence on its effectiveness.

literature

Web links

Individual evidence

  1. ↑ Guide of the DMKG , accessed on July 3, 2014.
  2. ↑ a b c d e Guideline therapy of episodic and chronic headache of the tension type and other chronic daily headaches of the German Society for Neurology . In: AWMF online (as of 2012)
  3. ↑ HG Endres, G. Böwing, HC Diener, et al. : Acupuncture for tension-type headache: a multicentre, sham-controlled, patient-and observer-blinded, randomized trial . In: J Headache Pain . tape 8 , no. 5 , October 2007, p. 306-314 , doi : 10.1007 / s10194-007-0416-5 , PMID 17955168 .
  4. ↑ K. Linde, G. Allais, B. Brinkhaus, E. Manheimer, A. Vickers, AR White: Acupuncture for migraine prophylaxis . In: Cochrane Database Syst Rev . No. 1 , 2009, p. CD001218 , doi : 10.1002 / 14651858.CD001218.pub2 , PMID 19160193 .