Tension headache: symptoms

Factors of chronic headache

An important role in the formation of a chronic pattern of pain (i.e., in the transformation of episodic cephalges into chronic), both with tension headache and with migraine, is played by the so-called chronization factors.

Among the mental factors predisposing to chronic pain, the first place is depression. A frequent mechanism for the formation of chronic stress and depression can be the accumulation of traumatic life events, when the patient is in the face of unsolvable problems for him.

It is also shown that the special characteristics of the personality and patient's choice of imperfect behavioral coping strategies also play an important role in the transformation of episodic cephalgia into chronic and its persistence.

The second most important factor of chronicization is the drug abusus, i.e. Excessive use of symptomatic pain medications. In Europe, more than 70% of patients with chronic daily headache abuse analgesics, derivatives of ergotamine, as well as combination drugs, which include analgesics, sedatives, caffeine and codeine-containing components. It is shown that in patients consuming a large number of analgesics, the chronic type of pain is formed twice as fast and that the drug abusus significantly complicates the treatment of patients with chronic daily headache. Therefore, the most important condition that guarantees the effectiveness of preventive therapy is the abolition of the drug that caused the abusus.

The muscular factor, which has already been mentioned, also contributes to the chronic course of cephalgic syndromes. Loose for patients with chronic forms of headache emotional stress and mental disorders (depression and anxiety), in turn, support muscular tension, leading to persistent pain.

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Symptoms and diagnostic criteria for tension headache

Patients with a tension headache, as a rule, describe it as diffuse, mild or moderate, more often bilateral, non-pulsating, compressive in type of "hoop" or "helmet". The pain does not increase with normal physical activity, it is seldom accompanied by nausea, however, photo or phonophobia is possible. The pain appears, as a rule, soon after awakening, is present throughout the day, then increasing, then weakening.

As already noted, the main difference between episodic headache and chronic tension is the number of days with a headache within a month. The remaining clinical manifestations of both forms are similar.

Criteria for the diagnosis of tension headache (ICGB-2, 2004)

• Headache lasting from 30 minutes to 7 days.
• At least two of the following:
  • two-sided localization;
  • Pressing / compressive / non-pulsating;
  • light or moderate intensity;
  • pain does not increase with normal physical activity (walking, climbing the stairs).
• Both of the following:
  • there is no nausea or vomiting (anorexia may occur);
  • only one of the symptoms: photo or phonophobia.
• Headache is not associated with other disorders.

[2], [3],

Additional diagnostic signs of a tension headache

• Pain pattern according to the type of "hoop" or "helmet".
• Weak or moderate intensity (up to 6 points according to the visual analogue scale of pain).
• Relief of pain with positive emotions and in a state of psychological relaxation.
• Increased pain on the background of emotional experiences.

Along with cephalalgia, most patients with tension headache complain of transient or persistent pain or a feeling of tension and discomfort in the back of the neck, the back of the neck and the shoulder (syndrome "coat hangers"). Therefore, an important element of examining a patient with a tension headache is the study of pericranial muscles, especially since other patients do not usually find other neurological manifestations.

It was shown that of the three diagnostic methods: normal palpation, EMG with surface electrodes and algometry - only the palpation method is most sensitive for detecting dysfunction of pericranial muscles in patients with tension headache and migraine. Therefore, in MCGB-2, only the palpation method is proposed for the differential diagnosis of headache subtypes with voltage and without muscle tension. Complaints about soreness and tension of the muscles of the neck and occiput (clinical reflection of dysfunction of pericranial muscles) increase as the intensity and frequency of episodes of headache increase, and as the strength of pain increases during the episode itself. It is shown that in the pathogenesis of chronic muscle-tonic pain syndrome lies the mechanism of the vicious circle, when the arising muscle tension causes overexcitation of spinal neurons, impaired posture and even greater pain intensification. A special role is assigned to the trigeminocervical system.

Dysfunction of pericranial muscles is easily detected by palpation with small rotational movements of II and III fingers, as well as when pressing in the region of the frontal, temporal, chewing, sternocleidomastoid and trapezius muscles. To obtain a common pain score for each patient, it is necessary to summarize the scores of local soreness obtained by palpation of each individual muscle and calculated using a verbal scale from 0 to 3 points. The presence of dysfunction of pericranial muscles should be considered when choosing a treatment strategy. In addition, when talking with a patient, you need to explain to him the mechanism of muscle tension and its significance for the course of the disease. In the presence of increased sensitivity (soreness) of pericranial muscles during palpation, it is necessary to diagnose "episodic tension headache (chronic tension headache) with pericranial muscle tension".

In addition, patients with tension headache almost always complain of increased anxiety, decreased mood background, melancholy, apathy or, conversely, aggressiveness and irritability, poor quality of night sleep. This is a manifestation of anxiety and depressive disorders, their degree in patients with tension headache varies from mild to severe. Significant depression is most often found in patients with chronic tension headache, it maintains muscle tension and pain syndrome, leading to severe maladaptation of these patients.

For most patients with tension headache, additional studies are not considered necessary. Instrumental methods and specialist consultations are shown only when there is a suspicion of the symptomatic (secondary) nature of cephalgia.

[4], [5], [6], [7], [8], [9], [10]

The combination of migraine and tension headaches

Some patients report a combination of episodic migraine and episodic tension headache. Typically, these are patients with a typical history of migraine, which eventually develop episodes of episodic tension headache. In view of the apparent differences in these two forms of cephalalgia, patients tend to distinguish migraine attacks from episodes of episodic tension headache.

The situation is more complicated if it becomes necessary to differentiate the chronic tension headache and chronic migraine when migraine attacks lose their typicality. If it is not possible to establish from the questioning how many episodes of cephalalgia meet the criteria of chronic migraine, and how much - chronic tension headache, it should be suggested to the patient to conduct a diagnostic diary of cephalgia for a certain time (1-2 months), noting in it clinical manifestations provoking and facilitating factors of each pain episode. In addition, along with diagnostic criteria, one should rely on anamnestic information: the previous history of episodic tension headaches for chronic tension cephalgia and typical episodic migraine attacks for chronic migraine.

The combination of chronic tension headache and abyssal headache

If a patient with a chronic tension headache abuses drugs, which corresponds to the diagnostic criteria for cephalgia with excessive use of medications (abusus headache), two diagnoses should be made: "possible chronic tension headache" and "possible abusic headache". If the 2-month withdrawal of the drug that caused the abusus did not cause relief of cephalalgia, the diagnosis is "chronic tension headache". If, with the withdrawal of the drug during these 2 months, there is an improvement and the criteria for chronic tension headache do not meet the clinical picture, it is more correct to establish the diagnosis of "abusus headache".

In very rare cases of headache, tension occurs in persons who have not previously had complaints about cephalgia, i.e. From the very beginning it proceeds without remissions by the type of chronic tension headache (cephalgia acquires a chronic character during the first 3 days after the onset, as though passing the stage of episodic tension headache). In this case, the diagnosis "New daily (initially) persistent headache" should be established. The most important factor in diagnosing a new daily persistent headache is the patient's ability to accurately recall the onset of pain, its initially chronic nature.

Clinical varieties of tension headaches

With infrequent episodic headache, patients rarely consult a doctor. Typically, a specialist has to face frequent episodic and chronic tension headaches. Chronic tension headache is a disorder that occurs from episodic tension headache and manifests itself in very frequent or daily episodes of cephalgia lasting from several minutes to several days. As well as chronic migraine, chronic tension headache is a form of chronic daily headache, characterized by the most severe course and always associated with severe maladaptation of patients, and consequently with significant individual and socioeconomic losses.

With chronic tension headache, cephalalgia occurs within 15 days per month and more during an average of more than 3 months (at least 180 days per year). In severe cases, there may be no painless gaps at all, and patients experience cephalgia continuously, from day to day. An important diagnostic sign of chronic tension headache is the previous history of episodic tension headache (as well as for the establishment of the diagnosis of "chronic migraine", it is necessary to have a typical episodic migraine attacks in the anamnesis).

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