Tension Type Headache.pptx
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The document provides an overview of headaches and headache disorders. It begins by classifying headaches into primary and secondary types according to the International Classification of Headache Disorders. Tension-type headache is discussed in more detail, including its clinical features, diagnostic criteria, prevalence, pathophysiology, treatment options including pharmacological and non-pharmacological approaches, and its high rates of comorbidity with mental health conditions like depression and anxiety. The document emphasizes screening headache patients for psychiatric symptoms.
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Tension Type Headache.pptx
- 1. HEADACHE Aziz Mohammad Asstt: Prof: Psychiatry KMC/KTH
- 2. Learning Objectives Overview and Classification of Headache Disorders Tension-Type Headache (TTH) Headache in Children Migraine Sinus Headache Headache due to Giant Cell Arteritis Headache & Computer Vision Syndrome and & Refractive Errors Headache: A Neurosurgeons Perspective
- 3. Key Facts: Headache Disorders are the 3rd leading cause of Years Lost Due to Disability (YLD) Worldwide.1 Migraine is the 6th Leading Cause of YLD.1 A minority of people with headache disorders are diagnosed. 1. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020 Oct 17;396(10258):1204-1222.
- 4. Barriers to effective care Health Care Providers Public Govt
- 5. International Classification of Headache Disorders 3rd Ed The Primary Headaches: (90%) 1. Migraine 2. Tension Type Headache 3. Trigeminal Autonomic Cephalalgias: (Cluster Headache, Paroxysmal Hemicranias)
- 9. International Classification of Headache Disorders 3rd Ed (Cont..) The Secondary Headaches: (Secondary To) 4. Trauma/Injury 5. Cranial/Cervical Vascular Disorder 6. Non Vascular Intracranial Disorders 7. Substance Use or Withdrawal 8. Disorders of Cranium, Neck, Eyes, Ears, Nose, Sinuses, Mouth, and Teeth
- 12. Tension Type Headache (TTH) • CLINICAL FEATURES — The typical presentation • Mild to moderate intensity, • Bilateral, • Nonthrobbing • Descriptions • "dull" • "pressure" • "band-like"
- 13. Tension Type Headache (TTH): The ICHD-3 Criteria At least 10 episodes of headache, each lasting 30 minutes to seven days, which fulfill the following conditions At least two of the following: 1. Bilateral location 2. Pressing or tightening (non-pulsating) quality 3. Mild or moderate intensity 4. Not aggravated by routine physical activity such as walking or climbing stairs Both of the following: 1. No nausea or vomiting 2. No more than one of photophobia or phonophobia
- 14. Burden of TTH The most prevalent headache in the general population.1 The Second-most prevalent disorder in the world.2 Because of the high prevalence of TTH, the global burden of disability caused by TTH is greater than that caused by migraine.3 1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629. 2. Martelletti P, Birbeck GL, Katsarava Z, et al. The Global Burden of Disease survey 2010, Lifting The Burden and thinking outside-the-box on headache disorders. J Headache Pain 2013; 14:13. 3. GBD 2015 Neurological Disorders Collaborator Group. Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol 2017; 16:877.
- 15. Tension Type Headache (TTH): Subtypes & Prevalence 1. Infrequent Episodic TTH: 63-86%1,2 2. Frequent Episodic TTH: 21.5%2 3. Chronic TTH: 0.9%2 • Peak Age: 40 Years • Gender: Female>Males 1. Russell MB, Levi N, Saltyte-Benth J, Fenger K. Tension-type headache in adolescents and adults: a population based study of 33,764 twins. Eur J Epidemiol 2006; 21:153. 2. Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Has the prevalence of migraine and tension- type headache changed over a 12-year period? A Danish population survey. Eur J Epidemiol 2005; 20:243.
- 16. Pathophysiology
- 17. Treatment Episodic Moderate TTH: • Recommended: (NSAIDs) ibuprofen (400 mg), naproxen sodium (220 mg or 550 mg) or aspirin (650 to 1000 mg), Acetaminophen 1gm. • Not Recommended: Opioids Analgesics Episodic Severe TTH needing treatment in a Medical facility: IM Ketorolac • Avoiding medication overuse headache is a major goal of therapy for TTH. This ideally requires limitation of acute therapy to nine days per month on average, and typically a maximum of two doses per treatment day.
- 18. Prophylaxis Amytriptyline 25-100mg:1 Nortriptyline25-100mg1 Mirtazapine 15-30mg2 Vanlafaxine 75-150mg3 1. Jackson JL, Shimeall W, Sessums L, et al. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ 2010; 341:c5222. 2. Bendtsen L, Jensen R. Mirtazapine is effective in the prophylactic treatment of chronic tension- type headache. Neurology 2004; 62:1706. 3. Zissis NP, Harmoussi S, Vlaikidis N, et al. A randomized, double-blind, placebo-controlled study of venlafaxine XR in out-patients with tension-type headache. Cephalalgia 2007; 27:315.
- 19. Nonpharmacological Treatment • Problem Solving & Stress Coping • Regulation of sleep, exercise, and meals • Cognitive-behavioral therapy • Relaxation • Biofeedback • Combinations of the above
- 20. Headache and Mental Health Epidemiological Research:1-2 TTH and Control Group • Depression: 4-5 times • Generalized Anxiety Disorder: 4-5 times • Panic Disorder: 3-10 times • OCD: 5 Times 1. Guidetti V, Galli F, Fabrizi P, et al Headache and psychiatric comorbidity: Clinical aspects and outcome in an 8-year follow-up study. Cephalalgia. 1998; 18: 455- 462. 2. Holroyd K, Stensland M, Lipchik GL, Hill KR, O'Donnell FS, Cordingley G. Psychosocial correlates and impact of chronic tension-type headaches. Headache. 2000; 40: 3- 16.
- 21. Headache and Mental Health • The lifetime prevalence rates of various psychiatric disorders among migraine patients:2 • Major depression (34%),Dysthymia (9%), PD (11%), GAD (10%), OCD (9%), Phobias (40%). 1. Lipchik GL, Penzien DB. Psychiatric comorbidities in patients with headaches. Semin Pain Med. 2004; 2: 93- 105. 2. Radat F, Swendsen J. Psychiatric comorbidity in migraine: A review. Cephalalgia. 2005; 25: 165- 178.
- 22. Take Home Message • Screen every patient of Headache Disorder for Symptoms of Depression and Anxiety.
- 23. Thank You
Notas del editor
- Almost half of the adult population have had a headache at least once within the last year. Headache disorders = Personal and Societal burden of pain, disability and economy. In the Global Burden of Disease Study, updated in 2013, migraine was found to be the sixth highest cause worldwide of years lost due to disability (YLD). Headache disorders collectively were third highest. A minority of people with headache disorders are diagnosed.
- Lack of knowledge among health-care providers is the principal clinical barrier. Worldwide, on average, only 4 hours of undergraduate medical education are dedicated to instruction on headache disorders. A large number of people with headache disorders are not diagnosed and treated: worldwide only 40% of those with migraine or TTH are professionally diagnosed, and only 10% of those with MOH. Poor awareness extends to the general public. Headache disorders are not perceived by the public as serious since they are mostly episodic, do not cause death, and are not contagious. The low consultation rates in developed countries may indicate that many affected people are unaware that effective treatments exist. Half of people with headache disorders are estimated to be self-treating. Many governments, seeking to constrain health-care costs, do not acknowledge the substantial burden of headache on society. They might not recognize that the direct costs of treating headache are small in comparison with the huge indirect-cost savings that might be made (eg, by reducing lost working days) if resources were allocated to treat headache disorders appropriately.
- Infrequent episodic TTH, with headache episodes less than one day a month ●Frequent episodic TTH, with headache episodes 1 to 14 days a month ●Chronic TTH, with headaches 15 or more days a month
- Prophylactic headache treatment is indicated if headaches are frequent, long lasting, or associated with a significant amount of disability. Preventive treatment is appropriate for most patients with chronic tension-type headache (TTH), and for many patients with frequent episodic TTH. (See 'Indications and approach to treatment' above.) ●The evidence regarding prophylactic drugs for TTH is limited and inconsistent, but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. (See 'Tricyclic antidepressants' above.) ●Other agents have been studied for TTH prophylaxis, including serotonin-norepinephrine reuptake inhibitors (mirtazapine and venlafaxine) and anticonvulsants (gabapentin and topiramate). However, the benefit of these drugs for TTH prevention is not established, and more clinical trial data are required. (See 'Other antidepressants' above and 'Anticonvulsants' above and 'Tizanidine' above.) ●Behavioral treatments for headache include biofeedback, relaxation, and cognitive-behavioral therapy (ie, stress management). The goal of these treatments is to prevent headaches by identifying and defusing behavioral headache triggers, and by using self-regulation to modulate involuntary and subconscious physiologic processes. (See 'Behavioral therapies' above.) ●EMG biofeedback, alone or combined with relaxation therapy, appears to have modest effectiveness for TTH prevention. There is no convincing evidence to support an effect of cognitive-behavioral therapy or relaxation training alone for TTH. (See 'Effectiveness' above.) ●For patients with frequent episodic TTH or chronic TTH we suggest treatment with combined tricyclic antidepressant therapy plus stress management therapy rather than treatment with tricyclics alone or behavioral therapy alone (Grade 2B). (See 'Combined behavioral and tricyclic therapy' above.) ●For patients with frequent episodic TTH or chronic TTH who have a preference for pharmacologic treatment rather than behavioral therapy, we suggest tricyclic therapy with amitriptyline (Grade 2B). Guidelines for drug dosing and duration of therapy are given above. (See 'Tricyclic antidepressants' above and 'Dosing and duration of therapy' above.) ●For patients with frequent episodic TTH or chronic TTH who wish to avoid pharmacologic therapy, we suggest electromyography (EMG) biofeedback combined with relaxation therapy (Grade 2B). (See 'Behavioral therapies' above and 'Effectiveness' above.) ●For patients with frequent episodic TTH and chronic TTH who do not tolerate or desire more effective treatments such as amitriptyline and biofeedback, we suggest treatment with acupuncture (Grade 2B) or physical therapy that includes craniocervical exercises, osteopathic manipulation therapy, or inactivation of muscle trigger points (Grade 2C). (See 'Other nonpharmacologic therapies' above.)
- Prophylactic headache treatment is indicated if headaches are frequent, long lasting, or associated with a significant amount of disability. Preventive treatment is appropriate for most patients with chronic tension-type headache (TTH), and for many patients with frequent episodic TTH. (See 'Indications and approach to treatment' above.) ●The evidence regarding prophylactic drugs for TTH is limited and inconsistent, but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. (See 'Tricyclic antidepressants' above.) ●Other agents have been studied for TTH prophylaxis, including serotonin-norepinephrine reuptake inhibitors (mirtazapine and venlafaxine) and anticonvulsants (gabapentin and topiramate). However, the benefit of these drugs for TTH prevention is not established, and more clinical trial data are required. (See 'Other antidepressants' above and 'Anticonvulsants' above and 'Tizanidine' above.) ●Behavioral treatments for headache include biofeedback, relaxation, and cognitive-behavioral therapy (ie, stress management). The goal of these treatments is to prevent headaches by identifying and defusing behavioral headache triggers, and by using self-regulation to modulate involuntary and subconscious physiologic processes. (See 'Behavioral therapies' above.) ●EMG biofeedback, alone or combined with relaxation therapy, appears to have modest effectiveness for TTH prevention. There is no convincing evidence to support an effect of cognitive-behavioral therapy or relaxation training alone for TTH. (See 'Effectiveness' above.) ●For patients with frequent episodic TTH or chronic TTH we suggest treatment with combined tricyclic antidepressant therapy plus stress management therapy rather than treatment with tricyclics alone or behavioral therapy alone (Grade 2B). (See 'Combined behavioral and tricyclic therapy' above.) ●For patients with frequent episodic TTH or chronic TTH who have a preference for pharmacologic treatment rather than behavioral therapy, we suggest tricyclic therapy with amitriptyline (Grade 2B). Guidelines for drug dosing and duration of therapy are given above. (See 'Tricyclic antidepressants' above and 'Dosing and duration of therapy' above.) ●For patients with frequent episodic TTH or chronic TTH who wish to avoid pharmacologic therapy, we suggest electromyography (EMG) biofeedback combined with relaxation therapy (Grade 2B). (See 'Behavioral therapies' above and 'Effectiveness' above.) ●For patients with frequent episodic TTH and chronic TTH who do not tolerate or desire more effective treatments such as amitriptyline and biofeedback, we suggest treatment with acupuncture (Grade 2B) or physical therapy that includes craniocervical exercises, osteopathic manipulation therapy, or inactivation of muscle trigger points (Grade 2C). (See 'Other nonpharmacologic therapies' above.)