Why don't tension-type headaches get more respect? They affect up to 80 percent of adults,1 are responsible for huge financial costs, and account for more than one half of the headache consultations patients have with family physicians.2 However, the amount of research and scholarly effort invested in understanding and treating this common condition is negligible. In this issue of American Family Physician, Millea and Brodie3 discuss the pathophysiology of tension-type headache and the examination and treatment of patients with this condition. Tension-type headache is a leading “heartsink”4 condition that “evokes feelings of frustration, defeat, and resentment”4 when encountered by a family physician on the daily schedule. For many reasons, we find patients with tension-type headache unrewarding to treat, and this attitude negatively affects the quality of care those patients receive. Nearly 25 percent of patients are dissatisfied with their treatment for chronic headache.5 Although family physicians pride themselves on treating common complex conditions well, something is wrong with the management of tension-type headache.
Part of the problem is accurate diagnosis. Tension-type headaches are specific entities that should be positively identified by the criteria created by the International Headache Society6; they are not identified by “wastebasket” diagnoses for any nonmigrainous headache. The history may require significant effort to exclude headaches secondary to other conditions, including depression, medication, or substance abuse, or situations where headache is an indicator of an underlying medical or neurologic disorder. Diagnosis must also distinguish between episodic tension-type headache and the more chronic forms, because the management strategies may be very different.
Once a diagnosis of tension-type headache is made, it is essential to convey to the patient that the syndrome is real and treatable. In one dated but valid study,7 the strongest predictor of long-term resolution of headache was the patient's belief that he or she had discussed the problem fully with an informed physician. This discussion must be accomplished without encouraging patient dependency on medications or the physician. The wise physician assumes the role of a coach and encourages patient responsibility in managing tension-type headache.
Management plans should be personalized but should always include consideration of lifestyle modifications and adjunctive treatments as well as conventional medications. Physicians must guide patients through the variety of suggested nonpharmacologic treatments, most of which have little rigorous evidence to support their use.8,9 Even so, patients who start exercising, for example, appear to benefit. Not only do they experience headache relief, but they also enjoy a sense of control over life, as well as the other positive effects of exercise. Conventional pharmacologic therapy for episodic tension-type headache is based on the logical use of analgesics plus strategies to minimize side effects and rebound or withdrawal problems. Studies10 suggest that nonsteroidal anti-inflammatory drugs are efficacious, and a variety of agents, dosages, and combinations are available to allow tailoring analgesia to the individual patient. It is essential to avoid “analgesic anarchy,” in which the patient takes multiple medications in futile attempts to control the pain. Evidence-based treatment guidelines for migraine headache are widely available online at Web sites such as the American Academy of Family Physicians (www.aafp.org) and the American Academy of Neurology (www.aan.com). In contrast, only the British Association for the Study of Headache (www.bash.org.uk) appears to be committed to providing accessible expert guidelines for tension-type headache, but these guidelines are not strongly evidence based. In many of the other headache resources for physicians and their patients (e.g., the American Council for Headache Education,www.achenet.org) migraine dominates, and other types of headaches receive little attention.
The patient with chronic unremitting daily headache deserves particularly careful attention for accurate diagnosis. If there are no neurologic signs present, the chance of intracranial pathology is very low at around 0.04 percent11; however, physicians and patients should always consider the possibility. A thorough physical examination, especially funduscopic findings (such as the absence of papilledema and the presence of spontaneous venous pulsations to help exclude serious disease) can be beneficial, especially as part of follow-up and monitoring of treatment. Overuse of neuroimaging is more likely to yield false-positive findings than useful information,12 unless the patient has “red flags” for pathology (such as an unexplained abnormal finding on the neurologic examination).13
Patients with chronic tension-type headache require a long-term multiphasic management strategy. While the best evidence is for analgesia plus amitriptyline (Elavil),14 other antidepressant medications also may be effective. All treatments require careful explanation of their specific action in chronic pain. Otherwise, patients may perceive that the physician believes the headache has a psychologic origin or that the physician is trying to deceive the patient about appropriate therapy. Relaxation therapy, biofeedback, and cognitive therapy are likely to be useful in selected patients who have confidence in these approaches.
Helping patients overcome tension-type headache is difficult but epitomizes the best of family practice. With the help of our successful coaching, most patients can accept that they are “headache vulnerable” and can successfully avoid becoming dysfunctional because of tension-type headache or inappropriate treatment.15