All about the treatment of chronic headaches and chronic tension headaches

Tension headache (cephalgia) is one of the most common complaints of patients visiting a neurologist.

A special category of primary headaches is tension-type headache (TTH). In ICD 10 it is classified as G44.2. Tension headaches are common, accounting for approximately 78% of headache cases overall. More often women suffer from it. Although it is common among men in sufficient quantities. Sometimes tension headaches occur in children and adolescents, most often from overwork.

In this case, the child most likely did not get enough sleep or is worried about something. To get rid of headaches, analgesics are usually taken. This can cause a very severe headache.

What it is?

In simple words, tension headache (muscle tension headache, tension, tensor headache) in medical terminology is listed as a separate diagnosis. It is a bilateral (one-sided) diffuse pain with moderate intensity. Pain can form in any area - on the crown, back of the head, forehead, and flow from one area to another. Often the tension is transmitted to the cervical and shoulder regions.

A connection indicating that tensor headache is a consequence of the patient’s existing pathologies has not been established, so doctors classify it as a primary disease. TTH is characterized by pressing pain. People complain mainly about discomfort - it’s like a vice is encircling their head, and they want to get rid of them immediately. Tension headaches intensify from any touch to the head: a hat, a comb, even from a light breeze, but the intensity does not increase from physical activity.

Patients suffering from tension-type headache experience nervousness, their sleep and appetite are disturbed, and they are uncomfortable with sharp sounds, noise and bright lighting. The pain usually occurs during the day and does not bother you at night. Nausea, vomiting, and other symptoms characteristic of, for example, migraine are not observed.

Types of HDN

First of all, it is worth identifying the subspecies.

1. Episodic pain occurs no more often than about 18 times a month, and a single attack lasts no more than half an hour. The severity of pain is usually low.
2. Another type, chronic tension headache, is noticeably high in intensity. Patients have attacks more than 20 times a month, or more than 180 cases per year. Often this type of pain is accompanied by the appearance of depression.

Features of tension headaches

Tension headache or tension cephalgia, as mentioned above, is the most common option among all types of cephalgia. This type of headache is usually functional in nature and does not have a high degree of intensity or duration.

TTH should not be confused with migraine, despite the similar pathogenetic mechanisms of formation; with migraine, the pain syndrome is much more pronounced and manifests itself as localized pain mainly in one of the hemispheres of the brain. Unlike migraines, tension headaches cause diffuse pain.

Clinical picture

Tension headaches have the following characteristic symptoms:

• Painful sensations of a diffuse nature.
• Pain can come from the parietal part of the head, forehead, temples, but the entire head is necessarily included in the pain process.
• Patients describe the nature of the sensation as squeezing, pressing or twisting.
• The intensity of pain can vary from mild to moderate intensity. With tension headaches, the pain is never too intense or severe.
• The duration of pain can vary significantly, from a few minutes to several days.

It is important to note that a small proportion of people with tension headaches may experience additional symptoms, such as photophobia.

The symptom of head compression in neurological practice is sometimes called the “neurotic helmet”, since many patients complain of a feeling of head compression in all areas. In most patients, tension-type headaches are symmetrical, but asymmetrical headaches may also occur.

Two thirds of patients experience episodic headaches, i.e. they occur only with any functional impairment, but approximately 30% of patients are diagnosed with chronic tension-type headache. The main criterion is the frequency of occurrence of attacks; to establish a chronic form, headaches must occur at least 15 episodes of headaches within a month and over a period of three months.

The Clinical Institute of the Brain is actively studying the processes of formation and manifestation of tension headaches, which makes it possible to introduce new original, and most importantly, effective treatment regimens into medical practice.

Causes of tension headaches

TTH develops during mental stress, as a result of chronic stress and as a result of prolonged muscle tension. Muscle tension is most often associated with professional posture - prolonged sitting at a computer, driving a car, work associated with prolonged visual strain, for example, with small parts (seamstresses, watchmakers, jewelers, assemblers of electronic equipment...), constant monitoring of video monitors. Poor sleeping posture can also cause tension headaches. In the mechanism of development of tension-type headache, tension in the muscles of the neck, eye muscles, and muscles of the scalp aponeurosis is important - the so-called “muscle stress”.

Long-term use of analgesics and tranquilizers contributes to the development of chronic headaches. In real life, all these factors are often combined.

Increased headaches can be triggered by emotional stress, changes in weather, strong winds, fasting, working in a stuffy room, mental and physical fatigue, working at night, poor posture when sitting, and drinking alcohol.

The following roles play a role in the pathogenesis of tension headaches:

1. Tonic muscle spasm, as a trigger for ischemia, edema, electrolyte and biochemical shifts, leading to vasospasm and increasing pain,
2. Disturbances in the central mechanism of chronic pain - decreased pain threshold, insufficiency of serotonergic systems, insufficiency of the antinociceptive system,
3. Depression.

“Pain behavior” – the patient’s behavioral reactions to chronic pain – disrupt the body’s adaptation processes and aggravate the pain syndrome. Neurons with increased excitability and an insufficient inhibitory mechanism appear in the brain structures in which nociceptive (pain) information is processed (the frontal and temporal lobes, their mediobasal part and the limbic system).

In the development of chronic tension headaches, disruption of the functioning of the antinociceptive system and psychosocial maladaptation as a consequence of behavioral, personal, and emotional reactions of the body at the level of neurotransmitter mechanisms are important.

The antinociceptive system is a neuroendocrine anti-pain mechanism. When the pain threshold decreases, ordinary receptor stimuli are perceived as painful. It is possible to perceive pain without pathological impulses from perceptive receptors, but due to the emergence of foci of excited neurons - “generators of increased pathological excitation” in the brain. Dysfunction of the antinociceptive system is expressed in a decrease in the descending inhibitory effect on neurons that perceive and conduct nociceptive sensory flows. Thus, both the perception of pain and its conduction, processing and response to it - its inhibition - are disrupted.

The main mediators of the analgesic system:

• opiate-like neuropeptides - enkephalins and endorphins have chemical similarities to narcotic analgesics,
• biogenic amines produced by serotonergic and noradrenergic neurons - affect pain perception similar to tricyclic antidepressants.

It turns out that the body itself produces painkillers. In pathology, this mechanism is disrupted or does not work sufficiently. With emotional stress, overwork, and psychopathological conditions, pain control decreases at all levels of processing pain impulses. Weak signals from tense muscles are perceived as inappropriate pain. The appearance of overactive neurons leads to chronic pain. Depression aggravates these disturbances at the level of neurotransmitter biochemical processes and maintains the pain syndrome.

Who is at risk

According to doctors' observations, tension-tension can occur in people of all ages, even small children, but most often it develops in women 30-40 years old. At the same time, we can safely say that knowledge workers are at risk. The working day of such employees is associated with high concentration, emotional stress, concentration in conditions of sedentary work and little physical activity. Increasing pain does not allow a person to work fully, and accordingly, labor productivity decreases.

It is noteworthy that tension headaches cause disability for a huge number of people in the world. In Europe alone, annual government budget losses associated with employee disability amount to more than $15 billion.

The vast majority of the population is in no hurry to seek professional medical help, preferring to treat tension in the head on their own with painkillers, not taking into account that medications should be prescribed by a specialist. Such a negligent attitude towards one’s own health leads to a deterioration of the condition, the transition of episodic tension-type headache to the chronic stage.

Causes of tension-type pain

The reasons why tension headaches occur are associated with excessive mental and muscle tension.

Muscles become tense due to forced posture throughout the day. Due to duty, tension headaches occur in:

• drivers;
• seamstresses;
• jewelers;
• watchmakers;
• office workers;
• secretaries.

Tensor headache occurs with prolonged tension in the muscles of the eyes and neck.

Pain can occur in people who take an uncomfortable position during sleep, causing muscle spasm. This usually happens if a person sleeps on a high pillow or too soft mattress.

Drug dependence also leads to the development of tension headaches; treatment does not mean recovery. Taking analgesics and tranquilizers for a long time, a person’s production of their own painkillers in the body decreases. Getting used to the pills and abruptly stopping them leads to the development of pain.

Tension headaches can intensify as a result of provoking factors:

• psychological stress;
• change in weather conditions;
• wind;
• blizzard;
• non-compliance with diet;
• mental and physical fatigue;
• night work shifts;
• consumption of alcoholic beverages;
• curvature of posture.

Tension headaches are directly related to:

1. Tonic muscle spasm. Ischemia (nutrition deficiency) and edema occur, which leads to vasospasm and increased pain.
2. Disturbances in the central mechanism of chronic pain. The pain threshold and serotonin production decreases.
3. Depressive states.

The human body is capable of producing substances that relieve pain. In the event of malfunctions or the occurrence of pathologies, the process of production of analgesic components is reduced. If a person is in a long-term depressive state, constantly overworked, susceptible to irritation and psychosis, control over pain syndromes is impaired. The body's signal that the muscles are overstrained is not perceived by the body, resulting in chronic pain. Depressive syndrome aggravates disturbances at the level of biochemical processes, which leads to the progression of pain.

Symptoms of HDN

Patients describe differently how tension headaches manifest. Its symptoms can be different:

• by nature it can be dull, diffuse, pressing and constricting, NOT pulsating;
• accompanied by increased fatigue, tiredness, irritability, decreased appetite, insomnia;
• appears on both sides of the head, sometimes asymmetrical;
• Its intensity is most often light to moderate, but it can also be severe.

As a rule, the pain is not accompanied by vomiting, but mild nausea and intolerance to sounds and bright light may be present. Physical activity usually does not aggravate the condition, but it is difficult for the person to “pull together” and perform any action that requires effort. During a headache, you can feel some lumps when you feel the muscles of the neck and head. Neurological symptoms with this diagnosis are usually absent (loss of consciousness, impaired taste, tactile sensitivity, motor and oculomotor disorders, etc.).

Typically, pain is localized in the forehead, temples, and upper part of the head. Sometimes, along with this, tension in the head, neck and back of the head can be observed.

This condition does not carry with it any serious consequences for the patient, but experiencing regular discomfort and pain reduces the quality of his life. In addition, constant self-treatment with analgesics, which allow you to quickly get rid of an attack, negatively affects the functioning of internal organs, and in some cases causes mental or physical dependence.

Two types of HDN can occur:

• episodic;
• chronic.

Episodic headaches include experiencing painful sensations no more than 15 days a month with low intensity, and chronic tension headache means more than 20 days with higher intensity. This type of tension-type headache is often accompanied by clinical depression, generalized anxiety disorder, and neuroses.

Table - Difference between tension headache and migraine

Combination of migraine and tension headache

Some patients experience a combination of episodic migraine and episodic tension-type headache. Typically, these are patients with a typical history of migraine who develop episodic tension-type headaches over time. Due to the obvious differences between these two forms of cephalalgia, patients usually distinguish migraine attacks from episodic tension-type headache attacks.

The situation is more complicated if there is a need to differentiate between chronic tension headache and chronic migraine, when migraine attacks lose their typicality. If it is not possible to establish from questioning how many episodes of cephalgia correspond to the criteria for chronic migraine, and how many correspond to chronic tension headache, the patient should be asked to keep a diagnostic diary of cephalgia for a certain time (1-2 months), noting in it the clinical manifestations that provoke and alleviate factors of each pain episode.

In this case, along with diagnostic criteria, one should rely on anamnestic information: a previous history of episodic tension-type headaches for chronic tension-type cephalalgia and typical episodic migraine attacks for chronic migraine.

Diagnosis of tension-type headache

The diagnosis is made based on the patient’s complaints, collection of anamnesis (developmental history) and examination. X-rays, MRIs of the brain and other clinical studies do not clarify the picture of the disease, because they are not informative in this case - no changes in the functioning of the brain or its structure are visible.

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Also, both forms of tension cephalgia are divided into pain “with tension of the pericranial muscles” and “without tension of the pericranial muscles.”

Tension and pain in these muscles are easily manifested by palpation. It is usually carried out with small rotational movements. Pain may occur when pressing on the masticatory, temporal, and muscles of the back of the neck. Moreover, it is sometimes so strong that the patient will resist palpation. Tension of the pericranial muscles will be a clear sign of tension-type headache if there is pain in 2 or more muscle groups when pressing on them. For each patient, a TPS or a total pain score is calculated - the doctor presses his fingers on each muscle group, the patient says how much he rates the pain on a scale from 1 to 4 points, then these points are summed up to obtain a total pain score (TPS).

Psychological research also plays a significant role. First of all, the overall mood scale is measured. Testing is carried out for the presence of depression, anxiety, fears, and neurosis. Sometimes a psychogenic headache is detected with symptoms similar to tension-type headache in some respects, but with this type of cephalalgia it is difficult to localize the source of pain and explain its nature. Tension headache and its treatment, in any case, require medical supervision.

Diagnostics

As a rule, establishing a diagnosis of tension headache is not difficult, but confirming the diagnosis is a labor-intensive process. To confirm the diagnosis, the patient must undergo a series of diagnostic studies, which allow not only to confirm the disease, but also to find out the degree of its severity, as well as the main cause, which qualitatively improves the further treatment of the patient.

At the clinic, the following is used to verify tension headaches:

• Ultrasound Dopplerography of the vessels of the head and neck to exclude or confirm atherosclerotic changes in the vascular wall.

For a more detailed and in-depth study of cerebral lesions, an X-ray examination - angiography - can be performed.

1. Angiography of cerebral arteries followed by contrast allows one to accurately determine the location of vascular pathology.
2. Tomographic research methods: computed tomography and magnetic resonance imaging allow detailed visualization of the tissues and structures of the brain, which has significant information weight in the diagnosis of headaches.
3. Electroencephalography is a classic method and the gold standard for diagnostic studies of the brain. EEG allows us to determine the functional activity of the brain and headache-related disorders.

Treatment

Some patients with tension headaches do not see a doctor and try to treat the pain on their own. Unfortunately, repeated self-use of painkillers can itself cause severe headaches.

Drug treatment

There are a wide variety of medications, including over-the-counter ones, that can help relieve pain, including:

• Painkillers. Simple over-the-counter pain relievers are usually the first line of treatment for headaches. These include aspirin, ibuprofen (Advil, Motrin IB, others), and naproxen (Aleve). Prescription medications include naproxen (Naprosyn), indomethacin (Indocin), and ketorolac (ketorolac tromethamine).
• Combined drugs. Aspirin or acetaminophen or both, often combined with caffeine or a sedative in one medicine. Combination medications may be more effective than medications with a single active ingredient.
• Triptans and drugs. For people who have both migraines and tension-type headaches, triptans can provide effective headache relief. Opiates, or narcotics, are rarely used due to their side effects and high risk of addiction.

How to treat tension-type headache and relieve pain at home?

Treatment approaches for episodic and chronic tension headaches vary.

Treatment of tension headache symptoms should primarily be done by a neurologist. The success of therapy and the likelihood of a final cure will depend on his competence and the degree of openness of the patient. In any case, treatment should be long-term. Approximately 4-6 months. And if the clinical picture includes depression or other mental disorders or disorders of a different nature, then the duration of therapy can last up to a year.

If treatment is interrupted, the likelihood of a relapse of the disease greatly increases; cephalalgia can come again even from a slight strain on the nervous system. Some patients get rid of it completely.

Brief treatment regimen for tension-type headache:

1. Therapy for muscle pain.
2. Complex pharmacotherapy (both for the relief of hypertension and for the prevention and treatment of depressive conditions, anxiety, etc.).
3. Treatment of depression and other psychological disorders.
4. Prevention of tension-type headache (its plan and stages are also determined by the attending physician).

TTH in children

Children suffer from this disease no less often than adults.

Symptoms of TTH in children are similar to those in adults. The child complains about:

• bilateral squeezing pain;
• fatigue;
• back and neck pain.

During the examination, the doctor notes that:

• blood pressure is increased or decreased;
• heart rate is increased;
• pupils are dilated.

Parents say that the child has become irritable.

The reasons leading to TTH in a child are:

• incorrectly selected desktop;
• unventilated room where the child arrives;
• workload at school;
• weather change;
• hunger.

Before relieving a tension headache in a child, the doctor carries out a series of diagnostic measures, after which he advises parents to adjust the daily routine, review the diet and ease the child’s mental and physical stress.

Drugs for the treatment of episodic tension-type headache

Drug therapy includes a list of specific medications that help relieve tension headaches at home. TOP 5 best products:

1. Citramon is a combination drug that contains 3 active ingredients - aspirin, paracetamol, caffeine. Indicated for people who have headaches combined with increased drowsiness. It has a good effect and a reasonable price (about 25 rubles). Not recommended for use in the evening, for people with arterial hypertension and peptic ulcer of the stomach or duodenum.
2. Paracetamol. The safest pain reliever with a minimum number of side effects and well tolerated by patients. This is a drug that should be used when tension headache first appears. Only if it is ineffective is it possible to switch to other medications. In adults, an effective single dosage starts at 1000 mg. An important advantage is the low cost (about 20 rubles) of the drug and its general availability. Contraindicated in people with liver failure.
3. Naproxen (Nalgesin, etc.). The drug of choice for headaches in several US states and European countries. A highly effective drug that also copes with toothache, headaches due to otitis media, sinusitis, etc. Price is about 80 rubles. Contraindicated for people with peptic ulcers. After taking, allergic reactions are possible, rarely bronchospasm.
4. Ketanov (Ketorolac). A drug with a very pronounced analgesic effect, it helps even with severe headaches. The cost is about 50 - 100 rubles. Long-term use is not advisable due to cardio-, gastro- and nephrotoxicity (negatively affects the heart, stomach, kidneys). Contraindicated for people with stomach, heart and kidney diseases.
5. Ibuprofen (Ibupron, Ibufen, Mig, Nurofen, etc.) is a fast-acting drug from the group of non-steroidal anti-inflammatory drugs. The price starts from 15 rubles. and higher depending on the manufacturer. The effect after oral administration is already within 20 - 30 minutes. Contraindicated for people with peptic ulcers.

Average dosages of medications for the treatment of episodic tension headaches:

Please be aware that some of the above medications may cause side effects such as blood thinning or stomach discomfort. In addition, their long-term use provokes headaches (caused by painkillers). Therefore, pharmacological agents are used as rarely as possible and in the lowest effective dosage. They can be taken only three days in a row and no more than ten days a month.

Taking analgin-containing drugs (Analgin, Tempalgin, Sedalgin, etc.) is contraindicated, especially for a long time, due to the latest evidence of its negative effect on the white blood sprout. After taking it, agranulocytosis often develops - a decrease in the number of leukocytes, i.e. leads to a decrease in the body's protective immune forces. Combination drugs that include substances such as codeine, phenobarbital (Pentalgin, Fasconal, etc.) are also not recommended for use, due to the development of drug dependence on these substances (drug abuse).

Treatment of chronic form of tension-type headache

A diagnosis of “chronic tension headache” is a contraindication to taking painkillers! In this case, they are ineffective and complicate the already difficult task of pain relief.

All over the world, antidepressants are used to treat chronic tension headache:

• tricyclic antidepressants (Amitriptyline) - prescribed long-term for 2-6 months. Start taking ¼-1/2 tablet, doubling the dose every 3 days, and bring it up to 75 mg. They take it this way for several months, and then successively reduce the dose until it is completely stopped;
• selective serotonin and norepinephrine reuptake inhibitors - Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Sirlift, Zoloft). They are very effective in combating chronic tension headaches and have significantly fewer side effects than tricyclic antidepressants.
• Other antidepressants - Mianserin (Lerivon) 15 mg 2 times a day, Tianeptine (Coaxil) 12.5 mg 3 times a day.

Treatment with antidepressants is carried out for at least 2 months. In this case, not only an analgesic effect is achieved, but also psycho-vegetative activity is normalized, that is, the level of anxiety, fear, emotional stress is reduced, and mood is normalized. Thus, they affect not only the pain itself, but also its causes.

Non-drug treatment methods must necessarily be present in the complex of measures to eliminate pain in chronic tension-type headache. The same methods are used as for episodic tension headaches. It is not always possible to help a patient from the first course of treatment. Sometimes only repeated and prolonged pharmacological and non-pharmacological interventions help get rid of the disease. And this requires patience from both the doctor and the patient.

Tension headaches are a common problem for modern people. Chronic stress affects all of us, and tension headaches are one of its many consequences. The disease is not dangerous to humans, but can make itself felt quite often and lead to significant limitation of life activities. Treatment of the disease requires a thoughtful and patient approach. For this purpose, both medicinal and non-medicinal methods are used.

Non-drug treatment

This group of treatment includes ways to get rid of tension pain without the use of drugs:

• psychotherapy;
• biofeedback therapy;
• manual therapy;
• acupuncture;
• post-isometric relaxation;
• massage of the head, back and neck-collar area;
• physiotherapy (electrophoresis with novocaine, magnetic therapy);
• Spa treatment.

At home, a bath with essential oils (orange, mint, eucalyptus) and walks in the fresh air will help against headache pain. Rest, healthy sleep and good nutrition can alleviate a person’s condition, and even completely relieve pain.

To understand how to treat tension headaches specifically in your case, consult a neurologist. He will accurately determine the causes of the disease and select the most suitable and safe drug. For those who do not want to be treated in a regular clinic, specialized Headache Centers are suitable, which are created at hospitals in many large cities of the country.

You should know that pain should not be accompanied by fever, rash, or joint pain. Tension pain should not be too severe, and should not intensify over time, or with coughing or physical activity. Severe, unbearable headaches, memory or vision problems are a reason to immediately consult a doctor.

Massage

This type of physiotherapy is especially indicated for concomitant cervical osteochondrosis. Classic massage movements help to achieve muscle relaxation, improve venous outflow, and relieve emotional tension. The simultaneous use of various herbal ointments and aromatic oils is useful. This has a positive effect on a person’s mood and relieves stress.

In case of tension-type headache, the cervical-collar region, the scalp, and the forehead and temples are targeted. The duration of the procedure does not exceed 20 minutes; the course will require from 7 to 15 sessions.

Folk remedies to relieve symptoms

The goals of therapy using traditional medicine are:

• elimination of muscle spasm;
• relaxation;
• anesthesia;
• calm.

Essential oils, baths with herbal infusions, and tension-relieving massages are highly relaxing.

You can prepare a relaxing bath by following these tips:

1. Pour 100 g of sea salt into a warm bath, add 30 - 40 grams of pine extract. For 10 days, take water procedures before bed.
2. Lavender, in the amount of 100 grams, pour boiling water (200 ml). Leave for 30 minutes and add to warm bath water. The water procedure will help relieve tension and relax muscles.
3. An effective method of relaxation is a bath with the addition of pine needles. Brew 200 grams of raw material in water, put on fire for 5 - 7 minutes. Then pour the resulting infusion into a warm bath.

A relaxing massage is best done with essential oil. Peppermint, cedar, eucalyptus, menthol, and juniper oils have high therapeutic properties.

The following are used as herbal preparations for oral administration:

• lemon balm;
• St. John's wort;
• Golden mustache.

You can prepare decoctions and infusions like this:

1. Combine half a large leaf of golden mustache with 1 orange, crushed with zest, add sugar (150 grams), half a liter of red wine and grated horseradish, in the amount of 75 grams. Cook the mixture in a water bath for 40 - 60 minutes, remove from heat, strain and take a third of a glass, 2 hours after eating.
2. Pour a tablespoon of lemon balm into 200 ml of boiling water and leave in a thermos for 1 hour. Drink 1 spoon of the prepared infusion 5 times a day.
3. St. John's wort, pour 15 grams of boiling water (200 ml), put on low heat for 10 - 15 minutes. Take 3 tablespoons three times a day.

Treatment with traditional recipes should be agreed with the doctor.

Prevention

In conclusion, I would like to note that if you take a number of simple preventive actions, you won’t have to undergo treatment at all. The main thing is to listen to your body and follow a few simple rules:

1. If possible, have a work and rest schedule that suits you.
2. Exercise daily.
3. Visit a psychologist once every six months.
4. Get healthy while on vacation, at least at health resorts.
5. Don't forget about water procedures.
6. Strictly follow doctors' orders.

The task of the first point may be difficult to complete, but the other five are completely in your hands. Good health to you, and may your head never hurt.

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