FEBUARY 1998 MEETING
TOPIC: "TENSION TYPE HEADACHES"
The East Bay Headache Support Group (EBHSG) met on February 10, 1998 to hear Dr. Michael Stein, co-founder of the group, talk about tension type headaches. The meeting was held in the Sequoia I and II Conference Rooms at John Muir Medical Center, with 36 people in attendance.
Before his formal presentation, Dr. Stein mentioned a new migraine drug now available:
Migranal is DHE (Dihydroergotamine) in a nasal spray dosage form. The nasal spray has been sold in Europe since 1988, but just received approval by the Food and Drug Administration to be marketed in the United States. DHE has to be packaged in glass ampules so the active ingredients stay fresh. A prescription for Migranal gives you four doses, each packaged in a glass ampule, and comes with a videotape to explain administration of the medicine.
What are tension-type headaches?
Tension-type is the official nomenclature. It is just a name--it doesn’t mean these headaches are caused by tension. They are often called tension headaches, regular headaches, muscle contraction headaches, essential headaches, stress headaches.
A tension type headache is typically a mild or moderate headache that either doesn’t interfere with daily activities or has a slight effect on daily activities. The pain is usually described as steady, dull, aching, pressure-like, constricting; often like a tight band or a sense of fullness in the head. The pain can last 30 minutes to hours.
Pain is usually felt on both sides of the head; most often in the front. The next most common location is the back of the head. If in forehead, it might be called a "sinus headache."
Pain is typically not worsened by physical activity, coughing, or straining.
Tension type headache is sometimes associated with trouble thinking, concentrating, lack of appetite. It is not usually associated with sensitivity to light, noise, or nausea.
The headache usually begins upon arising or shortly thereafter, and may then continue through the day, varying in severity; usually worse in the evening.
This headache should not be associated with any neurological abnormalities such as numbness, weakness, changes in speech, vision, etc.
Not getting enough sleep is a common cause mentioned by sufferers of this kind of headache.
Relationship to "tension," muscle contraction, stress, anxiety, anger is not always apparent; headaches can occur if not stressed. Dr. Stein mentioned again that stress is not necessarily a factor. Many people say they are happy, not stressed, and they still get tension type headaches.
These headaches are classified into episodic and chronic forms:
• Episodic Tension Type Headache (or ETTH) is defined as occurring 15 times per month or less (180 headache days per year).
• Chronic Tension Type Headache (or CTTH) is defined as occurring more than 15 times per month.
This type of headache is further classified as to whether or not the "pericranial muscles" are involved, i.e., muscles in the jaw, neck, or shoulders.
Lab tests (blood tests, scans, etc.) are always negative.
A recently published study in JAMA (Journal of the American Medical Association), based on telephone interviews of over 13,000 people living in the Baltimore area, revealed:
• Episodic tension type headache had a one year prevalence of 38.3% (over one-third had 15 or fewer attacks per month; that’s almost 5,000 people).
• Women were more likely to experience ETTH in all age, race and educational groups (ratio of women to men was 1.16 to 1).
• 47% of women and 42% of men between the ages of 30-39 experienced ETTH (age group with the highest prevalence).
• ETTH occurred more frequently in white Americans than in African Americans for both men (40% vs 23%) and women (47% vs 31%).
• Prevalence of ETTH increased with increasing educational levels in both sexes, reaching a peak in subjects with graduate school education in 49% of men and women.
• Majority of those with ETTH (72%) had a headache 30 or fewer times per year.
• CTTH (chronic) almost always starts as ETTH (episodic); rarely it is chronic from the outset.
• CTTH occurred in 2.2% of all those interviewed; it was twice as common in women than men (2.8% vs 1.4%).
• Unlike ETTH, CTTH appeared to decline with increasing education; this was most apparent in women.
• CTTH is actually associated with fewer missed work days and lowered productivity than ETTH.
What causes tension type headaches?
Original theory was that they are caused by sustained contraction of muscles of the scalp and neck. However, various studies have failed to reveal any increased muscle activity in muscles of the scalp or neck. There is increased tenderness of tissues of scalp and muscles in the neck to palpation, suggesting that there is a lowered pain threshold.
Pain-Pressure Threshold Chart (see attached).
Current theory of cause of tension type headaches: There is a heightened sensitivity of muscles and other tissues in the scalp and neck coupled with a lowered ability of mechanisms in the brain to suppress or control the pain signals coming in; this may occur on a genetic basis. With time, the brain mechanisms become less and less capable of suppressing the incoming signals, leading to the gradual increasing frequency of tension type headache with age.
Stress, anxiety, anger, lack of sleep may further lower the ability of the brain to control or modulate incoming painful stimuli.
And sleep or relaxation may increase the brain’s threshold for perception of incoming painful signals. OTC (over-the-counter) medicines such as Aspirin, Tylenol, Ibuprofen probably decrease the painful signals coming in from tissues in the scalp and neck muscles.
See attached Headache Threshold Models (Migraine and Menstrual Cycle) and Theory of Tension Type Headaches.
The question of chronic daily headaches:
Defined as a CTTH (chronic tension type headache) that is continuous, i.e., it never goes away, except when the individual is asleep. The chronic daily headache has all of the other characteristics of CTTH. It usually occurs in individuals with a history of migraine headaches, and often appears after an individual has had a number of migraine headaches. The chronic daily headache begins as an ETTH (episodic) and gradually occurs more and more frequently.
Dr. Stein presented the following slides to show an individual’s headache pattern evolving from an ETTH to a CTTH or chronic daily headache. See the four attached Typical Headache Patterns.
Individual will often continue to have episodic migraine headaches in a background of CTTH, usually provoked by lack of sleep, stress, anger, and in women, menses.
Most individuals are taking daily amounts of OTC medicines (the most noteworthy being Excedrin) or prescription abortive medications (especially Fiorinal, although all others have potential) in significant quantities; usually doing this for months or years. Dr. Stein said that some individuals take 6-8 Excedrin or Fiorinal per day. This headache caused by the daily use of medicines has been termed a "transformed migraine" or "rebound headache."
Individuals often complain of their headache worsening with the slightest physical or intellectual effort. The rebound headache is usually associated with irritability, restlessness, vague sense of ill-health, depression. There is a drug dependent rhythmicity of headaches with frequent early morning (2:00 am to 5:00 am) awakenings.
An individual develops an increased tolerance to analgesics over time. The rebound headache worsens and may become a migraine headache if the individual attempts to reduce or go off daily OTC or prescribed medicines.
The rebound headache may show little or no response to prescription medications used to abort headache, such as Imitrex or Zomig; and most medicines prescribed to prevent headache are ineffective.
Current theory is that chronic analgesic medicine use lowers the brain’s ability to regulate any incoming painful stimuli from scalp tissues, muscles in neck, effects of anger, stress, other emotional or hormonal fluctuations. The threshold is so low that it doesn’t take much to provoke a headache, and the headache is now continuous.
Treatment of rebound headaches is the discontinuation of all OTC and prescribed medicines used to abort the headache. Then the individual must start a preventative medicine and use certain medicines, most typically DHE, to abort the withdrawal headaches. DHE can be given every 8 hours for 3 days to break this cycle. This process may require admission to the hospital for 2-3 days. An individual can experience a withdrawal seizure if he suddenly goes off Fiorinal, which is a barbituate. Dr. Stein warned that the chronic daily headache may return to its former pattern if analgesics are again used in excess.
Treatment of tension type headaches:
Typically tricyclic antidepressant type medicines in low doses are prescribed if headaches are frequent, or prolonged. The most common is Elavil (Amitryptilene); but often Pamelor (Nortryptilene) or Sinequan (Doxepin) are prescribed. The initial doses are low, and gradually increased as needed. Depakote is helpful for some. Often a combination of medicines is needed to control symptoms; for instance, Corgard plus Pamelor. All of these medicines have various side effects (Depakote can cause hair loss and/or weight gain). Dr. Stein stressed that none of these medicines will do any good if OTC medicines are also taken while on this regimen. Dr. Stein also said that biofeedback and relaxation techniques are very useful adjuncts to treatment.
For treatment of episodic tension type headaches (ETTH), try OTC medicines such as Aspirin, Tylenol, Ibuprofen, or combination OTC medicines such as Anacin or Excedrin. Prescription medicines such as Fiorinal, Fioricet, Midrin, or Esgic may relieve the pain. Muscle relaxants may help; they usually work by causing sedation. Examples of muscle relaxants are Soma and Skelaxin. Various herbal remedies may be useful.
Various medicines, even OTC, can be cautiously used to abort the occasional severe headache. In individuals with rebound headaches, the overuse of OTC medicines has to be carefully avoided. The prognosis for rebound headaches is good if the individual follows treatment recommendations. About 66% will return to a former pattern of occasional severe or migraine headaches which can be readily aborted with either OTC or prescription medicines.
The prognosis worsens, however, the longer the headaches have been chronic and the longer the individual has been using analgesics on a daily basis. Dr. Stein said that certain individuals can only be treated by maintaining them on chronic daily doses of various analgesics--this is usually a last resort.
Chronic analgesic use does not alleviate the other symptoms (depression, irritability, lack of feeling of well-being, difficulty sleeping, etc.); these symptoms persist as long as the medicines are being used.
At the end of his presentation, Dr. Stein asked for questions from the audience.
Q. Are chronic daily headaches always caused by daily use of analgesics?
A. An individual can experience increased headaches without taking OTC analgesics, but it is a rare occurrence.
Q. Is taking one Excedrin a day too much?
A. Yes, one Excedrin per day is overuse.
Q. Do most doctors know how to treat headaches?
A. Some family physicians, etc., still prescribe Fiorinal for their patients, which can cause rebound headaches when overused.
Q. Can a tension type headache start over the eye?
A. Yes.
Q. Can overuse of any medicine cause rebound headaches?
A. Yes. Dr. Stein has heard of patients taking daily DHE injections. DHE is a constrictor of blood vessels. He also mentioned Cafergot, which constricts arteries. Chronic ergot use could conceivably bring on a heart attack, or gangrene.
Q. What about the overuse of Valium?
A. Overuse of any of these medicines can lead to the phenomena of rebound headache.
Q. Can you give us the pros and cons of Imitrex and DHE nasal sprays?
A. Imitrx nasal spray costs $20 per treatment. It seems to work more rapidly to relieve the headache, and it wears off slower. In comparison, DHE costs $17 per treatment. It seems to be more effective and lasts longer, but works slower and can cause nausea. DHE is derived from fungus growing on rye.
Dr. Stein added that in the next few months Amerge (naritriptan) in a tablet form will be available by prescription. Amerge apparently doesn’t work as quickly, but relief will last longer. And in June or July 1998 Maxalt (another triptan) will be released. We will then have five choices of medicine for migraine headaches. It was only three years ago that Imitrex was introduced.
Q. Is there any way I can keep Imitrex nasal spray from giving me a horrible taste in my mouth and a runny nose?
A. Dr. Stein said the directions for administering DHE nasal spray advise the patient to spray it in, and then don’t breathe in. Perhaps, when dosing yourself with Imitrex nasal spray, you should try not to breathe in--don’t inhale.
One person mentioned that her chronic tension type headaches seem to be triggered by changes in the weather (barometric pressure).
Q. If you take 1/2 aspirin or a baby aspirin each day to prevent a stroke or heart attack, will it cause chronic tension type headache?
A. It is unlikely that small an amount would cause CTTH.
Q. One man stated his doctor has prescribed Nortryptilene for him for three years. Should he be cutting back on it?
A. Yes. Dr. Stein said he tries to get his patients off each medication after six months (cutting down gradually to get off). His philosophy is to break the cycle of headache with preventive medicine, and then get off the medicine.
Q. Dr. Stein was asked about drugs such as Prozac, Zoloft, Zerzone, Paxil, Pamelor which have been prescribed for preventive therapy for headaches.
A. He said that he hasn’t found that they work well. A side effect of these drugs is that the patient will experience vivid dreams. Dr. Stein again mentioned that preventive medicines won’t work as long as OTC medicines are also being used.
Q. There are a number of new migraine drugs. Is there one specifically for women who experience menstrual migraines?
A. Dr. Stein said he has not heard of one.
Q. Is there constriction of blood vessels in both migraine and tension type headaches?
A. Possibly, but if there is, it is of little significance.
Dr. Stein mentioned fibromyalgia--where one experiences pain in other places in the body besides the neck and shoulders. A patient with fibromyalgia would be prescribed the same treatment, such as Elavil, etc. and exercise.
Exercise is good. Deep breathing, acupuncture, biofeedback all may help to raise your threshold.
Q. When should you take Imitrex?
A. You have to wait until you have a full-blown headache to take Imitrex. Otherwise, it could cause rebound headaches.
Q. What are the side effects from taking too much Tylenol, etc.?
A. A person can bleed to death from too much aspirin. 4000 mg Tylenol = 8 Extra Strength Tylenol. This is the limit per day. Dr. Stein hasn’t seen any patients with liver damage yet.
Sometimes Dr. Stein has had to prescribe four Fiorinal pills a day for patients with intractable headaches, because nothing else seems to work.
Q. Does Dr. Stein suggest herbal therapy?
A. No, he does not recommend herbs. He has found that most people don’t seem to get better when taking herbs.
The intention of the East Bay Headache Support Group is to provide information and resources. It does not provide medical advice, which should be obtained directly from a physician.