Tension Headache

Re @embasic The proper dose of opioids for acute headache is 0.0 mg/kg #foamed
— Mike Abernethy (@FLTDOC1) April 3, 2014

Tension Headache and Medication Overuse headache are very similar in my head (the former sometimes literally), so I'm going to cover both of them together!

Tension Headache
Tension headache can be episodic or chronic. It is normally described as a featureless headache. It can cause daily or very frequent headaches, lasting minutes to days.
- Symptoms begin before the age of 10 years in 15% of people with chronic tension-type headache.
- It affects 4.1% of the population
- 65% of cases are women
It is thought to be triggered at least partially by stress.

The 2004 International Headache Society criteria for chronic tension-type headache are:
- Headaches on 15 or more days a month (180 days/year) for at least three months
- Pain that is bilateral, pressing, or tightening in quality and non-pulsating, of mild or moderate intensity, which does not worsen with routine physical activity such as walking or climbing stairs
- Presence of no more than one additional clinical feature (mild nausea, photophobia, or phonophobia) and without moderate/severe nausea or vomiting.
- Causes of normal headache --> chronic daily headache:

Interesting review of tension headache therapeutics in ED http://t.co/74XEv6lqMG #FOAMed #FOAM4GP
— Casey Parker (@broomedocs) March 15, 2014

Treatment
- Prevention is better than cure
- Amitriptyline or mirtazapine are both helpful
- CBT

Medication Overuse Headache
Medication overuse headache is difficult to diagnose, as the type of headache that develops varies eg patients with underlying migraine report migraine-like daily headache.
It is caused by tolerance, and withdrawal.
They normally use large quantities of medication (eg 35 doses/ week; six different drugs). Opiods and barbiturates are more likely to cause it.
It is the frequence rather than the absolute quantity that is important. Caffeine is thought to make you more susceptible.
- Prevalence around 1% of adults and 0.5% of adolescents (aged 13–18 years)
- Most prevalent in those aged around 40–50 years and affects about three times more women than men.

Symptoms improve 1- 6 months after withdrawal of medication. Simply recognising medication overuse and advising patients about its bad effects can be enough to significantly reduce the problem- in one study after identification of the problem, 76% no longer overused medication, and 42% no longer had chronic headache. The rate of relapse is high (between one-third and one-half of patients in specialist headache clinics), being more likely with opiates and simple analgesics than triptans.

References
http://dtb.bmj.com/content/48/1/2.abstract
http://learning.bmj.com/learning/module-intro/chronic-tension-headache.html?moduleId=10007571&searchTerm=%E2%80%9Ctension%E2%80%9D&page=1&locale=en_GB
http://bestpractice.bmj.com/best-practice/monograph/12.html
http://www.bmj.com/content/336/7635/88?variant=pdf&sso=
http://emupdates.com/2009/01/03/664-features-of-tension-headache-causes-of-subarachnoid-hemorrhage-what-of-the-population-has-a-berry-aneurysm-diseases-associated-with-berry-aneurysm/ http://www.bmj.com/content/340/bmj.c1305
http://www.doctors.net.uk/ecme/wfrmNewIntro.aspx?moduleid=1517