Tension-Type Headache and Other Benign Episodic and Chronic Headaches

Chronic TTH (15 or more days monthly) is the most prevalent form of chronic daily headache. Episodic TTH usually lasts from 30 minutes to 7 days. It is subclassified into infrequent episodic TTH (<1 day monthly) and frequent episodic TTH (1-14 days monthly).

TTH pathophysiology is poorly delineated, possibly including peripheral and central nervous system mechanisms. The previous etiologic conjecture of sustained pericranial muscle contracture has not been documented.

Treatment involves two primary therapies: acute or abortive during an attack, and daily prophylactic to decrease headache frequency and/or severity. Acetaminophen or NSAIDs are first-line acute treatment agents. Combination analgesics containing caffeine are sometimes more effective. Opiates and butalbital should be avoided given their propensity to lead to side-effects and overuse, particularly the development of worsening headaches.

Prophylactic therapy is appropriate for frequent, disabling, long-lasting headaches, leading to significant disability. Tricyclic antidepressants are the principal agents used for TTH. Some studies suggest that serotonin-norepinephrine reuptake inhibitors (mirtazapine and venlafaxine) are useful. Behavioral modification using cognitive-behavioral therapy, relaxation, or electromyographic (EMG) biofeedback may be helpful. Combined tricyclic antidepressant therapy with behavioral therapy may be more effective than either modality alone.

Hypnic headache, (“alarm clock headache”) occurs in senior adults, typified by dull head pain stereotypically awakening them from sleep, occurring nightly at a similar time; and occasionally from daytime naps. These are unrelated to migraine or TACs. Controlled treatment trials for hypnic headache are lacking. Anecdotal successful treatments include evening caffeine, lithium carbonate, or indomethacin.

Primary stabbing headache is typified by spontaneous, transient, single or multiple, variably localized stabs of pain lasting a few seconds; occurring less than once daily to multiple times. These are more frequent in migraine headache individuals sometimes superimposed on an acute migraine. Most patients do not need treatment but individuals with frequent attacks may benefit from prophylactic indomethacin.

Primary cough headache has an abrupt onset triggered by coughing or straining, typically lasting from 1 second to 30 minutes. Although often benign, an intracranial abnormality, particularly a posterior fossa tumor or Chiari malformation, must be excluded with magnetic resonance imaging (MRI). Prophylactic treatment with indomethacin is often effective; acetazolamide, propranolol and other NSAIDs are effective in some patients.

Primary exertional headache occurs during or after physical exertion, typically building up over minutes during the physical activity. The pain is pulsatile, lasting minutes to more than a day. Exercise can sometimes precipitate migraine. Intracranial structural abnormalities, including supratentorial and posterior fossa tumors, aneurysms, and arteriovenous malformations with intracerebral hemorrhage also require consideration. Brain MRI and magnetic resonance angiography (MRA) are indicated. Exertional headache may be a manifestation of cardiac ischemia, and when suspected, an electrocardiogram (ECG) and other cardiac testing should be performed. Treatment of recurrent exertional headache includes indomethacin an hour before activity. Other medications that may be helpful include propranolol and naproxen.

Primary headaches associated with sexual activity are of two types. Preorgasmic headache begins with mild head and neck aching during sexual activity and builds with sexual excitement, and is often associated with neck and jaw tightness. Its average duration is 30 minutes, but it varies between minutes and a few hours. Orgasmic headache is sudden and severe, generalized and explosive/pulsatile, and occurs with or just before orgasm. Primary orgasmic headache must be differentiated from serious causes of thunderclap headache, including subarachnoid and intracerebral hemorrhage and cervicocephalic arterial dissections. Recurrent primary orgasmic headaches may be treated with prophylactic indomethacin an hour before anticipated sexual activity or daily propranolol. Triptan medications are effective for acute treatment of primary orgasmic headache.

Cold-stimulus headache, formerly known as “ice-cream headache,” is a generalized headache attributed to ingestion or inhalation of a cold stimulus. This may also follow exposure of the unprotected head to a low environmental temperature, such as very cold weather or diving into cold water.

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