NON-MIGRAINE HEADACHES

Tension-Type, Chronic Daily, and Drug-Induced Headache

Introduction

From Saunders Manual of Neurologic Practice; by Randolph W. Evans, MD, advisor to MAGNUM. The purpose of this section is to supply our members with the latest medical information regarding other Non-Migraine Headaches. Although MAGNUM keeps its focus on Migraine disease, but Tension-Type, Chronic Daily Headaches, and Drug-Induced Headaches can exist as a co-morbid condition(s). MAGNUM is also concerned with ALL headache disorders as well as pain public health issues.

This section is written for doctors, but will give a better understanding to sufferers and laypersons as well. In addition, it may help many to formulate questions to take to their physicians at their next visit to the doctorﾕs office. To our members in the medical community, we hope this section addresses some of your questions regarding Tension-Type, Chronic Daily Headaches, and Drug-Induced Headaches.

Excerpt from Evans RW, Saunders Manual of Neurologic Practice, Elsevier Science, Phildelphia, 2003, with permission.

To purchase this book directly from the publishers click here or visit: http://lww.com/cgi-bin/wwonline.storefront to view other selections available direct from this publisher. NOTE: This book is a 2003 release!

TENSION-TYPE HEADACHE

1. Epidemiology and Risk Factors
   1. The one year prevalence has been variably reported from 30%-90%
   2. The lifetime prevalence is 78% with 63% males and 86% females
   3. Male to female ratio about 1:1.3
   4. Prevalence peaks in the fourth decade
2. Etiology and pathophysiology
   1. Multifactorial and poorly understood
   2. Can arise from sustained contraction of pericranial muscles (muscle contraction headache)

1. However there is no correlation between muscle contraction, tenderness, and the presence of headache
2. There may be as much or more muscle contraction in those with migraine as in those with tension-type headache

3. May be referred from upper cervical structures (joints, ligaments, and muscles)
4. May be due to abnormal neuronal sensitivity and pain facilitation

1. Prolonged pain input from the periphery may cause central sensitization in the trigeminal nucleus caudalis neurons

5. May be triggered by physical or psychological stress, lack of sleep, anxiety, and depression
6. Tension-type headache in migraineurs may be different than in non-migraineurs

1. May respond to triptans in migraineurs
2. May have typical migraine triggers
3. Light or noise sensitivity more likely to accompany

3. Clinical features
   1. Episodic tension-type headache

1. International Headache Society (IHS) Criteria

1. At least ten previous headache episodes fulfilling the criteria. Number of days with the headache less than 180/year or 15/month..
2. Headache lasting from 30 minutes to 7 days
3. At least two of the following pain characteristics

1. Pressing/tightening (non-pulsating quality)
2. Mild or moderate severity
3. Bilateral location
4. No aggravation by walking stairs or similar routine physical activity

4. Both of the following

1. No nausea or vomiting (anorexia may occur)
2. Photophobia and phonophobia are absent, one but not the other is present

2. Character of pain

1. Variably described as pressure, soreness, tightness, a band or cap on the head, or weight on the head.
2. Occasionally pulsating during severe pain episodes

3. Location

1. 90% bilateral
2. Can be unilateral in the presence of trigger points or oromandibular dysfunction

Chronic tension-type headache

1. IHS criteria

1. Average headache frequency is more than 15 days/month or 180 days/year for 6 months.
2. The same pain characteristics as for episodic tension-type
3. Both of the following

1. No vomiting
2. No more than one of the following: nausea, photophobia or phonophobia

4. Some patients may have continuous headaches for years

3. Differential Diagnosis
   1. Secondary causes of headache should be excluded as appropriate (see Chapter Headaches in Section 1
   2. Medication rebound can cause frequent headaches 
4. Treatment
   1. Acute headaches may respond to aspirin, acetaminophen, or combinations with caffeine; NSAIDs; isometheptene combinations; butalbital combinations; and muscle relaxants.

1. Overuse may lead to rebound headaches.
2. Frequent butalbital use can also result in dependency

2. Frequent headache may require preventative medications

1. Tricyclic medications are generally more effective than SSRIs
2. Other migraine preventatives (see chapter migraine) may be helpful especially when tension-type and migraine are both present
3. Tizanidine

1. An a₂-adrenergic agonist that inhibits the release and effectiveness of norepinephrine at both central sites (eg, the locus ceruleus) and the spinal cord. It acts as a central muscle relaxant and has antinociceptive effects.
2. The most commonly reported adverse events include dry mouth, drowsiness, and dizziness. Less common side effects include asthenia, hypotension, elevated liver enzymes (reversible on drug discontinuation), nausea, speech difficulties, and dyskinesia.
3. Baseline and periodic aminotransferase monitoring is recommended.
4. Can start with 2 mg at bedtime and titrate upward to the maximum tolerated dose or a maximum daily dose of 18 mg, divided over three dose intervals per day, depending upon response.
5. May be beneficial for chronic tension-type and chronic daily headaches.

CHRONIC DAILY HEADACHE (CDH)

1. Definition
   1. Headache 15 or more days per months
   2. Includes different headache types

1. Transformed migraine (chronic migraine) with or without medication overuse

1. Previous history of intermittent migraine usually by age 20-30
2. In 80%, gradual transformation from episodic to CDH which may be associated with analgesic overuse and psychological factors (depression, anxiety, abnormal personality profile, and home or work stress).
3. In 20%, sudden transformation which may be triggered by head or neck trauma, flulike illness, aseptic meningitis, and operations, and medical illnesses.
4. Migraine characteristics to a significant degree intermittently or continuously

2. Chronic tension-type headache with or without medication overuse
3. Hemicrania continua with or without medication overuse

1. Rare entity with constant, unilateral pain of variable intensity.
2. Painful exacerbations associated with ptosis, lacrimation, and nasal stuffiness.
3. Responds dramatically to indomethacin.

4. New daily persistent headache with or without medication overuse

1. Fairly rapid onset of a daily persistent headache without a prior history of increasingly frequent migraine or tension-type headache.
2. Probably heterogenous disorder of uncertain cause. Some cases may be triggered by a viral infection.

2. Epidemiology
   2. In adults, about 3% of males and 5% of females. About 1% of adolescents.
   3. More than 50% with chronic tension-type headache and about 35% with transformed migraine
   4. 0.5% of the population has chronic severe daily headache 
3. Differential Diagnosis
   3. Rule out secondary causes of headache as appropriate (See chapter headache in section 1)
   4. Consider contribution of medication rebound
   5. Occasionally, pseudotumor cerebri can present with headaches without papilledema
4. Treatment

1. Taper medications which may be causing rebound (see below)
2. The headaches may get worse before improving which may not occur before three to six weeks
3. For outpatients, headaches may lessen with the transitional use of a tapering dose of prednisone (60 mg for 2 days, 40 mg for 2 days, and 20 mg for 2 days) for 6 days or the combination of tizanidine and a long-acting NSAID

1. Acute medications

1. Longer-acting NSAID (e.g. naproxen sodium), baclofen, tizanidine, and hydroxyzine 50 mg po tid prn which are not associated with rebound.
2. May use acute migraine agents as appropriate but limit to 2-3 days per week. Dihydroergotamine has little potential for causing rebound but frequent use of triptans can.

2. Preventative medications

1. Same as with chronic tension-type headaches as above. Consider use of tricyclics, SSRI, divalproex, topirimate, beta-blockers, etc (see chapter migraine).
2. Start at a low dose and gradually increase until the drug is effective or until side effects or the ceiling dose for the medication has been reached.
3. Have the patient keep a headache diary so efficacy can be monitored
4. Combination therapy may be helpful in some cases.
5. The effect of treatment may not be apparent for weeks.
6. Treatment may not be effective until rebound is eliminated.

5. Inpatient treatment

1. May be indicated if outpatient therapy fails, for detoxification, or if there is significant medical or psychiatric co-morbidity.
2. Medication detoxification

1. Tapering of narcotics preferable but abrupt withdrawal can be done with close supervision

3. Clonidine patch or 0.1 to 0.3 mg orally two or three times daily may reduce symptoms of opioid withdrawal

1. Abruptly stopping butalbital, a short acting barbiturate, may trigger withdrawal which can include apprehension, muscle weakness, tremors, dizziness, twitches, seizures, psychosis, and delirium.

1. Seizures usually occur on the second or third day of withdrawal but can occur up to the eighth day
2. To avoid withdrawal reaction, can substitute a long-acting barbiturate, phenobarbital at 30 mg three times daily for the first 2 days and then 30 mg daily for the next 2 days.

4. Intravenous dihydroergotamine (DHE) regimen (as described in chapter migraine)
5. DHE regimen may be combined as appropriate with other medications such as NSAIDs, oral or intravenous corticosteroids, intravenous prochlorperazine, and intravenous valproate sodium (as described in chapter migraine). One or more of these other treatments can be used in those who can not tolerate or have a contraindication to DHE.
6. Behavioral therapy and psychologic and psychiatric referral, as appropriate, may be beneficial.
7. Physical therapy may be useful if there is a myofascial contribution to the headaches.
8. Trigger point injections and occipital nerve blocks may be worthwhile in some cases.
9. Patient education

6. Prognosis
   1. Even with optimal therapy, about one third of those who improve will have return of their daily headache and medication overuse pattern.
   2. Regular follow-up is important
   3. There is a minority of patients with intractable CDH resistant to current treatments.

DRUG-INDUCED HEADACHE

1. Acute drug-induced headache

1. Many drugs can cause including

1. Nitroglycerin, antihypertensives (beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors, and methyldopa), dipyridamole, hydralazine, sildenafinil
2. Histamine receptor antagonists (such as cimetidine and ranitidine)
3. NSAIDs especially indomethacin
4. Cyclosporine, amphotericin, griseofulvin, tetracycline, and sulfonamides.

2. Drug-induced aseptic meningitis

1. Numerous causes

1. NSAIDs
2. Antibiotics (trimethoprim/sulfamethoxazole, sulfasalazine, cephalosporins, ciprofloxacin, isoniazide, and penicillin
3. Intrathecal drugs and diagnostics (antineoplastics such as methotrexate and cytarabine; gentamicin; corticosteroids; spinal anesthesia; baclofen; repeated iophendylate for myelography; and radiolabelled albumin)
4. Intraventricular chemotherapy
5. Intravenous immunoglobulin
6. Vaccines (polio;measles, mumps, and rubella; and hepatitis B)
7. Other drugs such as carbamazepine, muromonab CD-3, and ranitidine

2. Clinical presentation is the same as that of viral meningitis
3. CSF findings are similar to viral meningitis except for neutrophil predominance in most cases

1. Intravenous immunoglobulin is an exception with eosinophils in the CSF

4. The prognosis is generally good with discontinuation of the causative agent

3. Chronic drug-induced headache

1. Definition

1. Also called analgesic, drug, medication abuse, misuse, or rebound headache
2. Rebound headache

1. Frequent use of some immediate-relief medications can result in recurring or persistent headache in those with pre-existing headache and an individual susceptibility
2. The actual dose limits and time needed to develop rebound headaches have not been defined in rigorous studies
3. The best evidence is from a study of short-term caffeine withdrawal

1. Adults with a low-moderate daily caffeine intake of an equivalent of about 2.5 cups of coffee (mean of 235 mg) per day
2. Upon withdrawal of caffeine, 50% had a headache by day 2
3. Nausea, depression, and flu-like symptoms are common with withdrawal

4. In patients with frequent headaches, routinely obtain a history of caffeine use in over the counter and prescription medications as well as beverages and ice cream. Some examples

1. 12 ounces of Coca-Cola contains 45 mg
2. 8 ounces of brewed coffee contains 135 mg
3. A Fiorinal tablet 40 mg and 2 Excedrin Migraine tablets 130 mg

5. Overuse is related to the frequency of use and total consumption such as the following

1. Three or more simple analgesics (aspirin and/ or acetaminophen) a day (more than 1000 mg) more often than 5 days a week. Frequent use of short-acting NSAIDs such as ibuprofen can also be a cause.
2. Combination analgesics containing barbiturates (more than 3 tablets per day) or benzodiazepines more often than three times a week
3. Narcotics (more than one tablet per day) or ergotamine (1 mg orally or 0.5 mg rectally) more often than twice a week
4. Triptans may also induce rebound

2. Epidemiology and risk factors

1. Prevalence perhaps 1% of migraineurs and 0.5% of those with chronic tension-type headache
2. Persons with migraine and tension-type headache are especially susceptible to drug-induced headache.
3. Most patients with chronic headache overuse symptomatic medications

3. Pathophysiology

1. Not known
2. Some hypotheses

1. Central sensitization
2. Peripheral sensitization with alternation of nerve terminal sensitivity
3. Increased activity of the on-cells in the brainstem’s pain modulation system
4. Kindling
5. Depletion of 5-HT and upregulation of its postsynaptic receptors

4. Clinical features

1. The headaches are refractory, daily, or near daily
2. The headaches occur in those with a primary headache disorder who use immediate-relief medications frequently often in excessive quantities
3. The headache can vary in severity, type, and location
4. The threshold for headache is low
5. Headaches may be accompanied by asthenia, nausea, restlessness, anxiety, irritability, memory problems, difficulty with concentration, and depression.
6. A drug-dependent rhythmicity may be present with frequent early morning headaches (e.g. 2 AM to 5 AM)
7. Tolerance may develop over time so increasing doses are taken
8. Habituation and dependence (the psychological and physical need to repeatedly use drugs) may develop especially with butalbital, opiates, and caffeine

1. Beware of the warning behaviors of substance abuse and misuse (I) Unauthorized dose escalations

1. Frequent phone calls especially on weekends and after hours for more medication
2. Doctor shopping or obtaining medications from multiple physicians and emergency rooms
3. Reporting medications as lost, ruined, stolen, or left behind when out of town (e.g. stolen purses and ingestion by household pets)
4. Frequent office visits for medications
5. Resistance or unwillingness to reduce medications or use alternatives symptomatic and preventative medications (e.g. this is the only drug that works or I am allergic or have side effects to those other drugs)
6. Refusal to sign release to obtain information from other physicians or failure to disclose the names of prior or concurrent physicians

2. Withdrawal symptoms occur when the medications are abruptly stopped
3. Spontaneous improvement of headache occurs on discontinuing the medications
4. Preventative headache medications may not be effective until the symptomatic medications are tapered off

5. Treatment (see above under CDH)
6. Prognosis and complications

1. Withdrawal therapy can result in a 50% or greater improvement in headache frequency in about 70%
2. The relapse rate is about 40%
3. Frequent drug use can lead to a variety of complications including peptic ulcer disease (with NSAIDs and aspirin) and analgesic nephropathy.

7. Prevention

1. Try to limit symptomatic medication use which can cause headaches to 10 events or 24 tablets or capsules per month and limit use to # 2 days/week. Individual susceptibility to rebound is variable.
2. Limit or avoid caffeine ingestion in those susceptible to caffeine withdrawal headaches

REFERENCES

Evans RW, Mathew NT. Handbook of Headache. Philadelphia, Lippincott-Williams&Wilkins, 2000

Olesen J, Tfelt-Hansen P, Welch KMA. The Headaches. Second Edition. Philadelphia, Lippincott-Williams&Wilkins, 2000

Silberstein SD, Lipton RB, Dalessio DJ. Wolff’s Headache and Other Head Pain, Seventh Edition. New York, Oxford University Press, 2001