Tension headache is, perhaps, an unfortunate choice of terms because it implies that tension in the patient’s life is at the root of the headache. Although stress and tension are important contributing factors toward daily headaches, they do not, by themselves, cause daily headaches. There needs to be a predisposition toward headache. The vast majority of patients with daily headaches also experience episodic migraine headaches.

There are two types of tension headache: episodic tension headache and chronic tension headache (chronic daily headache). CDH (headache at least 15 days per month) is seen in about 4% of the population.  The “as needed” abortive medications are essentially the same for the two types.  When chronic daily headache (CDH) is more than mild, the preventive medication approach becomes very important.  It is possible that tension-type headaches have an underlying pathophysiology similar to migraine, and we are simply observing different parts of a spectrum.  It is clear that people are predisposed to these headaches, and the headaches are not simply a “psychological” problem.  Although stress does affect tension headaches, just as stress affects most illnesses, it is unfair to tension headache sufferers to attribute their headaches to stress or psychological problems.  Stress management and/or relaxation techniques should be introduced to these patients.

When patients require more than minimal amounts of daily abortive medication, we need to consider a prevention approach for the headaches.  By continually using drugs containing aspirin and caffeine, or similar compounds, many patients increase their headaches by creating a rebound headache situation.  The amount of daily analgesics that creates a rebound headache situation varies from person to person; with some patients, only two pills of aspirin and caffeine per day lead to a more severe headache the next day.

Criteria for the Use of Prevention Medication:

1.  The frequency and severity of the tension headaches significantly decreases the patient’s quality of life.

2.  The patient is willing to take daily medication, endure possible side effects, and change the medication, if necessary.

3.  Abortive medications have not provided sufficient relief in small to moderate amounts, or the patient overuses analgesics because of the pain.

If the headaches cannot be “ignored”, and are moderate to severe, it is usually best to utilize daily preventive medication.  The decision as to which daily medication to use depends upon many factors, such as the presence, and frequency of coexisting migraine, whether the patient sleeps well, presence of anxiety/depression, the presence of gastritis, etc.  Patients need to be aware of the possibility that the first preventive medication chosen may not be effective, and that we often need to try several preventives before achieving the goal of improving the pain with a minimum of side effects.  Realistic goals need to be set prior to initiating preventive medication;  I usually tell the patient that we are attempting to improve the headache situation 50% to 90%, while attempting to minimize medicine.  We wish to achieve a compromise between the headaches and medication and not overmedicate the person.  Most of the medications for headache have not received specific FDA indications for this use.  Prior to prescribing medications for patients, they need to be informed of, and accept, the complete set of contraindications and side effects as listed in PDR and package insert.


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