Learning Objectives
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Learn the common types of headache.
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Understand the difference between primary and secondary headaches.
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Develop an understanding of clinical presentation of specific headache types.
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Develop an understanding of the treatment of specific headache types.
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Develop an understanding of the differential diagnosis of headache.
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Learn how to identify factors that cause concern.
Abby Austin
Abby said that most days she had headaches, and that while they never kept her from going to work, she just felt worn out from them. “Doctor, my sleep is really messed up. I keep waking up around 4 AM with a headache brewing and I just can’t get back to sleep. I go ahead and get up, but by the end of the day, I feel pretty rough.”
I asked Abby how long she suffered from headaches and she said, “I’ve had headaches about as long as I can remember. My mom always had headaches, and I can remember her making my brother and me go outside and play because we were making her headache worse.” Abby denied any nausea, vomiting, or other neurologic symptoms associated with her headaches. She said, “By the end of the day, the brightness of my computer monitor seems to aggravate the headache, and I really just want my boss to shut up, but other than the tightness around my head and neck ache, I don’t have any other symptoms with my headaches.”
I asked Abby if she had identified anything that triggered her headache and she immediately answered, “My boss. I just can’t take the stress anymore.” I asked Abby if she knew whether she was going to get a headache before the headache actually started, and she said, “Not really.” She continued, “Often I wake up with a headache in the making, but it is just there. There are not really any warning signs.” I asked about her neck and she said, “By the end of the day, I just want someone to give me a neck massage. I thought it was my pillow, so I bought a MyPillow, and it only made it worse. I feel like the neck and headaches are one and the same.”
I asked her what made it better and she said, “I’ve tried all of the usual over-the-counter medications like Excedrin Migraine and Advil, but they really upset my stomach, so I can’t take them very often. A heating pad and a neck massage seems to help a little.”
I asked Abby to use one finger to point at the spot where it hurt the most, and she pointed to both her temples and then started rubbing her neck. I asked her what the pain was like: an ache, sharp, stabbing, burning. She immediately said, “It’s like my head is being squeezed in a vise. No throbbing, just a squeezing, achy feeling.” I asked whether the headache was on both sides or just one side, and she said it was always on both sides and in her neck. I asked Abby from the time that she knew she was going to get the headache until the time it was at its worst, whether it was a period of seconds, minutes, or hours. She said, “It is always at least hours to a day before it is at its worst.”
I asked Abby if I could examine her and she said, “That’s why I’m here. I just have to get rid of these headaches.” On physical examination, Abby was afebrile. Her respirations were 16 and her pulse was 78 and regular. Her blood pressure was 126/80. There were no cranial abnormalities and her head, eyes, ears, nose, throat (HEENT) examination was completely normal, as was her fundoscopic examination. Her cervical paraspinous muscles were tender to deep palpation, but no myofascial trigger points were identified. Her cardiopulmonary examination was normal, as was her thyroid. Her abdominal examination revealed no abnormal mass or organomegaly, and no rebound tenderness was present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and her deep tendon reflexes were normal. Abby’s mental status exam was within normal limits.
Key Clinical Points—What’s Important and What’s Not
The History
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Episodic headaches entire adult life
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Headaches are bilateral
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Headaches are bitemporal with bandlike tightness
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Headaches are associated with nuchal pain
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Character of pain of the headaches is aching in nature, without throbbing
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No prodrome or aura
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Significant sleep disturbance
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No fever or chills
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Patient denies significant nausea and vomiting associated with the headache
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Minimal disability associated with headaches
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Headaches associated with work stress
The Physical Examination
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Patient is afebrile
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Normal fundoscopic exam
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Examination of the cranium is normal
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Neurologic exam is normal
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Tenderness of the paraspinous muscles without myofascial trigger points
Other Findings Of Note
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
What Tests Would You Like to Order?
The following test was ordered:
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Magnetic resonance imaging (MRI) of the brain
Test Results
The MRI of the brain was normal.
Clinical Correlation—Putting It All Together
What is the diagnosis?
Tension-type headache
The Science Behind the Diagnosis
Clinical Syndrome
Tension-type headache, formerly known as muscle contraction headache, is the most common type of headache that afflicts humankind. It can be episodic or chronic, and it may or may not be related to muscle contraction. Significant sleep disturbance usually occurs. Patients with tension-type headache are often characterized as having multiple unresolved conflicts surrounding work, marriage, and social relationships, and psychosexual difficulties. Testing with the Minnesota Multiphasic Personality Inventory in large groups of patients with tension-type headache revealed not only borderline depression but somatization as well. Most researchers believe that this somatization takes the form of abnormal muscle contraction in some patients; in others, it results in simple headache.
Signs and Symptoms
Tension-type headache is usually bilateral, but it can be unilateral; it often involves the frontotemporal, and occipital regions ( Fig. 3.1 ). It may present as a bandlike, nonpulsatile ache or tightness in the aforementioned anatomic areas ( Fig. 3.2 ). Associated neck symptoms are common. Tension-type headache evolves over a period of hours or days and then tends to remain constant, without progression. It has no associated aura, but significant sleep disturbance is usually present. This disturbance may manifest as difficulty falling asleep, frequent awakening at night, or early awakening. These headaches most frequently occur between 4 and 8 AM and 4 and 8 PM. Although both sexes are affected, female patients predominate. No hereditary pattern to tension-type headache is found, but this type of headache may occur in family clusters because children mimic and learn the pain behavior of their parents.
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