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Tension Headaches in Dentist

Tension headaches vary considerably with regard to frequency, duration, and severity.

Tension headaches may range from infrequent, short-lasting, light headache attacks to permanent, daily headaches. Episodic (< 180 days/year); chronic (> 180 days/year).

Terms Often Used (Synonyms)

Headache of the tension type, muscle contraction headache, psychogenic headache, myogenic headache, stress-related headache, ordinary headache, essential and idiopathic headache.

Duration

30 minutes to 7 days.

Appearance (Clinical)

Bilateral, oppressive, dragging, increased muscle tone; migraine-related symptoms such as nausea and dizziness are either absent or mild.

Special Forms

If a daily tension headache is present alongside a migraine headache, then it is referred to as a combination headache. In case of organic causes of tension-type headaches, it is referred to as a headache of a pattern similar to the tension type headache. In individual cases, the headache tends to be more intense on one side and can even be one-sided and change sides.

Disease Mechanism (Pathophysiology)

Causal factors are the assumed triggers for tension headaches. (e.g. a disturbance in the masticatory apparatus, psychosocial and muscular stress, anxiety, depressions, abuse of medications). Several other diseases lead to increased muscle tone of the neck/head musculature. This increased muscle tone leads to changes in the central nervous system through special “muscle sensors,” and this “neuromodulation” triggers the headache.

Epidemiology

Tension-type headaches affect women more than men in a ratio of max. 1.5:1; at the same time, the prevalence of chronic tension-type headaches goes up with increasing age for both women and men. Tension-type headaches most often begin to occur during the second decade of life, but can occur during childhood as well. Chronic tension headaches in children under 10 are rare.

Diagnosis

Diagnosis for tension headaches is based on an extensive anamnesis and on outright clinical and neurological findings. Additional examinations such as cranial computer tomography, EEG, ultrasound methods, and evoked potentials should only be used if organic causes are assumed.

The indication for a cranium MRI should be carried out by a neurologist. A psycho-physiological examination is indicated if behavioral treatment is to be initiated. An organic cause must be excluded with regard to the following symptoms:

  • A change in the previous headache symptoms
  • The occurrence of focal neurological symptoms
  • Changes in personality
  • Epileptic seizures or syncope
  • Fever and stiffness of the neck
  • Intense headache not previously experienced

 

Treatment

If a tension-type headache occurs only occasionally or is of a short duration, then analgesics may be administered when pain is subjectively intolerable.

Guidance for Patient/General Measures

A prerequisite for successful treatment is for the patient to be informed, not just about the causes of the headache, but also about effective mechanisms of various substances utilized for tension-type headaches.

This applies in particular to antidepressants. It should to be clarified that the use of antidepressants is not meant to achieve an antidepressive treatment in the narrower sense, but to influence the central pain threshold. The frequent rejection of psychotherapeutic drugs must be countered with research that shows that antidepressants do not show any addictive potential.

The duration of treatment (approximately six months) should not be omitted in the information and neither should the possibility that treatment may not be effective (no earlier than after 6 weeks), in which case a different antidepressant should be prescribed.

To backup the diagnosis and monitor the course of the illness, a headache journal should be maintained during treatment. Pain killers should only be used in case of subjectively severe pain and no more than twice a week. Within the first three months of treatment, the patient should be examined at least every four weeks. Afterwards, longer examination intervals are sufficient. After a period of about six months, the medication may be slowly faded out over a period of four to eight weeks.

If tension-type headaches reoccur, treatment should be continued for an additional 6-12 months. In such cases, lower dosages in the evening are often sufficient. If, after a year of successful treatment and discontinuation of medication, tension-type headaches reoccur, additional behavioral treatment is obligatory.

Patients suffering from tension-type headaches often have an unhealthy lifestyle, with an overly demanding daily schedule, deadlines pressures, a tendency to expect a lot from oneself, and a lack of strategies for coping with daily burdens. The excessive performance demands the patient places on himself are particularly noticeable and are characterized by irrational attitudes (e.g. I must always be successful). Besides these striking psychological features, patients often display unfavorable body postures in daily life (e.g. while working at the computer), a lack of exercise, and an unbalanced diet. Distinctly depressive features, which may also arise as a secondary result of these chronic headaches, should be clarified psychiatrically or psychotherapeutically.

Staggered circulatory training (e.g. a jogging program) is also advisable. Furthermore, a dietary consultation, which should include emphasizing regular meals and a sufficient supply of liquids, is called for. In case of sleeping disorders, it is extremely important to initiate measures to promote sleep. In case of clearly recognizable depression, the patient should works towards psychotherapeutic counseling. One particularly important aspect is detailed information and advice for the patient regarding physiological connections, lifestyle, and triggering stress factors, which could be relevant for chronic tension-type headaches.

Because pharmacotherapy is often not effective by itself in the case of chronic tension headaches, behavioral therapy (with or without a simultaneous medicinal therapy) should be initiated in such cases. The following therapeutic procedures are worth considering:

  • Stress management training
  • Progressive muscle relaxation according to Jacobson
  • EMG biofeedback
  • Cognitive techniques

So-called stress management straining aims to immunize patients against external and internal stresses and simultaneously helps the patient develop preventive strategies for coping with everyday stressful situations.

Progressive muscle relaxation aims to progressively tighten and relax various muscle areas of the body. Aside from general relaxation, so-called conditioned relaxation reactions are to be achieved in cases of tension headaches. This means that the patient is able to generate a short-term relaxation reaction in all life situations. In particular, this means working towards suggestive relaxation of the forehead and neck muscles. Patients need to learn to recognize muscular tensions early in daily life and to counter these situations. This is referred to as the principle of counter-conditioning. In stress management training, patients are confronted with specific, individual stressful situations, during which they are asked to simultaneously relax.

EMG biofeedback training aims at learning conscious control of muscle tension in the frontalis muscle and/or trapezius muscle, or temporalis muscle, in which patients receive a visual or acoustic feedback about the state of relaxation or tension of their muscles. Learning to control the muscle tone with the help of the biofeedback procedure takes place in addition to various everyday situations, such as, e.g., sitting, standing, during dynamic body movements, or in stress situations.

Since depression is one of the main guiding symptoms in patients with years of chronic headaches, treatment with behavioral therapy in accordance with Beck (cognitive behavioral therapy) should be initiated in conjunction with pharmaco-therapeutic measures. Cognitive behavioral therapy is particularly indicated in patients with an excessively performance-oriented attitude. Psycho-vegetative measures such as exercise, physiotherapy, and a possible water treatment, are also useful for a behavior-medicinal treatment.

Although acupuncture, acupressure, and transcutaneous nerve stimulation (TENS) are often applied, there has not been any convincing, statistically proven evidence thus far that demonstrates the effectiveness of these methods in tension-type headaches.

Massages and chiropractic procedures are not indicated in tension-type headaches. In general, medical, and neurological practice, behavior-medicinal measures may only be taken to a limited degree. Therefore, it is advisable to transfer the patient to a medical or non-medical behavioral therapist.

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