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Dx Tension-Type Headache Treatments:

Tension-type Headaches

The Merck Manual Home Edition  states that
" A tension-type headache is usually mild to moderate pain that feels like a band tightening around the head. Pain in other parts of the head and neck may trigger these headaches. Headaches may occur several or many days each month. Doctors base the diagnosis on symptoms and results of a physical examination and sometimes do imaging tests to rule out other disorders. Pain relievers may help, as may relaxation and stress management. Many people occasionally have tension-type headaches. The cause is not well-understood but may be related to a lower-than-normal threshold for pain. Stress may be involved. However, how stress is involved is not clearly understood, and it is not the only explanation for the symptoms. Other problems may contribute to or trigger the headaches. For example, sleep disturbances, a problem with the joint of the jaw (temporomandibular joint disorder), neck pain, or eyestrain may trigger a tension-typeheadache. Symptoms Tension-type headaches feel like tightening of a band around the head, making the whole head ache. These headaches may be episodic or chronic. Episodic headaches occur fewer than 15 days a month. The pain is usually mild to moderate. It may last 30 minutes to several days. These headaches typically start several hours after waking and worsen as the day progresses. They rarely awaken people from sleep. Chronic headaches occur 15 or more days a month. Severity may increase as more headaches occur. The pain may vary in intensity throughout the day but is almost always present. Unlike migraine headaches, tension-type headaches are not accompanied by nausea and vomiting and are not made worse by physical activity, light, sounds, or odors. Some mild migraines resemble tension-type headaches.

Medications Used in Treatment
1. Barbiturate/ Acetaminophen: Fioricet®, Esgic®Plus, Fiorinal® Bupap® Dolgic®Plus
2. Barbiturates/ NSAIDs:
3. Barbiturates/ opioid/ mixed: Fioricet® with Codeine, Ascomp® with Codeine, Fiorinal® with Codeine
4. Sympathomimietic/ NSAIDs: isometheptene-dichloralphenazone-acetaminophen
5. Local anesthesia: lidocaine trigger point injections
6. Acetylcholine Release Inhibitors: Botox®,Xeomin®, Dysport®
7. Compounded flexeril 2% with
20% ketoprofen topical cream

Suggested Links:
*Video of Trigger Point Injection

Travell (JFK's physician) taught the injection of a dilute anesthetic (Xylocaine®) or saline into the multiple layers of muscles at the trigger point to diagnose tension-type headache by relieving the local muscle spasms and trapped nerves. We add a dilute corticosteroid (Kenalog® or Dexamethasone®) to the process and repeated the injections at 3, 7 and 10 days. Physical therapy is needed to improve posture, often with (1) negative heel shoes, and (2) a supportive cross-your-back bra for women. We prescribe a compounded topical muscle relaxer cream to the affected neck and shoulder muscles at bedtime and allow only one pillow. For tension-type headaches this often proves successful. BOTOX® can then be used, if the tension-type headache or muscle spasm persists having identified the proper locations. This systematic approach improves the pain relief of these whose in-office myofascial blocks temporarily relieve pain.

The same technique to trigger-point injections are used for those individuals who suffer with medication and rebound headaches. These can occur with pain medications, caffeine, sumatriptan, sedative and muscle relaxers. We use the trigger point injections to block the pain, the topical muscle relaxer for the neck spasms and chlordizaepoxide/ clidinium in low dose to manage the central symptoms.
There may be a limited but appropriate use for BOTOX®.

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