Tension-type Headaches in Children
and Adolescents
What are tension-type headaches?
Tension-type headaches are the most common type of headache in
adolescents. They are commonly referred to as muscle contraction
headaches, stress headaches, daily headaches, or chronic non-progressive
headaches.
A tension-type headache might occur periodically (episodic,
less than 15 days per month) or chronically (daily or > 15 days
per month). The headache is described as a mild to moderate, constant
band-like pain or pressure that lasts from 30 minutes to all day in
duration. Tension-type headaches usually begin gradually, and often occur
in the middle of the day.
The "severity" of a tension-type headache might increase
significantly with its frequency. Severe tension-type headaches occur
daily or almost daily, and the pain is usually described as a throbbing
pain affecting the front, top, or sides of the head. Although the
intensity of the pain might vary throughout the day, the pain is almost
always present. It is important to realize that although tension-type
headaches come and go over a prolonged period of time and might impair
your day-to-day function, they do not cause neurological symptoms, or
affect vision, balance, or strength.
What causes tension-type headaches?
There is no single cause for tension-type headaches. This type of
headache syndrome is not usually an inherited trait that runs in families.
In some people, tension-type headaches are thought to be caused by or
result in tightened muscles in the back of the neck and scalp. This muscle
tension might be caused by (1) inadequate rest, (2) poor posture, or (3)
emotional or mental stress, including depression. This stress might be
known (overt) or unknown (covert) to the patient and his or her parents.
The most common sources of stress in children and adolescents include
school, family, and friends or peers. Examples of stressors (not in any
particular order) include:
- Not getting enough sleep
- Being on the honor role or a straight-A student
- Having problems at home/difficult family life
- Going to a new school
- Having overly permissive or overly strict parents
- Having a substitute or strict teacher
- Having a new brother or sister
- Being a "teacher's pet"
- Having no close friends
- Preparing for school tests or exams
- Learning to drive
- Joining too many extra-curricular activities
- Starting a new part-time job
- Going on a field trip or vacation
- Being overweight
- Having other children make fun of you
- Competing in sports or other activities
- Learning difficulties
Having the adolescent seen by a headache specialist might be helpful,
particularly when the cause of tension-type headaches is difficult to
identify. Once the evaluation is completed, it is important to reassure
the patient that the headache pain they are experiencing is NOT likely to
be a brain tumor.
What are the symptoms of tension-type headaches?
Patients with tension-type headaches commonly report these symptoms:
- Constant or episodic, mild-to-moderate head pain
- Headache upon awakening
- General muscle aches
- Difficulty falling asleep and staying asleep
- Chronic fatigue
- Irritability
- Disturbed concentration
- Mild sensitivity to light or noise
- Occasional dizziness
- Occasional nausea
The presence of an aura (physical warning sign), significant
sensitivity to light or noise, nausea, and vomiting are not
symptoms associated with this type of headache syndrome. Often, the pain
associated with a tension-type headache is difficult for the patient to
describe. There are no associated neurological symptoms (for
example, balance or visual disturbances) in patients with tension-type
headaches.
How common are tension-type headaches?
Tension-type headaches affect 15 percent to 20 percent of adolescents
and a lower percentage of younger children. The percent of adults who
suffer with occasional tension-type headaches ranges from 30 percent to
about 80 percent. Women are twice as likely to suffer from tension-type
headaches as are men.
Most people with episodic tension-type headaches have them no more than
once or twice a month, but the headaches can occur more frequently.
Chronic tension-type headaches tend to be more common in females and in
students who are "high achievers." Many patients with chronic
tension-type headaches have already had the headaches for more than 60 to
90 days when evaluated, and many have missed an excessive amount of
school.
Nearly 60 percent of people with tension-type headaches report that
their daily activities are impaired because of the headaches.
Chronic tension-type headaches might co-exist in adolescents and
children who already have a history of migraines. These are called mixed
headaches.
How are tension-type headaches diagnosed?
The correct headache diagnosis is needed to develop an effective
treatment plan. The most important aspect of the headache evaluation is
the headache history, which should be obtained from both the child and his
or her parents.
The history includes asking patients to describe how they feel with the
headache, what happens when a headache occurs, the frequency and duration
of the headaches, and any associated symptoms experienced. A description
of previous and current medicines taken to treat the headaches is also an
important part of the headache evaluation. The results of any previously
conducted studies or tests should be brought with you to the headache
evaluation.
After completing the medical history part of the evaluation, your
doctor will perform physical and neurological examinations. Usually, the
results of these examinations are normal for people with tension-type
headaches.
An interview with a psychologist is commonly a part of the headache
evaluation. The psychologist usually meets with the child and the parents
together, and then with them separately for structured interviews. The
parents are typically asked to complete computerized questionnaires in
order to provide more in-depth information. Usually, no severe problems
are discovered, but stress factors are often identified.
After evaluating the results of the headache history, physical
examination, neurological and psychological examinations, your doctor
should be able to determine what type of headache you have, whether or not
a serious problem is present, and if additional tests are needed. Often,
no additional blood tests or X-rays are needed.
How are tension-type headaches treated?
Tension-type headaches are treated using several drug and non-drug
strategies. Among the non-drug strategies are lifestyle changes (sleep,
dietary changes), physical therapy, stress management/relaxation training,
and counseling. Regardless of the treatment, tension-type headaches are
best treated before the headaches become more frequent and painful —
that is, when the symptoms first begin and are mild.
Stress management/relaxation training and counseling
Both episodic and chronic tension-type headaches can be improved using
stress management and relaxation training. This is an essential part of
managing these types of headaches.
Recognizing and treating the underlying stress and tension that are
causing the headaches is very helpful. Often, however, patients forget
what stressful events initiated their headaches. Counseling helps patients
identify their headache triggers and learn useful coping methods.
Relaxation techniques include deep breathing exercises, progressive
muscle relaxation, mental imagery relaxation, or relaxation to music. Ask
your doctor for more information about these techniques.
Biofeedback is another method of learning how to manage stress. During
biofeedback, a series of sensors are connected to your body. The sensors
detect changes in physical functions, such as muscle tension, blood
pressure, heart rate, and skin temperature, and provide immediate feedback
through a tone displayed on a computer screen. Biofeedback helps you
recognize that your body is tense, identify the things that make it tense,
and learn ways to reduce the tension. Biofeedback usually requires several
sessions with a skilled biofeedback therapist.
If you miss more than five days of school per term, your counselor will
need to work with you and your parents to develop a plan so that you can
make up missed school work and ensure a smooth transition back to school.
Continued excessive school absence is an impediment to recovery.
Medicines
For occasional symptomatic relief of infrequent tension-type
headaches, over-the-counter (non-prescription) medicines are recommended.
Ask the advice of your doctor or pharmacist about the use of acetaminophen
(Tylenol), ibuprofen (Advil or Motrin), or naproxen sodium (Aleve). The
use of aspirin in children under age 14 is not recommended because of
aspirin's link with Reye's syndrome. Also, avoid compounds that contain
caffeine.
For relief of chronic tension-type headaches, daily preventive
medicines might be prescribed. These medicines — which are aimed at
reducing both the frequency and severity of the headaches — might
include antidepressants, such as amitriptyline hydrochloride (Elavil), and
non-steroidal anti-inflammatory medicines (NSAIDs), such as naproxen
sodium (Aleve). These medicines are not habit-forming.
Benzodiazepines, butalbital combinations, and narcotics (Codeine)
should be avoided because these medicines could become habit-forming or
addictive. Overuse of these medicines or the daily use of
pain-relieving medicines can cause analgesic rebound headaches, described
below.
Medicine overuse can increase headaches
An extremely important factor contributing to the development of
chronic daily headaches is the overuse of pain medicines. Medicine overuse
is most likely to occur in patients with chronic tension-type headaches.
Medicines associated with analgesic rebound headaches include
acetaminophen, ibuprofen, NSAIDs, triptans, ergotamine preparations,
butalbital combination analgesics, opiates, and combination analgesics
containing caffeine. Effective treatment of headaches associated with
medicine overuse requires withdrawal from the medicines causing the
rebound headaches. Rebound headaches might not go away for weeks after the
medicines are discontinued.
Treating tension-type headaches without medicines
Although medicines are helpful, it is important to learn other
headache treatment methods. Here are some suggestions:
- Apply an ice pack to the painful area of your head. Firmly
position it on your forehead, temples, or the back of your neck. (For
example, first place a thin cloth on your forehead, followed by the
ice pack, then finally secure it in place with a headband.)
- Take a warm bath or shower; take a nap; or take a walk.
- Ask someone to rub your neck and back, or treat yourself to a
massage.
- Apply gentle, steady rotating pressure to the painful area of your
head with your index finger and/or thumb. Maintain pressure for seven
to 15 seconds, then release. Repeat as needed.
- Rest, sit, or lie quietly in a low-lit room. Close your eyes and try
to release the tension in your back, neck, and shoulders.
- For patients who have excessive muscle contractions in the neck,
physical therapy exercises performed daily are often helpful.
How can I help reduce or prevent headaches?
- Follow your treatment plan — Avoid taking medicines that
have not been ordered by your doctor. Do not overuse over-the-counter
medicines.
- Reduce emotional stress — Take time to relax and take time
away from stressful situations. Learn relaxation skills, such as deep
breathing and progressive muscle relaxation.
- Reduce physical stress — Proper rest and sleep will allow
you to deeply relax so you can face the stressors of the new day. When
sitting for prolonged periods, get up and stretch periodically. Relax
your jaw, neck, and shoulders.
- Exercise regularly — Get at least 20 minutes of exercise
three times a week.
- Talk to a friend, family member, religious professional, or
health care professional — This can help if your problems
are getting to you.
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