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Distinguishing Between Migraine
and Tension Headache |
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BY MAURY BREECHER
Contributing Writer |
SCOTTSDALE, ARIZ. (ECCC)—
Episodic tension-type headache is the most frequent, but least
distinct of the primary headache disorders in the general
population, said Dr. Robert G. Kaniecki on February 20 during a
presentation at the annual headache symposium sponsored by the
Diamond Headache Clinic Research and Education Foundation.
Dr. Kaniecki, of the Headache Center at the University of
Pittsburgh Medical Center, explained that due to extensive
symptomatic overlap with secondary headache disorders and
migraine, the diagnosis of tension-type headache first requires
exclusion of other conditions, but the headache classification
system published by the International Headache Society helps
contribute to “diagnostic inaccuracy.”
“By definition these headaches exhibit pain that is not
localized, not throbbing, not made worse with activity, and are
not severe,” he said. “Furthermore, there is neither significant
gastrointestinal distress nor considerable disability. . . yet
despite the absence of noteworthy features, tension-type
headache remains a common office diagnosis.”
The first step in reaching that diagnosis is to rule out
secondary causes (Curr Pain Headache Rep. 2005;9:423-442).
“Many secondary headache disorders may present with headaches
symptomatically compatible with the diagnosis of tension-type
headache,” warned Dr. Kaniecki. “The diagnosis of tension-type
headache first requires exclusion of organic disease and
subsequent vigilance for migraine with a ‘tension’ phenotype.”
However, the phenotypic features of tension-type headache are
nonspecific.
The headache classification system published by the
International Headache Society divides headache disorders in two
large categories, primary and secondary (Cephalalgia
2004;24[suppl. 1]:9-160). However, Dr. Kaniecki pointed out,
that the basis for identification of those categories varies.
Primary headache syndromes are defined by symptomatology,
whereas the secondary headache category is defined by etiology.
“Although extremely helpful as a resource for clinical research,
such a system results in a degree of diagnostic inaccuracy when
employed in clinical practice due largely to the fact that
primary and secondary headache symptoms often provoke similar
symptoms,” said Dr. Kaniecki. “It is not unusual for a woman
with subarachnoid hemorrhage to describe a severe headache
suggestive of migraine, or for a man with giant cell arteritis
to report discomfort which could be interpreted as tension-type
headache.”
Due to extensive symptom overlap “one feature crucial to
understand” during clinical assessment is the temporal pattern
of the headache disorder, added Dr. Kaniecki. “It is imperative
. . . to identify those with ‘new,’ ‘different,’ and
‘progressive’ headaches.”
Once identified, general and neurological exams are key
components to the clinical evaluation providing additional clues
to the potential of organic disease. Where such suspicions are
raised, further diagnostic workup might include neuroimaging of
the brain or cervical spine or cerebrospinal fluid analysis.
Either extracranial or intracranial disorders may present with
symptoms of tension-type headache. Intracranial mass lesions
presenting in such a fashion can include
primary or metastatic neoplasm, subdural hematoma, hemorrhagic
and ischemic stroke, or subacute or chronic meningitis.
According to Dr. Kaniecki, the second step in diagnosing tension
headache is to exclude migraine.
“The difficulty in distinguishing episodic tension-type headache
from migraine headache, two of the most common episodic headache
types, is widely acknowledged, said Dr. Kaniecki (Headache
2004;44:856-864; Can J Neurol Sci 1993;20(2):131-137).
“Physicians are likely to diagnosis tension-type headache when
bilateral or non-throbbing head pain is present, if the patient
reports that the headache is triggered by stress or muscle
tension, or when neck pain is present,” said Dr. Kaniecki. “In
fact, migraine is often associated with these features.”
A temporal profile of the condition is of utmost importance
since this often provides the framework for both diagnostic and
therapeutic decisions. The average monthly frequency of “total”
headache days and “severe” headache days may assist with
screening for migraine, and “total treatment days per month” for
the presence of medication-overuse headache, said Dr. Kaniecki.
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