|Tension headaches have
historically proved frustrating to both physicians and patients. The
pathophysiology is poorly understood. Just about everything under the
sun has been blamed for the chronicity of these headaches including
caffeine, OTC drug withdrawals, etc. Without a specific etiology in
mind, they have traditionally been treated with analgesics and muscle
relaxants. The unfortunate result of this habit is that many patients
become dependent upon their Fioricets and Vicodens while the headaches
persist unabated. We then wonder why we see so much drug-seeking
behavior in our urgent cares and office practices.
As a physician with an extremely busy occupational
practice, I see an average of five "tension headaches" a day.
I would like to suggest a simpler and more effective approach to this
First, I would suggest tension headaches appear to
be, in actuality, occipital headaches, i.e. they are mechanical in
nature. In other words, the occipitoatlantal (OA) joint on one or both
sides develops a restriction that results in local effects that may
include increased muscle tension in the affected occipital triangle, and
irritation of the greater occipital nerve. Irritation of the greater
occipital nerve radiates its discomforts around the side of the skull,
often reaching the orbital region. In short, the regions typically
attributed to muscle tension headaches (occipital neuralgia).
The headaches may be mild and described as a band
around the head, or they may be as severe as migraines and associated
with nausea and non-vertigo type dizziness with head movement (reflexes
induced by nerve pain). In fact, I see many patients whom have been
misdiagnosed as suffering from migraines because the term was used
merely to describe a very severe headache, rather than because of the
underlying pathophysiology. (This is one reason why chiropractors often
advertise that they can cure migraines - because the headache is, in
reality, not a migraine, but of occipital origin.)
These headaches are usually the result of a
chronic awkward static posture, although they may also develop acutely
(e.g. a plumber working under a sink with his neck bent to one side).
One common example is the individual who constantly secures a telephone
receiver tucked under their chin while working, rather than using a
headset device. This non-neutral posture of the head tilted on the neck
can induce the OA joint on one side to lock (which is why these usually
are unilateral), resulting in headache symptoms a few hours later.
Patients whose computer monitors sit either too high or too low may also
develop restrictions in the OA regions leading to chronic problems
(often bilaterally). As neither of these acts are likely to cause
discomforts at the time of the activity, most patients are not likely to
attribute them as the source of their problems. The offending postures
may be as benign as a habit of reading in bed at night with the head
maintained in an awkward position by a pillow. These patients may awaken
in the mornings with these headaches.
Ignorance of our patients' daily activities and
poor ergonomics is probably the most likely reason for their chronicity.
Rather than blaming the syndrome on withdrawals from caffeine or the OTC
product de jour, physicians need to inquire about their patients'
postural habits. We are creatures of habit i.e. we tend to perform the
same tasks in the same manner day after day. This is why many of these
If no one suggests using a headset, they will
continue to engage in this poor ergonomic behavior and the condition
will persist - no matter what medications are thrown at the patient.
Analgesics won't unlock the affected joint, but will sedate the patient
until it eventually unlocks itself within a matter of a few days. The
typical worker cannot afford to be sedated, however, hence it's best to
recognize the condition for what it is - a mechanical one- and then to
treat it appropriately.
So how should a physician approach these patients?
Begin by taking a good history and be sure to include questions dealing
with their employment and hobbies (do they spend hours of time knitting
or at a home computer?). Ask specifics regarding their job and home
postures. If they provide a long history of severe headaches that fail
to respond to the "triptans," a mechanical source for the
headache should be considered.
During the physical examination, in addition to
the standard neurological examination, be sure to palpate the OA regions
and check their motion, even if the patient doesn't describe the
headache as affecting them. You'd be surprised how often you can
reproduce their symptoms when you palpate a tender, restricted OA joint.
If they experience sensations of wooziness with head movement, this also
is suggestive of occipital cephalgia.
There are no specific laboratory or radiographic
studies that will identify occipital cephalgia. However, if faced with a
patient with severe unilateral headaches, perhaps associated with jaw
claudication, temporal arteritis should be ruled out.
Treatment of the acute headache involves
"unlocking" of the restricted OA joints. As long as the nerve
is irritated, it will continue to hurt. There is no medication that we
can prescribe that will directly unlock the joint(s). The natural course
of the headache is that it usually unlocks itself, generally reducing
the restriction while turning in the midst of sleep-induced relaxation.
This may take days, however. Therefore, the fastest way to reduce the
restriction is through gentle mobilization such as is incorporated as
part of Osteopathic manipulative therapy, or via a chiropractor. These
headaches usually resolve within an hour or so after reduction, hence
there is often no necessity to prescribe a narcotic.
If the OA region is so tight/locked that it cannot
be reduced at the time, an injection of a local anesthetic into the OA
joint region can provide some temporary relief of pain and perhaps
permit enough local muscle relaxation in order to accomplish a
successful mobilization. I follow my mobilizations with the application
of a cold pack applied to the affected occipital region. In the rare
instance where the joint cannot be successfully mobilized in the office,
the use of analgesic/sedating medications is appropriate to comfort the
patient and may help the region to relax enough to in order to reduce on
it's own. Do not get into the habit of prescribing large quantities of
narcotic analgesics for these patients!
The best treatment in the long run, of course, is
prevention. This is where ergonomics come
in handy. Obtaining the telephone headset, raising the computer video
display monitor to an appropriate height, or giving up reading in bed,
may be all that's required to permanently cure this chronic and
Jeffrey Pearson, D.O.
San Marcos, CA
In addition to his private family and industrial
practice, Dr. Pearson works with The Zenith Insurance Company (Workers
Compensation). He sits on the Patient Care Board of Editors.