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An Alternative Approach to Tension Headaches

[The following letter was published in Patient Care magazine, in response to a previously published article on headaches.]
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 condition.

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 headaches recur.

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 frustrating condition.

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.

Additional comments (10/3/02):

- One shouldn't assume that all post-traumatic headaches are due to cerebral concussions. In my practice, occipital neuralgia/cephalgia is often seen following head trauma due to falls, football tackles, etc.  Of course, brain injury needs to be ruled out, but gentle reduction of the restricted O-A joints often resolves these severe headaches quite quickly and without the need for strong pain meds.

- Occipital neuralgia does not have to be associated with headache. In fact, it's not uncommon for us to see patients who present with sensations of feeling whoozy/dizzy (not vertigo) with neck/head movements that involve the O-A joints. Reducing the restriction often makes the patient feel better very soon afterwards.

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