So You Have Tension-Kind Headache – How Do You Really feel About This Diagnosis?
It was probably virtually a throw away line and immediately dismissed as absolutely nothing to worry about – just get on with your life! But in my experience typically ‘tension-type’ headache, whilst typically much less severe than a ‘migraine’, is much more annoying with the constancy of it, the inability to shake it off, wearing you down. One wonders whether it would be better to have severe discomfort for a day and then be pain-free for a period of time!
More than 150 years ago, primarily due to the fact of the throbbing nature of headache, it was presumed that the main dilemma was (expansion or dilatation of) the blood vessels – and since any headache that was/is throbbing in nature was diagnosed as migraine and non-throbbing headaches were excluded from a diagnosis of migraine – the notion of tension headache developed, for regardless of the lack of evidence, the cause of non-throbbing headaches was regarded as to be muscular (of the scalp and forehead) and/or anxiety related yet another assumption was created!
However a landmark study (1) in the late 1970s demonstrated that:
- the tension in muscles of the scalp and forehead in tension headache sufferers during a headache was no different from group with no headache
- the tension headache sufferers had elevated (and more) tension in their neck muscles when compared with the group with no headache – possibly indicating that tension headache is an unrecognised cervicogenic headache
Other analysis (2) has shown that tension headache was considerably reduced after rehabilitation of neck musculature i.e. treating the neck, offering a lot more evidence that tension headache is really a headache with its origin in the neck.
A significant physique of recent research has demonstrated that sensitisation or hyper excitability of the brainstem is the main disorder in tension-sort headache sufferers (this is also the case in migraine – supporting the notion that tension headache and migraine are not separate conditions but are diverse expressions of the identical condition) … and that this sensitisation is present consistently i.e. even when tension headache totally free – confused? In addition the ‘triptans’, medication developed specifically for migraine, are also effective in eliminating tension headache. But … do not the ‘triptans’ work by decreasing the dilatation of the blood vessels? Properly initially this was thought (and largely assumed) to be the case, but experiments have shown that the triptans lower the sensitisation of the brainstem.
Now what is this thing named the ‘Brainstem’. The brainstem is an area at the leading of the spinal cord, which receives input from (activity of) structures inside the head (such as blood vessels) and also from structures of the upper neck (ligaments, joints and their capsules, and muscles) which are supplied by the best three spinal nerves. The brainstem is also influenced by serotonin and a program recognized as the Diffuse Noxious Inhibitory Control method – do not be overwhelmed by these terms – I will clarify this elsewhere. Now all info or activity in relation to headache, head discomfort and migraine, passes by way of the brainstem to the greater brain centres exactly where it is interpreted, where the decisions are created! The Brainstem is to headache what the black box is to the airplane – it is the final widespread pathway for all headache and migraine details.
The question remains as to what is causing the sensitisation.
As I mentioned just before the brainstem is influenced by four systems. The Serotonin technique and the Diffuse Noxious Inhibitory Control program (DNICs) both act to inhibit or desensitise the brainstem – if either program is not functioning satisfactorily then the brainstem would become sensitised or hyper excitable.
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I’m sure you have heard of serotonin and it is role in headache. Serotonin is a neurotransmitter and its role is to act as a filter, screening out minimal or non threatening (discomfort) signals. Below typical circumstances, satisfactory serotonin levels counteract discomfort signals. However serotonin levels in headache sufferers are frequently too low. Investigation has shown a clear relationship. When injected with a drug that depletes serotonin, test subjects got headaches. Likewise, when they had been injected with serotonin, headaches had been relieved – so it might that the brainstem is sensitised by unsatisfactory levels of serotonin
or,
The Diffuse Noxious Inhibitory Control system (DNICs) is poorly understood. This mechanism involves a reduction in awareness of pain when a simultaneous pain is felt elsewhere in the body. For example, headache or migraine discomfort is perceived as considerably, significantly much less severe right after having hit your thumb with a sledgehammer! If the DNICs is deficient then it would be comparable to hitting your thumb with a much smaller hammer, and your headache discomfort would be only slightly less severe. Perhaps consequently, sensitisation of the brainstem could happen secondary to a disorder of the DNICs. Nevertheless, whilst investigation findings have been inconsistent, a decisive study (three) has shown this is unlikely in migraine sufferers. Moreover other research has shown that the DNICs plays a less considerable role in females … and of the sexes, females are more susceptible to headache, making the DNICs less most likely to be involved
or,
Sensitisation or hyperexcitability of the brainstem can also happen as result of ongoing abnormal signals from an injury to, or a dangerous disorder of the upper neck structures such as joints, muscles, and ligaments
or,
Sensitisation could also result from a similar situation i.e. ongoing abnormal messages from a disorder of a structure from inside the head, for example, an infected tooth, a diseased sinus (though accurate sinus headache is rare), irritation of the meninges …
However, the results of the decisive study conducted in the late 1970s (1) and far more lately (two) suggest that the most most likely source of sensitisation lies in the neck. My extensive clinical encounter overwhelmingly supports these findings.
The evidence has prompted a shift away from the musculature of the forehead and scalp as the cause of tension headache pain and is now focusing on “What is causing the sensitization of the brainstem?” …… why is there so considerably energy, so several resources when it is so obvious – the reason is that the role of the neck does not fit the medical model of headache and migraine, and consequently the model has demonstrated small interest in exploring this as an selection. It is essential that all variables, which have the possible to sensitise the brainstem, be investigated equally.
Currently this is not the circumstance – the neck is largely disregarded.
Remain tuned …!
Dean
Dean H Watson
Consultant Headache & Migraine Physiotherapist International Teacher Director, The Headache Clinic & Watson Headache Institute PhD Candidate Murdoch University, Western AustraliaAdjunct Lecturer, Masters Program, Physiotherapy School, University of South Australia MAppSc(Res)GradDipAdvManipTher
Skilled well being practitioners trained in the Watson Headache Method perform the examination and therapy techniques developed by Dean Watson. These methods are based on his extensive expertise of 7000 headache patients (21,000 hours) over 21 years and are now taught internationally.
For your nearest practitioner who has completed training in the ‘Watson Headache Approach’ please refer to the ‘Practitioner Directory’.
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