Chronic Tension Headache

8/6/2019 Chronic Tension Headache

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OBJECTIVES

General Objective

As nursing students, we deal with patients of different diseases during our exposure in

different hospitals. As we learn, it is our duty and responsibility to improve ourselves in

dealing with patients having disease. This case study aims to identify the defining

characteristics of chronic tension type headache, and its signs and symptoms in order to

gain knowledge about the disease and provide quality nursing care to the patients

inflicted by it.

Specific Objectives

To identify risk factors why this type of disease arises and also to identify risk

areas and situations that is prone to chronic tension type headache

To promote awareness to the public regarding the incidence of chronic tension

type headache

To have an idea of specific programs that we can suggest to the authorities to

lessen the events of chronic tension type headache cases, and therefore improvethe quality of life.

To know specific management and immediate interventions that we can apply

whenever we encountered this type of disease.


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INTRODUCTION

Case Definition

Tension headaches are the most common type of primary headaches among adults. They

are commonly referred to as stress headaches. Tension headachesare similar to migraine in

many respects, although the location of the headache may be somewhat different and the cause is

more obvious. Prolonged nervous tension often seems to produce a spasm of the muscles in the

back of the neck, particularly in certain people. This muscles spasm draws the tissues over the

surface of the cranium very tight, so the pain is felt not only in the back of the neck, but also over

the top and front of the head as well. This is a steady, aching type of pain. Usually there is

no nausea, vomiting, orflashing lights, for the problem does not appear to affect the brain but is

due to external causes.

Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of

the population has chronic tension-type headaches.

A tension headache may appear periodically ("episodic," less than 15 days per month) or

daily ("chronic," more than 15 days per month). An episodic tension headache may be described

as a mild to moderate constant band-like pain, tightness, or pressure around the forehead or back

of the head and neck.

These headaches may last from 30 minutes to several days. Episodic tension headaches

usually begin gradually, and often occur in the middle of the day.

The "severity" of a tension headache increases significantly with its frequency. Chronic

tension headaches come and go over a prolonged period of time. The pain is usually throbbing

and affects the front, top, or sides of the head. Although the pain may vary in intensity

throughout the day, the pain is almost always present. Chronic tension headaches do not affect

vision, balance, or strength.

Tension headaches usually don't keep a person from performing daily tasks.
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Incidence

Headache is a painful and common symptom. A number of primary headache disorders

have been characterized, including tension-type headache, migraine and cluster headache, and

overall these disorders account for approximately 95% of all headache complaints. Where

studied, primary headache disorders have a lifetime prevalence of 90% . Migraine on its own

ranks among the top 20 causes of years of life lived with disability. Tension-type headache

afflicts more on women than of men living in developed countries. The epidemiology and

experiences of patients with headache disorders in the developing world are uncertain, because

the majority of research on headache disorders comes from a limited number of high-income

countries. Where sought, regional variation in the incidence, prevalence and economic burden of

headache disorders has been found. Social, financial and cultural factors can all influence the

experience of the individual headache sufferer, and patients in resource-poor settings could

presumably experience an even greater impact of these influences. Yet the contribution of low-

and middle-income countries to the understanding of headache disorders has not been

characterized.

Little wonder, then, that tension headaches are the most common kind of all headaches.

They have recently been renamed "tension-type headaches" because of the possible role

researchers now believe that the chemistry in the brain may play in their origin. TTH can occur

at any age, but onset during adolescence or young adulthood is common. It can begin in

childhood.

About 30%-80% of the adult population suffers from occasional tension headaches;

approximately 3% suffer from chronic daily tension headaches. Women are twice as likely to

suffer from tension-type headaches as men. One study found that almost 90 percent of women

and about 70 percent of men experience tension headaches are estimated to suffer from the dull

pressure and aches caused by tension-type headaches at some time in their lives. The symptom is

also frequently described as feeling like a rubber band tightly gripping one's head.

Tension headaches can occur at any age, but they generally strike during adolescence or

adulthood. This sort of headache occurs most often in people between 20 and 50 years of age.


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Most people with episodic tension headaches have them no more than once or twice a

month, but the headaches can occur more frequently.

Chronic tension headaches tend to be more common in females. Many people with

chronic tension headaches have usually had the headaches for more than 60-90 days.

Etiology

The exact cause or causes of tension headache are unknown. Experts used to think that

the pain of tension headache stemmed from muscle contraction in the face, neck and scalp,

perhaps as a result of heightened emotions, tension or stress. But research suggests that there

doesn't appear to be a significant increase in muscle tension in people diagnosed with tension

headache.

The most common theories support interference or "mixed signals" involving nerve

pathways to the brain, which is demonstrated by a heightened sensitivity to pain in people who

have tension headaches. Increased muscle tenderness, a common symptom of tension headache,

may be the result of overactive pain receptors.

There is no single cause for tension headaches. This type of headache is not an inherited

trait that runs in families. In some people, tension headaches are caused by tightened muscles inthe back of the neck and scalp. This muscle tension may be caused by:

Inadequate rest

Poor posture

Emotional or mental stress, including depression

Anxiety

Fatigue

Hunger

Overexertion

In others, tightened muscles are not part of tension headaches, and the cause is unknown.


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Tension headaches are usually triggered by some type of environmental or internal stress. The

most common sources of stress include family, social relationships, friends, work, and school.

Examples of stressors include:

Having problems at home/difficult family life

Having a new child

Having no close friends

Returning to school or training; preparing for tests or exams

Going on a vacation

Starting a new job

Losing a job

Being overweight

Deadlines at work

Competing in sports or other activities

Being a perfectionist

Not getting enough sleep

Being over-extended (involved in too many activities/organizations)

Episodic tension headaches are usually triggered by an isolated stressful situation or a build-

up of stress. Daily stress can lead to chronic tension headaches.

Medication-overuse headache is caused by taking painkillers (or triptan medicines) too often

for tension-type headaches or migraine attacks. For example, you may take a lot of painkillers

for a bad spell of headaches. You may end up taking painkillers every day, or on most days.

Your body then becomes used to painkillers. A withdrawal headache then develops if you do not

take painkillers each day. You think this is just another tension-type headache, and so you take a

further dose of painkiller. When the effect of each dose of painkiller wears off, a furtherwithdrawal headache develops, and so on. This is how medication-overuse headache develops. It

is a common cause of headaches that occur daily, or on most days.

Until recently it was believed that tension headaches were caused by muscle tension around

the head and neck. One of the theories says that the main cause for tension type headaches and


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migraine is teeth clenching which causes a chronic contraction of the temporal muscle. Although

muscle tension may be involved, many researchers now question this idea, and recent research

has shown that tension headache patients do not have increased muscle tension

Another theory is that the pain may be caused by a malfunctioning pain filter which is

located in the brain stem. The view is that the brain misinterprets information, for example from

the temporal muscle or other muscles, and interprets this signal as pain. One of the main

neurotransmitters which are probably involved is serotonin. Evidence for this theory comes from

the fact that chronic tension-type headaches may be successfully treated with certain

antidepressants such as amitriptyline. However, the analgesic effect of amitriptyline in chronic

tension-type headache is not solely due to serotonin reuptake inhibition, and likely other

mechanisms are involved. Patients with chronic tension-type headache have increased muscle

and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain

thresholds. Hyperexcitability of central nociceptive neurons (in trigeminal spinal nucleus,

thalamus, and cerebral cortex) is believed to be involved in the pathophysiology of chronic

tension-type headache. Recent evidence for generalized increased pain sensitivity or

hyperalgesia in CTTH strongly suggests that pain processing in the

central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction

in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type

headache

General Signs and Symptoms

Signs of tension headaches include:

A headache that is constant, not throbbing, Pain or pressure on both sides of head.

Pressure that makes feel like head is in a vise.

Aching pain at temples or the back of head and neck.

Steady, constant feeling of pressure that usually begins in the forehead, or the back of the

neck.


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Tension headaches tend to come back, especially when under stress. They can last from

30 minutes to several days.

Tightness around forehead that may feel like a vise grip

Mild to moderate pain or pressure affecting the front, top or sides of the head Headache occurring later in the day

Difficulty falling asleep and staying asleep

Chronic fatigue

Irritability

Disturbed concentration

Mild sensitivity to light or noise

General muscle aching

Other signs and symptoms

Can be described as a weight on top of my head

Steady, constant feeling of pressure usually begins in the forehead, temple, or back of the

neck.

Excruciating pain localized to the eye and orbit and radiating to the facial and temporal

regions.

The pain is accompanied by watering of the eye and nasal congestion.

Cranial arteritis often begins with fatigue, malaise, weight loss, and fever.

Clnical manifestations associated with inflammation (heat, redness, swelling, tenderness,

or pain over the involved artery) usually present.

Usually, pain from a tension headache is not severe and does not get in the way of your work or

social life. But for some people the pain is very bad or lasts a long time. You have chronic

tension headaches if they occur at least 15 days a month


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PATIENTS PROFILE

Patients data

RN is a 42 year old female, Married, Roman Catholic, Filipino citizen, born on February

28, 1969, and presently residing at Manila. She consulted in ADU Hospital last July 29, 2011

with a diagnosis of Chronic Tension Headache. Vicente Falcon M.D as his admitting

physician.

Nursing History

Chief complaint

Headache for 15 days.

Present History

2 weeks prior to consultation patient has been suffering a constant, daily

headache. The headache is making her tired and it is difficult for her to concentrate at

work. She has seen her Doctor in Marians Hospital about this complaint. The Doctor

diagnosed stress and recommended paracetamol three times a day. The treatment was

not effective, headache still persisted, which prompted her to have a consultation in ADU

Hospital.

Past History

No previous injuries and serious illness reported.


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Personal and social history

RN is a 42 year old female, a Filipino citizen who resides at Manila. She was born on

February 28, 1969 in Pampanga, her religious affiliation is Roman Catholic and she is married to

MSN. She is a Highschool Teacher. She usually works for 10 hours a day around 7:30 am to

5:30 pm. She always sleeps around 11 in the evening and wakes up at 5 in the morning. Her

husband is a jeepney driver bound in Baclaran-Monumento route, and also the president of their

jeepneys association. RN has 2 children. Her only day-offs is Saturdays and Sundays but uses

these days working in the house and taking care of her 2 children.

Family Health and Illness History

According to RN, the familial disease she knows that they have in their family was

hypertension that is on her fathers side. Her father died because of heart attack and her mother

died of senility.

Feeding History

She usually eats 3 meals and 1 snack (in the afternoon). She eats 1rice per meal. She is

also fond of eating vegetables and fatty and spicy foods. She drinks 1 liter of water a day.

Immunization History

She was able to receive all childhood immunizations and complete Tetanus Toxoid.

OB History

She had her first menses when she was 12 years old. She has 2 children, both NSD.

G2P2.

Gordons Functional Health Pattern

Health Perception Pattern


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The patient says Kung may sakit ako, kumukunsulta ako kaagad sa doctor, magastos

magpakunsulta pero mas magastos kung lumala.

Nutrition Metabolic Pattern

She usually eats 3 meals and 1 snack (in the afternoon). She eats 1rice per meal.

She is also fond of eating vegetables and fatty and spicy foods. She drinks 1 liter of water a day.

Elimination Pattern

The patient usually defecates every other day. The stool is usually brownish in color. She

urinates 3 to 4 times a day, yellowish in color. She has no complained of any pain when voiding

and defecating.

Activity and Exercise Pattern

The patient is a highschool teacher. She usually works for 10 hours a day around

7:30 am to 5:30 pm, Mondays to Fridays. She considers doing household chores every weekend

as her exercise. The patient says these past two weeks I cannot concentrate well on my work

and even at home because of this headache.

Sleep and Rest Pattern

She usually has 5 hours of sleep. She always sleeps around 11 in the evening and

wakes up at 4 in the morning.The patient says nito ngang nakaraang dalawang lingo hirap

akong makatulog dahil sumasakit ang ulo ko.

Cognitive Perceptual Pattern

She didnt have any difficulty in understanding, following instructions and formulating

sentences. She answers the questions appropriately. It is evident that she is bothered and irritated

due to her headache.

Role relationship Pattern


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The patient is happily living with her family.

Self perception/concept Pattern

The patient said ok naman ako eh, but for the past two weeks hindi na dahil dito sa

headache ko. She maintains an eye to eye contact during the interview.

Coping/ Stress Pattern

When she has problems, she tells it to her husband and prays.

Values/Belief Pattern

The patient is a Roman Catholic and she has faith in God. She usually goes to mass every

Sunday with her husband and children. According to her she always prays.

Review of systems

SYSTEMS ACTUAL FINDINGSIntegumentary Fair complexion

Turgor returns 1-2 seconds.

Hair is black and equally distributed. Hair is coarse and no parasites;

pink nails- round and firm.

Respiratory (-) DOB, (-) SOB

Cardiovascular No murmur

BP of 120/90

Neurologic Presence of weakness

Headache

Cooperative


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Gastrointestinal No loss of appetite

Musculoskeletal Equal ROM (range of motion)

Hematologic No incidence of bleeding or hemorrhage

Endocrine No heat and cold intolerance

No loss of appetite

Immunologic No fever

Urinary Has no history of Urinary tract infection

Has no changes in elimination pattern

Physical Assessment

Vital Signs:

T- 36.7 CP- 68 bpm

RR- 15 cpm

BP- 120/90

HEAD:

(+) Headache with a pain scale of 7/10

Afebrile

AREAS TO ASSESS ACTUAL FINDINGS NORMAL FINDINGS

SKULL Normal - Generally round, with

prominences in the frontal and

occipital area.

(Normocephalic).

- No tenderness noted upon

palpation.Scalp Normal -Lighter in color than the

complexion.

- Can be moist or oily.

- No scars noted.

- Free from lice, nits and


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dandruff.

- No lesions should be noted.

- No tenderness nor masses on

palpation.

Hair Normal -Can be black, brown or

burgundy depending on the

race.

-Evenly distributed covers the

whole scalp (No evidences of

Alopecia)

-Maybe thick or thin, coarse or

smooth.-Neither brittle nor dry.

Face Normal -palpebral fissure (distance

between the eye lids) equal in

both eyes.

-bilateral Nasolabial fold

(creases extending from the

angle of the corner of the

mouth). Slight asymmetry in

the fold is normal.

Eyes Normal Eyebrows

Symmetrical and in line

with each other.

Maybe black, brown or

blond depending on race.

Evenly distributed.

Eyes

Evenly placed and inline

with each other.

Non protruding.

Equal palpebral fissure.


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Eyelashes

Color dependent on race.

Evenly distributed.

Turned outward.

Eyelids

Upper eyelids cover the small

portion of the iris, cornea, and

sclera when eyes are open.

No PTOSIS noted. (drooping

of upper eyelids).

Meets completely when eyes

are closed.

Symmetrical.

Lacrimal Apparatus

Lacrimal gland is normally

non palpable.

No tenderness on palpation. No regurgitation from the

nasolacrimal duct.

Conjunctiva

Both conjunctivae are

pinkish or red in color.

With presence of many

minutes capillaries.

Moist

No ulcers

No foreign objects


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Sclerae

Sclerae is white in color

(anicteric sclera)

No yellowish discoloration

(icteric sclera).

Some capillaries maybe

visible.

Some people may have

pigmented positions.

Cornea

There should be no

irregularities on the surface.

Looks smooth.

The cornea is clear or

transparent. The features of

the iris should be fully visible

through the cornea.

There is a positive cornealreflex.

Anterior chamber and Iris

The anterior chamber is

transparent.

No noted any visible

materials.

Color of the iris depends on

the persons race (black, blue,

brown or green).

From the side view, the iris

should appear flat and should


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not be bulging forward. There

should be NO crescent shadow

casted on the other side when

illuminated from one side.

Pupils

Pupillary size ranges from

3 7 mm, and are equal in

size.

Equally round.

Constrict briskly/sluggishly

when light is directed to the

eye, both directly and

consensual.

Pupils dilate when looking

at distant objects, and constrict

when looking at nearer

objects.

EARS Normal The ear lobes are bean

shaped, parallel, and

symmetrical.

The upper connection of the

ear lobe is parallel with the

outer canthus of the eye.

Skin is same in color as in

the complexion.

No lesions noted on

inspection.

The auricles are has a firm

cartilage on palpation.


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The pinna recoils when

folded.

There is no pain or

tenderness on the palpation of

the auricles and mastoid

process.

The ear canal has normally

some cerumen of inspection.

No discharges or lesions

noted at the ear canal.

On otoscopic examination

the tympanic membrane

appears flat, translucent and

pearly gray in color.

NOSE and PARANASAL

SINUSES

Normal -Nose in the midline

- No Discharges.

- No flaring alae nasi.

- Both nares are patent.

- No bone and cartilage

deviation noted on palpation.

- No tenderness noted on

palpation.

- Nasal septum in the mid line

and not perforated.

- The nasal mucosa is pinkish

to red in color. (Increased

redness turbinates are typical

of allergy).

- No tenderness noted on

palpation of the paranasal

sinuses.

NECK Normal -May not be palpable. Maybe


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normally palpable in thin

clients.

-Non tender if palpable.

-Firm with smooth rounded

surface.

-Slightly movable.

-About less than 1 cm in size.

-The thyroid is initially

observed by standing in front

of the client and asking the

client to swallow. Palpation of

the thyroid can be done either

by posterior or anterior

approach.

THORAX Normal -The shape of the thorax in a

normal adult is elliptical; the

anteroposterior diameter is

less than the transverse

diameter at approximately a

ratio of 1:2.

-Moves symmetrically on

breathing with no obvious

masses.

-No fail chest which is

suggestive of rib fracture.

-No chest retractions must be

noted as this may suggest

difficulty in breathing.

-No bulging at the ICS must

be noted as this may


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obstruction on expiration,

abnormal masses, or

cardiomegaly.

-The spine should be straight,

with slightly curvature in the

thoracic area.

-There should be no scoliosis,

kyphosis, or lordosis.

-Breathing maybe

diaphragmatically of costally.

-Expiration is usually longer

the inspiration.ABDOMEN Normal -Skin color is uniform, no

lesions.

-Some clients may have striae

or scar.

-No venous engorgement.

-Contour may be flat, rounded

or scapoid

-Thin clients may have visible

peristalsis.

-Aortic pulsation maybe

visible on thin clients.

EXTREMITIES Normal -Both extremities are equal in

size.

-Have the same contour withprominences of joints.

-No involuntary movements.

-No edema

-Color is even.

-Temperature is warm and


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even.

-Has equal contraction and

even.

-Can perform complete range

of motion.

-No crepitus must be noted on

joints.

-Can counter act gravity and

resistance on RO


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Assessment Diagnosis Planning Interventions Rationale Evaluation

SUBJECTIVE

CUES:

The patient

verbalized I feel

like my head is being

crumpled from the

inside and banged on

a hard surface

repetitively.

OBJECTIVECUES:

Rated pain

as 9 out of10

Facialgrimace

Gurading

behavior

(clutches

head and

assumes

fetal

position)

Palmar and

Acute Pain r/t

decreased cerebral

blood flow secondaryto migraine as

manifested byguarding behavior,

facial grimace and

pallor

After 4 hours of

nursing

interventions, the

patient will be able

to:

Become relieved of

signs and symptoms

of pain experienced

as

evidenced by:

Verbalize pain is

relieved (rate pain

from 0-4 out of 10)

Demonstrate use of

diversional

activities such as

relaxing and/orsleeping

Assess

contributingfactors to pain

such as bright

lights and strongfumes

Reviewmedication

regimen

Provide comfortmeasures such as

repositioning theclient in a

comfortable

position andproviding a hot

or cold compress

Providecalm and quietenvironment

Instruct use of

relaxation techniques

such as deepbreathing

To determine

underlying causeof pain and treat

accordingly.

Certain drugs

may cause fatigueand drowsiness.

To allow nonpharmocological

pain relief andpromote good

circulation to thebrain and

decrease

vasoconstriction

To decrease

environmental

factors whichcontribute toheadache and

promote rest

To distract

attention from pain anddecrease tension

After 4 hours of

nursing interventions

the patient:

Verbalized feeling ofrelief of pain and feel

better

Pain scale 0 out of 10

Was able to use

relaxation techniquessuch as deep breathing


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facialpallor


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DISCHARGE PLANNING

M (MEDICATION)

Take the entire course of any prescribed medications.

E (EXERCISE & ACTIVITY)

Have adequate rest and assisted exercises to maintain muscle tonicity and also avoid

engaging in extraneous activities to avoid tension headache.

T (TREATMENT)

Undergo necessary procedure as needed. Observe self for any suspicious condition and

notify to your doctor.

H (HOME TEACHING)

Encourage nutrition supplements to prevent weight loss. Observe safety measure at home

to prevent for injuries. Provide quiet, comfortable and peace environment. Proper preparation offood and water to have adequate nutrition and hydration.

O (OUT PATIENT FOLLOW UP)

Return to the doctor as frequent as possible to monitor your present condition. Keep all of

follow-up appointments. Even though you feel better, there are some complications that may stilloccur. Its important to have the doctor monitor his progress.

D (DIET)

Planning meal and having regular family meals can help ensure that you gets enough

calories, protein and other necessary nutrients; these can also become ways to engage yourself in

nutritional health care.

S (SPIRITUALITY)

Keeping faith in God and believing in Him can uplift some distress in the whole family.


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NURSING IMPLICATIONS

Nursing Research

This case study is important to nursing research because it opens new opportunity to

conduct another research in relation to the disorder even though there are many existing

researches with regards to this disorder. Even if we know that chronic tension headache is stillcommon nowadays, research will still be a key to discover a better treatment for it. As a part of

medical team, and as a nursing student, it is very vital for us to be aware for the new researches

because we are the primary care giver for our client. We are the one who is always in contact

with our client. Nursing research is our way to have a new knowledge and understanding aboutthe disease that we can use to render the best quality of care for our client.

Nursing Education

In Nursing Education, it is an advantage for us to have this case study because it gives usadditional and new knowledge about the disorder. As a nursing student, it is important to know

everything about a certain disease. When we have the knowledge about the disease, we can be

able to give the best quality of care when we encounter a patient with the same disorder. This

case study does have nursing care management. We, student nurses are also an educator to ourclient. It is important that we teach accurate details to our client because they believe on what we

say. Even a single mistake about the information that we give to our client can take away their

life. As an educator, we should be responsible enough to spread the knowledge about this certaindisease to prevent acquiring the disease. Prevention will always be better than cure.

Nursing practice

Through the help of this study we can acquire more informations and knowledge aboutchronic tension headache. Knowing that chronic tension headache can be acquired in several

ways, we can also prevent ourselves in acquiring such disease. We are very prone to acquire this

disease because we are always in contact with many clients and due to a tiring job. This case

study will be an essential tool to render the best quality of care that we can render to our client.

Documents

Chronic Tension Headache