In response to Kernick, et al's1 article I would like to describe my approach to primary headache. In the 1980s my husband, then a medical registrar, would regularly spend Mondays after weekends on call in bed with a prostrating symmetrical headache accompanied by vomiting. During my first pregnancy he came with me as a dutiful father-to-be to relaxation classes. The relaxation techniques we learnt and practised were invaluable to me in labour. The unexpected outcome was that my husband's headaches resolved. It is debatable whether they were tension headaches, or migraine without aura. According to Goadsby2 classification is still controversial. However, many headaches in primary care fall in this uncertain category.
When patients present with tension headache I encourage them to think about muscular relaxation particularly of the muscles around the head, neck and shoulders. I explain that the scalp is covered by a layer of muscle like a swimming cap, which connects with the face, the jaw, the back of the neck and shoulders, and that tightness in these muscles may produce pain as in any clenched muscle. Often examination reveals tenderness at the temples or occiput or in the neck extensors, which illustrates the point. I encourage the patient to become aware of frowning, or raising the eyebrows, or clenching the jaw, and to focus on relaxing these muscles.
This explanation might be simplified or inaccurate as pathophysiology, but there are benefits of a clear diagnosis and explanation. First, if patients fear brain tumour, it is much more satisfactory to have a definite diagnosis than to be told ‘nothing is wrong’. Second, some patients resent the label of tension headache for its psychological implications. Often, patients with tension headache do have anxiety or depression which may be rewarding to explore, but others say, ‘I'm not tense!’ Here it is helpful to discuss muscular relaxation.
I note in BMJ Clinical Evidence on tension headache3 that relaxation is mentioned, but is described as time-consuming to apply. I would dispute this. I think the principle can be explained quite quickly, and patients can be referred to self-help materials and relaxation tapes. Some women remember being taught relaxation at antenatal classes.
I also encourage patients to look for precipitants and trigger factors. The pathophysiology of these, and whether they apply to migraine without aura or tension headaches is again not clear to me, but pragmatically the following list is worth considering, and patients often notice something they had not previously thought of:
caffeine, chocolate, cheese, citrus fruits and juices, onion, raw apple, alcohol; also
fatigue, lack of fluid intake, or missed meals.
I note that Goadsby2 says, ‘so much good can be done for migraine sufferers and so little for tension-type headache’. This impression may well be behind GPs' difficulties. I suspect the lack of research into tension headache reflects the lack of pharmaceutical prospects. I would be interested to know how other GPs approach this problem.
- © British Journal of General Practice, 2008.
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