Tension-type headache

Abstract

A 59-year-old woman referred by a neurologist to the Danish Headache Center, a tertiary headache centre, for the treatment of refractory migraine presents for the initial consultation. The patient has suffered from frequent headaches since childhood and in the last couple of years from daily headaches. She told me that she was so tired of the headaches that have ruined her life and of all the various treatments she has received during her life. None of the treatments has had any effect, several have been costly and several had bothersome side effects. She had almost given up hope. The patient did not fill out the 4-week headache diary that has been mailed to her from the headache centre prior to the initial consultation, and it was difficult for her to give a detailed headache history. She reported that her headaches could be unilateral or bilateral, of moderate to severe intensity, throbbing and at times pressing in character and could be aggravated by waking stairs. She also reports frequent nausea and sometimes sensitivity to sounds and light. The headaches are clearly provoked by psychological stress and to a lesser extent by physical activity. Sometimes headaches are preceded by visual disturbances. She had been on sick leave due to the headaches in the past 3 months. She reports being often anxious but she denies depressed mood. She works as a teacher and had some stress at work. Otherwise, she is healthy. Her mother had suffered from life-long migraines. Her paternal uncle had brain aneurysm. At the first consultation, it was obvious that the patient suffered from migraine, tension-type headache (TTH) and anxiety on the most severe headache days. General and neurological examination demonstrates increased pericranial myofascial tenderness. Her blood pressure and pulse are within normal limits. Electrocardiogram and routine blood tests are unremarkable. What to do for this severely incapacitated woman?