Tension Type

Headache

Nyeri kepala : Rasa nyeri atau rasa tidak

enak
pada bagian atas kepala dari
daerah orbita sampai ke
daerah
occiput dan tengkuk

Bagian kepala yang peka terhadap

nyeri
1.
2.
3.
4.
5.

Kulit kepala
Otot-otot kepala
Periosteum
Duramater
Pembuluh darah intrakranial /
ekstrakranial
6. Organ / alat sekitar kepala

2. Bedakan NK primer dan sekunder

Primary headaches
atau Idiopathic
headaches
The headache is
itself the disease
No organic lesion
in the beackground
Treat the
headache

Secondary headaches
atau Symptomatic
headaches
The headache is
only a symptomatic
of an other
underlying disease
Treat the underlying
disease

 Nyeri yang berasal dari bangunan intrakranial

tidak dirasakan didalam rongga tengkorak
melainkan akan diproyeksikan ke permukaan
dan dirasakan di daerah distribusi saraf yang
bersangkutan.

Nyeri yang berasal dari dua pertiga bagian

depan kranium, di fosa kranium tengah dan
depan, serta di supratentorium serebeli
dirasakan di daerah frontal, parietal, di dalam
atau belakang bola mata dan temporal bawah.
Nyeri ini disalurkan melalui cabang pertama
nervus Trigeminus.

 Nyeri yang berasal dari bangunan di

infratentorium serebeli di fosa posterior
biasanya diproyeksikan ke belakang telinga, di
atas persendian serviko-oksipital atau diatas
kuduk.
Nervi kraniales IX dan X &saraf spinal C1, C2 &
C3 berperan untuk perasaan dibagian
infratentorial.
Bangunan peka nyeri ini terlibat melalui
berbagai cara yaitu oleh peradangan, traksi,
kontraksi otot dan dilatasi pembuluh darah.

 Nyeri yang berhubungan dengan penyakit

mata, telinga & hidung cenderung di
frontal pada permulaannya.
Nyeri kepala yang bertambah hebat
menunjukkan kemungkinan massa
intrakranial yang membesar (hematoma
subdural, anerysma, tumor otak)

 Pada nyeri kepala, sensitisasi terdapat di nosiseptor

meningeal dan neuron trigeminal sentral
lnervasi sensoris p.d intrakranial sebagian besar
berasal dr. ganglion trigeminal dlm serabut sensoris
yg mengandung neuropeptid, dimana jumlah &
peranannya yg paling besar CGRP(Calcitonin Gene
Related Peptide), kemudian diikuti oleh SP(substance
P), NKA(Neurokinin A), pituitary adenylate cyclase
activating peptide (PACAP), NO, prostaglandin E2,
bradikinin, 5-HT & ATP

 Menurut H.G.Wolf terdapat 6 mekanisme dasar yang

menimbulkan nyeri kepala yang berasal dari sumber
intrakranial :
Tarikan pada vena yang berjalan ke sinus venosus dari
permukaan otak dan pergeseran sinus-sinus venosus utama.
Tarikan pada A. Meningea media
Tarikan pada pembuluh-pembuluh arteri besar di otak atau
tarikan pada cabang-cabangnya.
Distensi dan dilatasi pembuluh-pembuluh nadi intrakranial
(A.Frontalis, A. Temporalis, A. Discipitalies)
Inflamasi pada atau sekitar struktur kepala yang peka terhadap
nyeri meliputi kulit kepala, periosteum,
Tekanan langsung pada nervus cranialis V, IX, X saraf spinal
dan cervikalis bagian atas yang berisi banyak serabut aferen
rasa nyeri.

PENDAHULUAN
International Headache Society(HIS)2004
Primary Headaches: Migraine, Tension
type Headache; Cluster Headache and
other trigeminal-autonomic cephalgias and
Other Primary Headaches

 Tension-type headaches (TTHs) are

characterized by pain that is usually mild
or moderate in severity and bilateral in
distribution. Unilateral pain may be
experienced by 10-20% of patients.
Headache is a constant, tight, pressing, or
bandlike sensation in the frontal, temporal,
occipital, or parietal area (with frontal and
temporal regions most common)

 TTH is the most common type of

headache, and it is classified as episodic
(ETTH) or chronic (CTTH). It had various
ill-defined names in the past including
tension headache, stress headache,
muscle contraction headache,
psychomyogenic headache, ordinary
headache, and psychogenic headache.

 The International Headache Society (IHS) defines TTH more

precisely and differentiates between the episodic and the
chronic types.
Episodic tension-type headache
At least 10 previous headaches fulfilling the following criteria;
number of days with such headache fewer than 15 per month
Headaches lasting from 30 minutes to 7 days
At least 2 of the following pain characteristics:
Pressing/tightening (nonpulsating) quality
Mild or moderate intensity (may inhibit but does not prohibit
activities)
Bilateral location
No aggravation from climbing stairs or similar routine physical
activity

Both of the following:

No nausea or vomiting
Photophobia and phonophobia absent or only one present

Secondary headache types not suggested or confirmed

 Chronic tension-type headache

Average headache frequency of more than 15 days
per month for more than 6 months fulfilling the
following criteria
At least 2 of the following pain characteristics:
Pressing/tightening (nonpulsating) quality
Mild or moderate intensity (may inhibit but does not prohibit
activities)
Bilateral location
No aggravation from climbing stairs or similar routine
physical activity

Both of the following:

No vomiting
No more than one of the following: nausea, photophobia, or
phonophobia

Secondary headache types not suggested or

confirmed

Pathophysiology
Pathogenesis of TTH is complex and
multifactorial, with contributions from both central
and peripheral factors.
In the past, various mechanisms including
vascular, muscular, and psychogenic factors
were suggested.
The more likely cause of these headaches is
believed now to be abnormal neuronal sensitivity
and pain facilitation, not abnormal muscle
contraction.

 TTH is associated with exteroceptive

suppression (ES2), abnormal platelet
serotonin, and decreased cerebrospinal fluid
beta-endorphin.
pathophysiologic mechanisms may be
responsible for TTHextracranial myofascial
nociception Headache is not related directly
to muscle contraction, and possible
hypersensitivity of neurons in the trigeminal
nucleus caudalis has been suggested.

Imaging Studies
Neuroimaging studies are important to rule out
secondary causes of headache, including
neoplasms and cerebral hemorrhage.
MRI imaging shows the greatest detail of
cerebral structures and is especially useful in
evaluating the posterior fossa.
CT scan with contrast is a viable alternative but
is inferior to MRI for viewing structures in the
posterior fossa.
Neuroimaging is indicated if the headaches are
atypical in any way or if they are associated with
abnormalities in the neurologic examination.

Various precipitating factors

One half of patients with TTH identify stress or
hunger as a precipitating factor.
Stress - Usually occurs in the afternoon after
long stressful work hours
Sleep deprivation
Uncomfortable stressful position and/or bad
posture
Irregular meal time (hunger)

THERAPY
The goals of pharmacotherapy are to
relieve the headache, reduce morbidity,
and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

These agents inhibit inflammatory reactions and pain by decreasing activity of
cyclooxygenase, which is responsible for prostaglandin synthesis. They generally are
used in mild to moderately severe headaches; however, they also may be effective for
severe headaches.
Drug Name

Ibuprofen (Motrin, Advil)

Description

First choice for treatment of headache, especially during

pregnancy and breastfeeding.

Adult Dose

400-800 mg PO q8h, not to exceed 3200 mg/d

Pediatric Dose

<12 years: Not recommended

>12 years: Administer as in adults

Contraindications

Documented hypersensitivity; active peptic ulcer disease;

renal or hepatic impairment; concomitant or recent use of
anticoagulants; hemorrhagic conditions

Interactions

Probenecid may increase toxicity; may decrease effects of

loop diuretics; may increase serum lithium levels; may
prolong PT if given with anticoagulants

Pregnancy
Precautions

B - Usually safe but benefits must outweigh the risks.

Long-term use enhances potential for adverse effects,
particularly gastropathy or nephropathy

Drug Name

Naproxen sodium (Anaprox, Naprelan)

Description

First choice for treatment of headache, especially during pregnancy

and breastfeeding.

Adult Dose

275 mg PO tid or 550 mg PO bid

Pediatric Dose

<12 years: Not recommended

>12 years: Administer as in adults

Contraindications

Documented hypersensitivity; active peptic ulcer disease; renal or

hepatic impairment; concomitant or recent use of anticoagulants;
hemorrhagic conditions

Interactions

Probenecid may increase toxicity; may increase serum lithium levels;

may prolong PT if given with anticoagulants

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Long-term use enhances potential for adverse effects, particularly

gastropathy or nephropathy

Drug Category: Analgesics

These agents can be used for abortive therapy.
Drug Name

Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall, Tempra)

Description

First choice for treatment of headache, especially during pregnancy and

breastfeeding.

Adult Dose

650-1000 mg PO initially; dose may be repeated if necessary after 6h

Pediatric Dose

Contraindications

Interactions

Pregnancy

Precautions

<3 years: Not established

3-6 years: 10 mg/kg/dose PO; not to exceed 720 mg/d
6-12 years: 10 mg/kg/dose PO; not to exceed 2.6 g/d
>12 years: Administer as in adults
Documented hypersensitivity; active peptic ulcer disease; renal or hepatic
impairment; concomitant or recent use of anticoagulants; hemorrhagic conditions
Probenecid may increase toxicity; may increase serum lithium levels;
anticoagulants may prolong PT; may interfere with barbiturates, carbamazepine,
ethyl alcohol, hydantoins, rifampin, sulfinpyrazone, and other drugs
B - Usually safe but benefits must outweigh the risks.

Class A in pregnancy for short-term use; should not be used in higher and daily
doses; long-term use enhances potential for adverse effects, particularly
gastropathy or nephropathy

Drug Category: Antidepressants

These drugs increase the synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their
reuptake by the presynaptic neuronal membrane.
Cymbalta can also be helpful for patients who have coexisting depression.

Drug Name

Nortriptyline (Pamelor, Aventyl HCl)

Description

Has demonstrated effectiveness in treatment of pain.

Adult Dose

25-100 mg PO hs; not to exceed 200 mg/d

Pediatric Dose
Contraindications

Children: 0.1 mg/kg PO hs; increase as tolerated, not to exceed 0.5-2

mg/d hs
Adolescents: 25-50 mg/d PO; increase gradually to 100 mg/d
Documented hypersensitivity; narrow-angle glaucoma; MAOIs within 14 d

Interactions

Cimetidine may increase levels; may increase PT in patients stabilized

with warfarin

Pregnancy

D - Unsafe in pregnancy

Precautions

Patients with cardiac conduction disturbances or history of

hyperthyroidism or renal or hepatic impairment; avoid using in elderly
patients

Drug Name

Amitriptyline (Elavil)

Description

Has demonstrated effectiveness in treatment of pain.

Adult Dose

25-100 mg PO hs; not to exceed 150 mg/d

Pediatric Dose

Contraindications

Children: 0.1 mg/kg PO hs; increase as tolerated, not to exceed 0.5-2 mg/d qhs
Adolescents: 25-50 mg/d PO; increase gradually to 100 mg/d

Documented hypersensitivity; narrow-angle glaucoma; MAOIs within 14 d

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system

inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of
guanethidine; may interact with thyroid medications, alcohol, CNS depressants,
barbiturates, and disulfiram

Pregnancy

D - Unsafe in pregnancy

Precautions

Caution in cardiac conduction disturbances, history of hyperthyroidism, renal or hepatic

impairment; avoid using in elderly patients

Drug Category: Serotonin reuptake inhibitors

These agents specifically inhibit presynaptic reuptake of serotonin. May be considered
as an alternative to TCAs.
Drug Name

Fluoxetine (Prozac)

Description

Has potent specific 5-HT uptake inhibition with fewer anticholinergic and
cardiovascular adverse effects than TCAs.

Adult Dose

10 mg PO on waking; can be increased q2wk; not to exceed 60 mg/d

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic

disease

Interactions

Serious, potentially fatal reactions such as autonomic instability may occur

with concurrent MAOIs; other antidepressants, phenothiazines, group IC antiarrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and warfarin

Pregnancy

Precautions

C - Safety for use during pregnancy has not been established.

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other
sexual dysfunctions have been reported; nausea, flulike symptoms, and
agitation that resolve within 1-2 wk also are noted

Drug Name

Paroxetine (Paxil)

Description

Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and
fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult Dose

10 mg/d PO initially; titrate prn; not to exceed 50 mg/d

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic

disease

Interactions

Serious, potentially fatal reactions such as autonomic instability may occur with
concurrent MAOIs; other antidepressants, phenothiazines, group IC antiarrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and warfarin

Pregnancy

Precautions

C - Safety for use during pregnancy has not been established.

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual
dysfunctions have been reported; nausea, flulike symptoms, and agitation that
resolve within 1-2 wk also noted

Drug Name

Sertraline (Zoloft)

Description

Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition

and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult Dose

Start at 50 mg/d PO; increase at weekly intervals after several weeks; not to
exceed 200 mg/d

Pediatric Dose

Contraindications

Not established

Documented hypersensitivity; pregnancy and lactation; severe renal or

hepatic disease

Interactions

Serious, potentially fatal reactions such as autonomic instability may occur

with concurrent MAOIs; other antidepressants, phenothiazines, group IC antiarrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and warfarin

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other

sexual dysfunctions have been reported; nausea, flulike symptoms, and
agitation that resolve within 1-2 wk also are noted

Drug Category: Electrolyte supplements

Electrolytes such as magnesium may help in the treatment of tension headache.

Drug Name

Magnesium chloride (Slow-Mag, Mag-Delay)

Description

Magnesium metabolism may have a significant role in both the etiology and
the treatment of muscle contraction tension headache.

Adult Dose

1-2 tab PO qd/bid

Pediatric Dose
Contraindications

Interactions

Pregnancy

Precautions

Not established
Documented hypersensitivity; heart block; Addison disease; myocardial
damage; severe hepatitis
Concurrent use with nifedipine may cause hypotension and neuromuscular
blockade; may also worsen neuromuscular blockade seen with
aminoglycosides, tubocurarine, vecuronium, and succinylcholine; magnesium
may increase CNS effects and toxicity of CNS depressants, betamethasone,
and ritodrine
D - Unsafe in pregnancy
May alter cardiac conduction leading to heart block in digitalized patients;
monitor respiratory rate, deep tendon reflex, and renal function when
administered parenterally; caution when administering magnesium dose
since may produce significant hypotension or asystole

Patient Education
Advise the patient to take the following actions:
Avoid stressful situations if possible
Maintain a regular sleep schedule
Exercise regularly
Eat balanced meals
Avoid uncomfortable stressful positions and bad
posture
Avoid eyestrain
Try biofeedback and relaxation techniques

KESIMPULAN
Tension type headache didapati gejala yg
menonjol nyeri tekan yg bertambah pd
palpasi jr.miofascial perikranial.
Impuls nosiseptif dr otot perikranial yg
menjalar ke kepala mengakibatkan
timbulnya nyeri kepala & nyeri yang
bertambah pada daerah otot maupun
tendon tempat insersinya.

 TTH kondisi stress mental, nonphysiological motor stress, dan miofasial

lokal yang melepaskan zat iritatif atau
kombinasi dari ke tiganya yang menstimuli
perifer mengaktivasi struktur persepsi
supraspinal painke sentral modulasi yg
masing2 individu mempunyai sifat self
limiting yg berbeda beda dlm hal
intensitas nyeri kepalanya

 Mediator kimiawi substansi endogen :

serotonin (dilepas dr platelet), bradikinin
(dilepas dr belahan precursor plasma
molekul kallin) & Kalium (yg dilepas dari
sel otot), SP & CGRP dari aferens otot
berperan sebagai stimulan sensitisasi
terhadap nosiseptor otot skelet. Pada saat
ini peran miofascial thdp timbulnya
tension type headache.

 Pada penelitian Bendtsen tabun 1996

terhadap penderita chronic tension type
headache (yang dikutip oleh Bendtsew8)
teryata otot yang mempunyai nilai Local
tenderness score tertinggi adalah otot
Trapezeus, insersi otot leher dan otot
sternocleidomastoid.