Tension-type headaches can be painful and disabling, but they are still considered a normal, everyday occurrence. Here is a look at the causes behind headaches and how pharmacy can support sufferers

Those people lucky enough not to suffer from regular headaches can often view them as simply a niggling inconvenience. Yet for the 40 per cent of people who suffer at least once a week, headaches can be extremely debilitating, with 53 per cent of sufferers saying headaches have a negative effect on their quality of life, according to a 2014 survey of 2,000 adults by Nurofen.

“Headaches are often trivialised in the general population,” says community pharmacist Dr Terry Maguire. “But they represent a huge burden.” Indeed, the World Health Organization describes headaches as a “personal and societal burden of pain, disability, damaged quality of life and financial cost.” By far the most common type of headache is a tension-type headache (TTH), which is thought to affect around half of UK adults once or twice a month. According to NHS Choices, one in three UK adults suffer up to 15 times a month, while up to three in every 100 experience a TTH more than 15 times a month for at least three consecutive months (known as ‘chronic TTH’).

TTH is what most people consider to be a ‘normal, everyday’ headache that does not usually prevent day-to-day activities. It typically develops on the forehead above the eye or on the temples and can last from 30 minutes to several hours. Symptoms include:

• Mild to moderate tight or pressing pain
• A feeling of a tight band around the head. Can be unilateral (affecting just one side of the head) but is more often generalised
• Occasional tight neck muscles
• A feeling of pressure behind the eye.

Most people will experience a TTH at some point in their life. They can develop at any age, but usually begin during adolescence and are more common in women than men. NHS Choices does not recommend TTH sufferers visit a GP unless symptoms are severe or occur several times a week. The following cases require immediate medical attention:

• Sudden first time symptoms
• TTH symptoms alongside a very stiff neck, fever, nausea, vomiting or confusion
• TTH symptoms alongside weakness, numbness, slurred speech or confusion
• Symptoms that occur after an accident, particularly a blow to the head.

Why do TTHs occur?

One opinion is that TTHs do not exist on their own but actually feature on the mild end of the migraine spectrum, without the associated symptoms of light sensitivity or nausea. “I think at one end of the spectrum there are a very small percentage of people who get pure TTHs without any migrainous symptoms and no severe pain ever,” says Julie Sugrue, chartered physiotherapist at the Beaumont Hospital Headache Clinic. “The majority of people live somewhere along the TTH-migraine spectrum and there are only a tiny proportion of people with migraine who never get any ‘milder’ TTHs in between their migraine attacks.”

Yet Dr Fayyaz Ahmed, consultant neurologist and trustee at The Migraine Trust, disagrees: “My personal view is that TTHs do exist and are usually in people with worry or stress that makes the muscles in the head go into spasm. The head is like a bed sheet that covers the head, so when it goes into spasm, it feels like a vice crushing and putting tension on the forehead.”

TTH sufferers often have tender head and neck muscles, with increasing tenderness being linked to heightened headache frequency. Within a taut band of muscle, tender knots can develop into hyperirritable areas called myofascial trigger points. These may develop due to muscle overuse or overload, such as poor posture forcing the head to hunch forwards, or as consequence of stress, for instance clenching the jaw. While the pain may be shortlived, lasting a few hours to several days on average, the underlying cause can be chronic.

When activated, these trigger points release pain-causing chemicals, such as prostaglandins and bradykinin, which sensitise nerve endings until they reach a threshold. Once this threshold is exceeded, pain signals are sent to the brain and felt as TTHs.“The potential for a muscle to refer pain to another area of the body was first understood in the area of cardiac medicine when during a heart attack a person can feel pain in their jaw and left arm,” explains Julie.

“We now understand that sensitised nerve endings can allow any muscle to send pain to another area.” The head and neck contain more than 36 muscle groups, of which more than 20 have been identified as potential myofascial trigger points. These muscle groups are used almost constantly in everyday activities, from eating and talking to maintaining posture. Other triggers for TTH include fatigue and stress.

 

 

How to self-treat

TTHs are not life threatening and can usually be prevented with effective lifestyle changes. “TTHs should not prevent everyday activities as they’re very mild and there’s no association with the features of migraines,” says Dr Ahmed. “If you suffer frequently, consider whether it’s due to perhaps a change in your job or family situation.” Relaxation techniques including yoga, massage and regular exercise can help to reduce tension, maintain good posture and ensure the individual is well rested to prevent the development of myofascial trigger points.

“Regular exercise is excellent for the prevention of musculoskeletal pain,” explains Julie. “Moderate intensity aerobic exercise gets the blood pumping and we think this may be valuable in cleaning out pain chemicals and metabolites in muscles that can lead to pain. Stretching can also be beneficial for muscles that are tight and sore.” Applying a warm flannel to the forehead and neck may also help to ease symptoms, while NICE guidelines state that a course of up to 10 sessions of acupuncture over five to eight weeks can help to prevent chronic TTH.

Yet according to Dr Ahmed, managing stress is the most effective method of prevention: “Don’t worry – they say the past is history, tomorrow’s a mystery, so live in the now.” Dr Ahmed also recommends:

• Eating a healthy, balanced diet
• Maintaining consistent eating and sleeping habits
• Avoiding caffeinated drinks
• Limiting sugar intake.

“The easiest way to think about it is that a sensitive brain is really easy to ‘switch on’ and doing anything ‘out of routine’ can switch it on,” adds Julie. If customers are unaware of the underlying cause of their TTH, keeping a symptom diary that records diet and lifestyle habits can help to identify triggers. “TTH is a lifestyle issue,” explains Dr Ahmed. “People who have late nights and eat fast food or just eat and sleep when they can are more likely to suffer.”If lifestyle changes are ineffective or if immediate relief is required, OTC analgesics are usually effective. However, they should not be taken for more than a few days at a time to avoid medication overuse headaches.

“For occasional headaches that occur once every few months, I would say it is sensible to treat with OTC painkillers, but look at the contents,” says Dr Ahmed. “They should contain paracetamol or a NSAID but no codeine or caffeine. If someone is taking painkillers for TTH more than two days a week then you should be worried as it can become three days a week and then four days a week and then you have a medication overuse headache.”

The role of pharmacy

Headaches are one of the most common reasons why people visit pharmacies. In fact, a 2013 survey of 247 community pharmacists, conducted by Nurofen, revealed that 50 per cent of staff serve customers who are suffering from headaches more than once a day. In addition, 43 per cent believe that only a minority of customers understand the cause of their headaches, while 45 per cent feel people mistreat the pain.

“Pharmacies can support individuals in monitoring their condition before it becomes chronic,” says Dr Maguire. Staff should stress the importance of taking analgesics as prescribed, or directed by the manufacturer’s instructions, to prevent TTHs from worsening. “If you don’t use products as directed then people often use them for longer and that leads to overuse headaches,” explains Dr Maguire. Research suggests that 70 per cent of sufferers wait 20 minutes or more before treating their headache, possibly due to concerns over potential side effects or in the hope that the pain will eventually subside.

“Due to the risk of ‘adverse reactions’, patients often wait until their headache is intense before treating it and that leads to the development of trigger points,” says Dr Maguire. Eighty-nine per cent of pharmacy staff believe they could help patients manage their headaches better, while 53 per cent of customers said they would be happy for a member of the pharmacy team to approach them with advice and support, revealed the survey led by Nurofen.

This highlights the vital role pharmacies can play in treating TTHs before they become chronic. “Customers welcome advice,” explains Dr Maguire. “Intervention done properly shouldn’t be a burden as long as it’s done in a sympathetic way. Don’t ask token questions – get into a conversation that focuses on the patient. If it’s a persistent headache then they need that intervention.”