Case - Tension Type Headache

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Mr. Y, a man who works as a civil servant in Padang, aged 26 years old, declares Islam as his religion, visited Neurology Ambulatory Service on September 6th 2011 complaining headache. He reported that this headache

occurred since 10 days continuously, non pulsatile, and felt all around his head. Pain is felt as if pressing his head and affected his daily activity such as typing at the office, but routine physical activity did not increase pain intensity. The intensity in pain didn’t increase either when exposed to bright light or noisy sound. He stated that there was no occurance of nausea or vomiting, no history of head injury, and no fever. This kind of headache had been felt since 5 years ago at least twice monthly which subside after swallowing medicine in the nearby store. No member in his family has this kind of ailment. This man who does not smoke or drinks coffee spent most of his hours in front of the computer monitor. He lived with his wife and one 2 years old child.

Physical examination reveals that the patient was moderately ill, full alert, moderately nourish, and cooperative. He has black hair which it is not easily pulled from his head. The pulse was regular at 78 times/ minute without pulse deficit, breathing 22 times / minute, blood pressure 120/70 mmHg, and temperature 37.50C. Skin resiliency was good, no cyanotic sign on the skin or nail,

and jugular vein pressure was 5-2 cmH2O without carotid murmur. No

enlargement was found at lymph nodes in the neck, armpit, or inguinal.

Chest examination showed symmetric appearance statically and dynamically. Fremitus sound was equal on both sides, sonorous at percussion. Auscultation result in vesicular respiratory sound without rales or wheezing. Ictus cordis was not visible but can be felt 1 finger to the medial of left midclavicular line. Heart border was normal in percussion and auscultation reveals regular rhythm, pure


No bulging was seen on the abdomen, heart and spleen were not palpable, tympani on percussion, and abdominal sound was positively normal. There was no deformity seen on the spine and on palpation there was no pain on percussion and no tenderness.

Neurological examination uncover GCS 15 (E4M6V5). There was no sign of

meningeal excitation as revealed by negative result in the examination of stiffness in the nate of the neck, Brudzinki sign of I and II, and Kernig sign. There was neither sign of the increase in the intracranial pressure as showed by no progressive headache, no projectile vomiting, and pupil isochors at 3mm / 3mm.

Cranial nerve examination showed good smell function, normal visual acuity, normal visual field, and capable of normally recognizing colors. Pupil was isochors at 3mm diameters, positive light reflex, and eyeball can be moved toward all directions. Corneal reflex was good, chewing was normal, and also touch and pain sensation in the face were also normal. Facial appearance was symmetric, capable of closing both eyes and furrowing the forehead. The patient could hear whispering sound and the sound of the wrist watch, and no nystagmus was observed. Vomiting reflex was normal.

Faringeal arch and uvula was in normal shape, patient was capable of swallowing and creating of normal sound. Patient was also capable of turning his head and lifting his both shoulders. The tongue was in normal position either inside or outside of the mouth, was in normal shape, and no jerky movement.

Motor function was normal in all aspect at the right and left side of superior and inferior extremities. All movement were active, of normal strength, tone, and trophic. Sensibilities were good at fine and rough sensation.

Deep tendon reflex was normal at both side biceps and triceps muscles, ancle and knee joints. No pathological reflexes was found. There was no problem in urination, defecation, and sweat secretion. Limbic system was normal.


There was pericranial tenderness, positive invisible pillow sign, and positive arm chair sign.


A 26 years old male visited Neurology Ambulatory Service with headache. He had felt this kind of headache since 5 years ago at least twice monthly. On physical examination, there was pericranial tenderness, positive invisible pillow sign, and positive arm chair sign.


Frequent episodic tension type headache associated with pericarnial tenderness TOPIC DIAGNOSIS Intracranial ETIOLOGY Idiopatic SECONDARY DIAGNOSIS -THERAPY a. Medicinal therapy


b. Supportive therapy

- Perfect the posture - Prevent stress - Massage



A 26 years old male visited Neurology Ambulatory Service with headache and diagnosed Frequent episodic tension type headache associated with pericarnial tenderness. Diagnosed made by anamnesis and physical examination that associated with American Headache Society diagnostic criteria.


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.

It's likely other factors also contribute to the development of tension headaches. Potential triggers may include stress, depression and anxiety, poor posture, working in awkward positions or holding one position for a long time, and jaw clenching.

Some people with tension headaches don't seek medical attention and try to treat the pain on their own. The problem with that is that repeated use of over-the-counter (OTC) pain relievers can actually cause overuse headaches.

A variety of medications, both OTC and prescription, are available to stop or reduce the pain of an existing headache attack, including pain reliever and combination medications. Also there are preventive medications include tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and anticonvulsants and muscle relaxants. For this patient, we choose combination aspirin and caffeine to relief the pain, and also give muscle relaxants based on the theory.

Then, the patient should manage his stress. Stress is a commonly reported trigger for tension headache. One way to help reduce stress is by planning ahead and organizing your day. Another way is to allow more time to relax. And if


According to his behavior and job, he has to perfect his posture. Good posture can help keep your muscles from tensing up. It places minimal strain on your muscles, ligaments, tendons and bones. Good posture supports and protects all parts of your body and allows you to move efficiently. When standing, hold your shoulders back and your head high. Pull in your abdomen and buttocks and tuck in your chin. When sitting, make sure your thighs are parallel to the ground and your head isn't slumped forward.

Massage can help reduce stress and relieve tension. It's especially effective for relieving tight, tender muscles in the back of your head, neck and shoulders. For some people, it may also provide relief from headache pain. Gently massage the muscles of your head, neck and shoulders with your fingertips. Or have someone else do the massage for you. The American Massage Therapy Association can provide referrals to licensed practitioners.


1. ICSI Health Care Guideline: Diagnosis and Treatment of Headache, Tenth Edition. January 2011.

2. Scottish Intercollegiate Guidelines Network. Diagnosis and management of headache in adults. November 2008.

3. Mayoclicnic. Tension Headache.

4. Perdossi: Konsensus Nasional III Diagnostik dan Penatalaksanaan Nyeri Kepala. 2010.