What Is Tension-Type Headache?
General Description of Headache
Over three quarters of women and nearly 60% of men report at least one significant headache a month and nearly everyone has a least one major headache in their lifetime. Headache pain occurs in the tissues covering the brain, the attaching structures at the base of the brain, and the muscles and blood vessels around the scalp, face, and neck. The brain itself is insensitive to pain. Headache is defined as primary or secondary. Headache is considered primary when a disease or other medical condition does not cause it.
Primary Headaches. The three most common primary headaches are tension or muscle contraction, migraine, and cluster. It is not uncommon for someone to experience a combination of these headaches. In fact, some experts believe that all headaches are derived from the same mechanisms that cause migraine, and they are simply variations on a single biologic theme.
Secondary Headaches. Secondary headaches are caused by other medical conditions, such as sinusitis infection, neck injuries or abnormalities, and stroke. Research has reported over 300 disorders that can cause secondary headaches.
Tension-Type Headache
General Description. Tension-type headache (also called muscle contraction headache) is the most common of all headaches. It is often experienced in the forehead, in the back of the head and neck, or in both regions; it is described as a tight feeling, as if the head were in a vise. Soreness in the shoulders or neck is common. Tension-type headaches do not cause nausea or limit activities as migraine headaches do, although depression, anxiety, and sleeping problems may accompany persistent headaches. Sufferers of tension-type headaches are more sensitive to light than the general population, even between attacks, although not as severely as people with migraines are. They also may suffer from visual disturbances. Tension-type headaches can last minutes to days. In some cases they become chronic and may even occur daily in some sufferers.
Chronic Tension-Type Headaches. The International Headache Society has developed a classification called chronic daily headache, which is any benign headache that occurs more than 15 days a month and is not associated with a serious neurologic abnormality. Chronic, daily headaches affect about 4% to 5% of the population. Chronic daily headache is, in turn, subdivided into two categories: short-duration headaches (those lasting less than four hours) and long-duration (lasting more than four hours). The most common short-acting chronic headaches are cluster headaches. Tension-type headaches are the most common long-duration chronic headaches, and, in fact, the most common chronic headaches in general. (The other common long-duration chronic headache is chronic daily migraine, also known as transformed migraine.)
Other Common Headaches and Their Symptoms
Acute Migraine
A typical migraine attack produces throbbing pain on one side of the head, often accompanied by nausea, sometimes with vomiting; visual symptoms are common, and facial tingling or numbness may occur. Pain sometimes spreads to affect the entire head and is worsened by physical activity. Extreme sensitivity to light and noise are common, and patients may feel cold and look pale. Up to half of migraine sufferers have preheadache sensory and visual disturbances called auras.
Chronic Daily Migraines (Transformed Migraine)
In some cases, migraines evolve into chronic, daily headaches, sometimes called transformed migraines. Such headaches resemble tension-type headaches but are more likely to be accompanied by gastrointestinal distress and mental or visual disturbances and to be affected by menstrual cycles.
Sinus Headaches
Acute sinus headaches can occur in the front of the face, usually around the eyes, across the cheeks, or over the forehead. They are usually mild in the morning and increase during the day, and are typically accompanied by fever, runny nose, congestion, and general debilitation. Sinus headaches tend to be more generalized than migraines, but it is often difficult to tell them apart; they even coexist in many cases. In rare cases, sinusitis can cause double vision and even vision loss, a sign of very serious infection. Chronic sinusitis can cause a low grade general headache.
Cluster Headaches
Cluster headaches are very severe, stabbing pain centered in one eye. People often awake with them a few hours after they go to bed. Associated symptoms include excessive tearing, a drooping eyelid, and one stuffy or runny nostril, all on the same side as the pain. Feelings of intense restlessness are common, unlike migraine attacks, during which the tendency is to sleep. People in the throes of a cluster headache may pace the floor or may even bang their heads against the wall in an attempt to cope with the pain. Attacks are usually brief, lasting between 30 and 90 minutes, although they can persist for up to 3 hours. During an active period, sufferers can experience one or more bouts a day, or as few as one every other day. Patients typically experience recurrent cluster attacks over 4 to 12 weeks, with headache-free periods lasting several months or even years.
Headache Due to Neck Problems
Some headaches may be caused by abnormalities of the neck muscles resulting from prolonged poor posture (such as that caused by sitting in front of a computer keyboard or driving daily for long periods), arthritis, injuries of the upper spine, or abnormalities in the cervical spine (the spinal bones in the neck). Nerves in the neck converge in the trigeminal nerve in the face and can generate pain signals that the brain may interpret as headache. Pain is usually on one side; even if it effects both sides of the head it is usually more severe on one side. The quality of the headache may be similar to an aching tension-type headache or a mild migraine without auras.
Temporomandibular Joint Dysfunction (TMJ)
TMJ is caused by clenching the jaws or grinding the teeth (called bruxism) or by abnormalities in the jaw joints themselves. Because these actions usually happen during sleep, most people wake up with these headaches. The diagnosis is easy if chewing produces pain or if jaw motion is restricted or noisy. TMJ pain can occur in the ear, cheek, temples, neck, or shoulders.
Neuralgia
Neuralgia is pain due to nerve abnormalities, which can occur in the facial area and resemble migraine or sinus headaches. Neuralgia at the back of the head, called occipital neuralgia, may also cause headache as well as ringing in the ear, visual disturbances, and abnormal sensations in the scalp.
Transformed Migraines
Transformed migraines resemble tension-type headaches but are more likely to be accompanied by gastrointestinal distress and mental or visual disturbances and to be affected by menstrual cycles. They are often confused with rebound headache, since one evolves from migraines.
Rebound Headache
Symptoms of chronic headache caused by withdrawal from caffeine or headache medications often occur in the morning upon waking up. Tracking any triggers and times of medications and withdrawal is helpful in differentiating from other types, such as transformed migraine. Rebound headaches are usually more variable in severity and location and are more sensitive to triggers than transformed migraines.
How Serious Are Tension-Type Headaches?
The negative impact of chronic headaches on quality of life, families, and even work productivity can be significant and is generally underrated by the health profession.
In one 2000 study, two-thirds of patients with chronic tension-type headaches reported daily or near daily headaches for an average of seven years. Only 12% reported headaches occurring less than 20 days a month. In the study, 74% of the patients had to take some time off from work because of the headaches, and about a third reported impaired sleep, energy, and emotional well-being on 10 or more days a month. Most were able to carry out their daily responsibility even when in pain, although at lower than normal capacity. This and other studies report a strong association between anxiety and depression and chronic tension-type headaches.
One group of researchers studied the ability of people with chronic headaches to cope during an attack. Those with tension-type headaches tended to have higher anxiety and lower quality of life than people with migraines (who, however, were less able to cope during a headache). People with any chronic, persistent headache had greater psychologic disabilities than those who experienced only episodic headache.
What Causes Tension And Other Chronic Daily Headaches?
Because of its high prevalence, tension-type headache is among the most costly diseases in the US ; given this, it is surprising that so little scientific attention has been focused on determining the cause or causes of this widespread problem. There does not appear to be a single cause of chronic tension-type headache but many factors are involved in causing the disorder.
Muscle Contractions
The basic source of tension-type headaches is most likely muscle contraction in the head, neck, and shoulders. Reduced blood flow in the tensed areas may result in the buildup of irritating waste products in the tissues, which, in turn, cause the pain of headache. Pain can last long after the muscles have relaxed. Tension-type headache may be either an acute response to specific events or a chronic syndrome caused by repeated or continuing states of muscle contraction. Little is known about the basic biologic events that cause such contractions.
Increased Muscle Tenderness and Sensitivity to Pain
Studies have suggested that tension-type headache sufferers may have higher-than-average muscle tenderness in the face and head that make them more susceptible to headache after muscle contractions. A few studies suggest that some patients with chronic headaches may be overly sensitive to pain in general or may overestimate muscle contraction pain. (Actual peptides and other biologic factors in the central nervous system involved in regulating pain appear to be normal in chronic tension-type headache.)
Biologic Factors
Serotonin Levels. Abnormalities in serotonin levels have also been observed in tension headache sufferers. Serotonin is a neurotransmitter (chemical messenger in the brain) that is important for sleep, well-being, and other factors that affect quality of life.
Gynecologic Factors. Women can experience persistent headaches during periods of hormonal changes, including menstruation, onset of pregnancy, termination of pregnancy or delivery, and menopause. Many clinicians have also anecdotally linked gynecologic problems, such as ovarian cysts and menstrual disorders, to chronic headaches, and data are emerging to support this association.
Temperomandibular Joint Dysfunction (TMJ). Muscle contractions that cause headaches may be a result of temperomandibular joint dysfunction, which is caused by clenching the jaws or grinding the teeth (usually during sleep), or by abnormalities in the jaw joints themselves.
Genetic Factors
Genetic factors appear to play a role in predisposing people to recurrent tension headaches. One study of twins suggested that the chances of inheriting the susceptibility to recurring headaches (both migraine and tension) were about 70% in close relatives. The trait is equal in both boys and girls. Because such headaches tend to occur in females, however, other factors, such as hormonal, social, or psychological, must play a role in their development.
Psychologic Factors
Stress. Tension-type headache episodes are highly associated with stress and stressful events. (Sometimes the headache doesn’t even start until long after a stressful event is over.) Some research suggests that tension-type headache victims may actually have some biological predisposition for translating stress into muscle contraction.
Emotional Disorders. Although one study indicated that nearly half of those with chronic tension-type headaches had anxiety or depression disorder, people with such headaches do not often show signs of emotional problems. One study suggested that people with panic disorder had a very high risk for headaches, particularly migraine without auras and tension-type headaches. Having such headaches also increased the severity of the anxiety disorder. It is not clear whether the emotional disorders cause the headaches or are a result of them.
Causes of Other Chronic Daily Headaches
Transformed Migraines. In some cases, migraines naturally evolve into chronic, daily headaches referred to as transformed migraines.
Rebound Headache. Many persistent headaches are actually the result of the rebound effect caused by the overuse of migraine medications. In such cases, drugs have usually been taken for more than three days a week on an ongoing basis. If patients stop taking them, they experience rebound headaches, so they start taking the drugs again. Eventually the headache simply persists and medications are no longer effective. Medications implicated in rebound migraines include simple painkillers (eg, aspirin, ibuprofen), barbiturates, sedatives, narcotics, and migraine medications, particularly those that also contain caffeine. (Heavy caffeine use can also cause this condition.)
Head Injury. One study of patients who had chronic headaches after suffering an injury reported that the symptoms were similar to patients with chronic headaches of unknown cause. More men than women had post-traumatic headache, which is a reversal of the tension-headache gender ratio. Experts believe this might suggest actual changes in brain function. However, it is not known whether liability and worker’s compensation issues may have some effect on the persistence of some of these headaches.
Who Gets Tension And Chronic Daily Headaches?
Age, Gender, and Ethnicity
Tension-type headaches account for about two-thirds of all headaches. Almost 40% of Indians have episodes of tension-type headache each year, and virtually everyone experiences tension-type headache at some point in their life. International studies suggest that the prevalence is as high in any other developed country in both the East and the West. Surveys indicate that about up to 5% of people have chronic tension-type headaches, which can last up to several weeks. Tension-type headaches usually begin in adulthood, but can occur in childhood as well. Those at highest risk are middle-aged women, and people who are well educated.
Some Specific Risk Factors for Tension-Type Headaches
Ruling Out Other Common Headaches
Diagnosing the cause of persistent daily headache is a difficult one, even for expert physicians. Tension-type headache, although the most common chronic daily headache, is usually diagnosed after ruling out other types. [See Box Common Headaches and Their Symptoms, above.] It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.
Medical and Personal History
For an accurate diagnosis, the patient should describe the duration and frequency of headaches, recent changes in their character, the location of the pain, the type (eg, throbbing or steady pressure), the intensity, and any associated symptoms, such as visual disturbances or nausea and vomiting. To diagnose migraine headaches. The patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is very useful. The patient should report any chronic or recent illness or injuries, particularly head or back injuries, and their treatments. The physician should be told about uncharacteristic dietary changes, any current medications, or recent withdrawals from any drugs, including over-the-counter or so-called natural remedies. The patient should be honest about any history of caffeine, alcohol, or drug abuse. Patients should also discuss with the physician any serious stress, depression, and anxiety. The physician will also need a general medical and family history of headaches or diseases, such as epilepsy, that may increase their risk. Migraine, in particular, tends to run in families.
Physical Examination
In order to diagnose a chronic headache, the physician will examine the head and neck and will usually perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The physician may ask questions to test short-term memory and related aspects of mental function.
If the results of the history and physical examination suggest other or accompanying causes of headaches or serious complications, more extensive tests are performed. [See Box, Headache Symptoms of Serious Underlying Disorders.]
Imaging Tests
In general, imaging tests are expensive and not warranted in patients with tension-type headaches unless complications or serious causes are suspected. Indications for more advanced testing include the presence of seizures, changes in headache patterns, or abnormal neurologic signs or symptoms. Some experts also believe they should be used for patients who come to the emergency room with sudden headaches after exertion. A computed tomography (CT) scan may be ordered to rule out brain disorders or headaches caused by chronic sinusitis. X-Rays and other tests may also be used if sinusitis is strongly suspected. A neck X-Ray can reveal arthritis or spinal problems. Other tests include an MRI (magnetic resonance imaging), EEG (electroencephalogram), lumbar puncture, ultrasound testing, and cerebral angiography, which are only performed if there is reason to suspect an underlying disease.
Identifying Emergency or Serious Conditions
Headaches indicating a serious underlying problem, such as stroke or malignant hypertension, are uncommon. People with existing chronic headaches who experience changes in their pattern or intensity, however, might miss a more serious condition believing the pain to be one of their usual headaches. Such patients should call a physician promptly if they experience such changes. Everyone should call a physician for any sudden, severe headache that persists or increases in intensity over 24 hours or for chronic or severe headaches that begin after age fifty. In fact, in the elderly with persistent headaches, it is most important to rule out age-related disorders, including stroke, hypoglycemia, hydrocephalus, and head injuries (usually from falls). [See Table, Headache Symptoms of Serious Underlying Disorders.]
Headache Symptoms of Serious Underlying Disorders
Given the very high prevalence of tension-type headaches, some experts express frustration over the dearth of serious scientific attention given to this problem. As a result, although simple over-the-counter pain relievers are sufficient for mild symptoms, there are few proven therapies for chronic tension-type headaches. Fortunately, most tension-type headaches resolve on their own without any treatments. Studies on remedies for prevention of chronic daily headaches are even weaker. Only antidepressants have been extensively studied; the value of most treatments is known only from anecdotal reports.
Over-the-Counter Medications
NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, substances that dilate blood vessels and cause inflammation. NSAIDs are usually the first drugs tried for almost any kind of headache. There are dozens of NSAIDs. Aspirin is the most common; others include ibuprofen (Brufen), indomethacin (Inmecin), naprosyn (Naprosyn), piroxicam (Pirox), and ketorolac (Ketanov).
Acetaminophen. Acetaminophen (Crocin,Metacin,Calpol) is a good alternative to these drugs when stomach distress, ulcers, or allergic reactions prohibit their use. COX-2 Inhibitors. Celecoxib (Celact), Etoricoxib(Ezact) are known as COX-2 (cyclooxygenase-2) inhibitors, the so-called super-aspirins. They may prove to be beneficial for chronic tension-type headache without incurring as high risk for ulcers and bleeding.
Antidepressants
Antidepressants may be useful in preventing tension-type headaches. Those known as the tricyclics and monoamine oxidase inhibitors are the gold-standard for prevention of severe chronic tension-type headaches. Others, known as SSRIs, are also sometimes used in milder cases.
Tricyclic Antidepressants. Tricyclics are useful not only for depression but appear to help relieve muscle pain and improve sleep as well. The tricyclic drug most commonly used is amitriptyline (Eliwel), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include doxepin (Spectra), imipramine (Tofranil), and nortriptyline (Sensiwal).
Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) work by increasing levels of serotonin in the brain. SSRIs include fluoxetine (Prodep), sertraline (Serta).
Antianxiety Agents
Mild antianxiety agents are occasionally used as an adjunct in treating chronic headaches to decrease muscle contraction or to treat anxiety symptoms during periods of extreme stress. They include alprazolam (Restyl) and clonazepam (Epitril). They tend to be highly addictive, however, and should therefore be used only on a short-term basis.
Botulism
Botulinum toxin A (Botox) injections are now widely used to relax muscles and reduce skin wrinkles. They are also being investigated for chronic headaches. (This potentially deadly toxin is very safe when minuscule amounts are injected into small muscles.)
Tizanidine
Tizanidine (Tizan) is an agent that helps prevent muscle spasms. In two studies of patients with chronic tension-type headache who took tizanidine for at least three months, nearly 70% of patients reported a reduction in headache days by 50% or more. Side effects are minor and include fatigue and dry mouth.
What Are Non Drug Treatments For Tension-Type Headaches?
Good Health Habits
Good health habits, including adequate sleep, healthy diet, regular exercise, and good stress management are important, along with the following specific measures for headache management. Quitting smoking is essential in reducing the risks for all headaches.
Healthy Diet
A healthy diet rich in fresh fruits and vegetables and whole grains and low in saturated fats (animal fats) is important to everyone. Fish (particularly oily fish such as salmon and tuna) and soy are protein sources that may be a good alternative to red meats.
Caffeine
In some people with headaches, caffeine appears to be an excellent companion to medications. One study found that the caffeine equivalent of two and a half of cups of coffee can help treat a tension-type headache by itself. Taking ibuprofen along with caffeine is even more effective than either substance alone. (It should be noted that in some people with migraines, the tannin found in coffee or tea may be a trigger for the headache.)
Trigger Point Needling
In trigger point needling, the physician uses an instrument called a pressure algometer, finds the source of the headache pain (the trigger point), and injects a pain reliever directly into the site. The needle is then used to break up any fluid or scar tissue in the area. The patient is required to perform therapeutic exercises after the procedure. This treatment may sound worse than the headache itself, but studies are reporting success with it in treating tension-type headaches and some migraines.
Spinal Manipulation
A number of small studies have suggested that spinal manipulation by chiropractors or osteopaths may have some benefits for people with tension-type headache. Although techniques vary, the basic approach is to manipulate and stretch the spine beyond an elastic barrier of resistance but not so far as to impair the structure. The vertebrae may be moved directly or by stretching a muscle, such as in the thigh. One 1998 study found that spinal manipulation had no benefit for patients with episodic tension-type headaches. Some practitioners argued that the specific techniques studied were not appropriate ones for tension-type headaches, that the study was too short (19 weeks), and only areas around the neck and upper body were manipulated in the study rather than the entire body, which may have provided more benefit. (Evidence is stronger, however, on benefits of spinal manipulation for patients with headaches originating from nerve or muscular problems in the neck. In fact, some experts believe that tension-type headaches relieved by spinal manipulation are probably really caused by neck problems.)
Side effects of spinal manipulation include local or radiating discomfort, headache, and fatigue; they rarely last longer than 24 hours. It should be noted that there have been reports of stroke or blood clots after spinal manipulation in the neck area, even in people without a previous history of these events. Although these complications are rare, people with risk factors for stroke should not use this approach.
Cervical Epidural Nerve Block
In cases where abnormalities or injuries in the cervical spine (the spinal bones in the neck) cause headaches, a cervical epidural nerve block may be beneficial in treating and preventing further pain. This procedure involves injecting small amounts of a corticosteroid and anesthetic into spaces between the vertebrae in the neck to block the nerves. Some patients have reported significant pain relief from this procedure.
Dental Adjustments
One interesting 1999 European study tested whether dental adjustment to help teeth bite down evenly might help some people with chronic headaches. The results indicated that those who underwent real dental adjustments had a better long-term response than those who had a mock adjustment. People with an uneven bite and chronic headaches might consider discussing this option with their dentists.
Treatment of Sleep Disorders
Headaches that occur during the night and early morning may be related to sleep disorders. One study reported that treating an underlying sleep disorder, such as sleep apnea or insomnia, in patients who also had headaches resulted in headache cure or improvement in all patients except those who suffered from restless legs syndrome.
What Are The Alternative Treatments Used For Tension-Type Headache?
Many alternative therapies are used for headache management, including meditation, acupuncture, acupressure, and yoga. Some have proven to be helpful and most are not harmful. A few are discussed below. Patients should always be wary, however, of methods that are unproven.
Relaxation and Related Stress Reduction Therapies
A number of stress-reduction methods are available that may help may help counteract the tendency for muscle contraction and uneven blood flow associated with some headaches. In choosing specific strategies for treating stress, several factors should be considered. First, no single method is uniformly successful: a combination of approaches is generally most effective. Second, what works for one person does not necessarily work for someone else. Third, stress can be positive as well as negative. Appropriate and controllable stress provides interest and excitement and motivates the individual to greater achievement, while a lack of stress may lead to boredom and depression. Among the stress reduction techniques that may be helpful are cognitive-behavioral therapy, muscle relaxation exercises, massage therapy, hypnosis, and biofeedback. One expert reported that correct breathing from the diaphragm relieved tension-type headaches in some of his patients. Hypnosis appears to be very effective in some people. Any of these therapies may be used in conjunction with drug therapy.
Acupuncture and Acupressure
An analysis of studies on acupuncture and tension-type headache suggest that they may have some benefit. In one study, more patients improved with relaxation methods than with acupuncture, but both treatments were helpful. However, evidence is still weak and better research is needed. One acupressure practitioner reports that pressing for 60 seconds on the web space between the forefinger and thumb of the dominant hand erases headache in patients with migraine and tension-type headaches. The specific spot pressed should be the most tender point in the web area. The patient should than lie down for about 15 minutes.
Ice Water
A novel treatment uses ice water that circulates for 15 minutes through metal tubes placed in the back of the jaw. In one small study, this procedure reduced pain in four out of six patients whose headaches were associated with neck problems.
Percutaneous Electrical Nerve Stimulation
A technique called percutaneous electrical nerve stimulation (PENS) uses low-level electrical pulses delivered through acupuncture needles into soft tissue. Patients are barely aware of the sensation. In a 2000 study, patients with chronic tension, migraine, and post-injury headache treated using either PENS or just needles. After six months of such treatments, those using PENS reported reductions in pain score of nearly 60% in migraine and tension-type headaches and 52% in injury-related headache, which were significantly greater than the needles alone. Energy levels and quality of sleep also improved.
Where Else Can Headache Sufferers Get Information?
National Headache Foundation, 428 West St. James Place , 2nd Floor, Chicago , Internet (http://www.headaches.org)
Publishes an excellent quarterly newsletter, Head Lines , containing news, research reports, book reviews, letters and other items.
American Headache Society (http://www.ahsnet.org/) and affiliated organization American Council for Headache Education (http://www.achenet.org/)
American Academy of Neurology, 1080 Montreal Avenue , St. Paul , Minnesota 55116 . Call (651-695-1940) or on the Internet (http://www.aan.com/)
Web site offers good information and provides names of neurologists for specific locations.
National Institute of Neurological Disorders and Stroke, PO Box 5801 , Bethesda , MD 20824 . Call (301-496-5751) or on the Internet (www.ninds.nih.gov)
General Description of Headache
Over three quarters of women and nearly 60% of men report at least one significant headache a month and nearly everyone has a least one major headache in their lifetime. Headache pain occurs in the tissues covering the brain, the attaching structures at the base of the brain, and the muscles and blood vessels around the scalp, face, and neck. The brain itself is insensitive to pain. Headache is defined as primary or secondary. Headache is considered primary when a disease or other medical condition does not cause it.
Primary Headaches. The three most common primary headaches are tension or muscle contraction, migraine, and cluster. It is not uncommon for someone to experience a combination of these headaches. In fact, some experts believe that all headaches are derived from the same mechanisms that cause migraine, and they are simply variations on a single biologic theme.
Secondary Headaches. Secondary headaches are caused by other medical conditions, such as sinusitis infection, neck injuries or abnormalities, and stroke. Research has reported over 300 disorders that can cause secondary headaches.
Tension-Type Headache
General Description. Tension-type headache (also called muscle contraction headache) is the most common of all headaches. It is often experienced in the forehead, in the back of the head and neck, or in both regions; it is described as a tight feeling, as if the head were in a vise. Soreness in the shoulders or neck is common. Tension-type headaches do not cause nausea or limit activities as migraine headaches do, although depression, anxiety, and sleeping problems may accompany persistent headaches. Sufferers of tension-type headaches are more sensitive to light than the general population, even between attacks, although not as severely as people with migraines are. They also may suffer from visual disturbances. Tension-type headaches can last minutes to days. In some cases they become chronic and may even occur daily in some sufferers.
Chronic Tension-Type Headaches. The International Headache Society has developed a classification called chronic daily headache, which is any benign headache that occurs more than 15 days a month and is not associated with a serious neurologic abnormality. Chronic, daily headaches affect about 4% to 5% of the population. Chronic daily headache is, in turn, subdivided into two categories: short-duration headaches (those lasting less than four hours) and long-duration (lasting more than four hours). The most common short-acting chronic headaches are cluster headaches. Tension-type headaches are the most common long-duration chronic headaches, and, in fact, the most common chronic headaches in general. (The other common long-duration chronic headache is chronic daily migraine, also known as transformed migraine.)
Other Common Headaches and Their Symptoms
Acute Migraine
A typical migraine attack produces throbbing pain on one side of the head, often accompanied by nausea, sometimes with vomiting; visual symptoms are common, and facial tingling or numbness may occur. Pain sometimes spreads to affect the entire head and is worsened by physical activity. Extreme sensitivity to light and noise are common, and patients may feel cold and look pale. Up to half of migraine sufferers have preheadache sensory and visual disturbances called auras.
Chronic Daily Migraines (Transformed Migraine)
In some cases, migraines evolve into chronic, daily headaches, sometimes called transformed migraines. Such headaches resemble tension-type headaches but are more likely to be accompanied by gastrointestinal distress and mental or visual disturbances and to be affected by menstrual cycles.
Sinus Headaches
Acute sinus headaches can occur in the front of the face, usually around the eyes, across the cheeks, or over the forehead. They are usually mild in the morning and increase during the day, and are typically accompanied by fever, runny nose, congestion, and general debilitation. Sinus headaches tend to be more generalized than migraines, but it is often difficult to tell them apart; they even coexist in many cases. In rare cases, sinusitis can cause double vision and even vision loss, a sign of very serious infection. Chronic sinusitis can cause a low grade general headache.
Cluster Headaches
Cluster headaches are very severe, stabbing pain centered in one eye. People often awake with them a few hours after they go to bed. Associated symptoms include excessive tearing, a drooping eyelid, and one stuffy or runny nostril, all on the same side as the pain. Feelings of intense restlessness are common, unlike migraine attacks, during which the tendency is to sleep. People in the throes of a cluster headache may pace the floor or may even bang their heads against the wall in an attempt to cope with the pain. Attacks are usually brief, lasting between 30 and 90 minutes, although they can persist for up to 3 hours. During an active period, sufferers can experience one or more bouts a day, or as few as one every other day. Patients typically experience recurrent cluster attacks over 4 to 12 weeks, with headache-free periods lasting several months or even years.
Headache Due to Neck Problems
Some headaches may be caused by abnormalities of the neck muscles resulting from prolonged poor posture (such as that caused by sitting in front of a computer keyboard or driving daily for long periods), arthritis, injuries of the upper spine, or abnormalities in the cervical spine (the spinal bones in the neck). Nerves in the neck converge in the trigeminal nerve in the face and can generate pain signals that the brain may interpret as headache. Pain is usually on one side; even if it effects both sides of the head it is usually more severe on one side. The quality of the headache may be similar to an aching tension-type headache or a mild migraine without auras.
Temporomandibular Joint Dysfunction (TMJ)
TMJ is caused by clenching the jaws or grinding the teeth (called bruxism) or by abnormalities in the jaw joints themselves. Because these actions usually happen during sleep, most people wake up with these headaches. The diagnosis is easy if chewing produces pain or if jaw motion is restricted or noisy. TMJ pain can occur in the ear, cheek, temples, neck, or shoulders.
Neuralgia
Neuralgia is pain due to nerve abnormalities, which can occur in the facial area and resemble migraine or sinus headaches. Neuralgia at the back of the head, called occipital neuralgia, may also cause headache as well as ringing in the ear, visual disturbances, and abnormal sensations in the scalp.
Transformed Migraines
Transformed migraines resemble tension-type headaches but are more likely to be accompanied by gastrointestinal distress and mental or visual disturbances and to be affected by menstrual cycles. They are often confused with rebound headache, since one evolves from migraines.
Rebound Headache
Symptoms of chronic headache caused by withdrawal from caffeine or headache medications often occur in the morning upon waking up. Tracking any triggers and times of medications and withdrawal is helpful in differentiating from other types, such as transformed migraine. Rebound headaches are usually more variable in severity and location and are more sensitive to triggers than transformed migraines.
How Serious Are Tension-Type Headaches?
The negative impact of chronic headaches on quality of life, families, and even work productivity can be significant and is generally underrated by the health profession.
In one 2000 study, two-thirds of patients with chronic tension-type headaches reported daily or near daily headaches for an average of seven years. Only 12% reported headaches occurring less than 20 days a month. In the study, 74% of the patients had to take some time off from work because of the headaches, and about a third reported impaired sleep, energy, and emotional well-being on 10 or more days a month. Most were able to carry out their daily responsibility even when in pain, although at lower than normal capacity. This and other studies report a strong association between anxiety and depression and chronic tension-type headaches.
One group of researchers studied the ability of people with chronic headaches to cope during an attack. Those with tension-type headaches tended to have higher anxiety and lower quality of life than people with migraines (who, however, were less able to cope during a headache). People with any chronic, persistent headache had greater psychologic disabilities than those who experienced only episodic headache.
What Causes Tension And Other Chronic Daily Headaches?
Because of its high prevalence, tension-type headache is among the most costly diseases in the US ; given this, it is surprising that so little scientific attention has been focused on determining the cause or causes of this widespread problem. There does not appear to be a single cause of chronic tension-type headache but many factors are involved in causing the disorder.
Muscle Contractions
The basic source of tension-type headaches is most likely muscle contraction in the head, neck, and shoulders. Reduced blood flow in the tensed areas may result in the buildup of irritating waste products in the tissues, which, in turn, cause the pain of headache. Pain can last long after the muscles have relaxed. Tension-type headache may be either an acute response to specific events or a chronic syndrome caused by repeated or continuing states of muscle contraction. Little is known about the basic biologic events that cause such contractions.
Increased Muscle Tenderness and Sensitivity to Pain
Studies have suggested that tension-type headache sufferers may have higher-than-average muscle tenderness in the face and head that make them more susceptible to headache after muscle contractions. A few studies suggest that some patients with chronic headaches may be overly sensitive to pain in general or may overestimate muscle contraction pain. (Actual peptides and other biologic factors in the central nervous system involved in regulating pain appear to be normal in chronic tension-type headache.)
Biologic Factors
Serotonin Levels. Abnormalities in serotonin levels have also been observed in tension headache sufferers. Serotonin is a neurotransmitter (chemical messenger in the brain) that is important for sleep, well-being, and other factors that affect quality of life.
Gynecologic Factors. Women can experience persistent headaches during periods of hormonal changes, including menstruation, onset of pregnancy, termination of pregnancy or delivery, and menopause. Many clinicians have also anecdotally linked gynecologic problems, such as ovarian cysts and menstrual disorders, to chronic headaches, and data are emerging to support this association.
Temperomandibular Joint Dysfunction (TMJ). Muscle contractions that cause headaches may be a result of temperomandibular joint dysfunction, which is caused by clenching the jaws or grinding the teeth (usually during sleep), or by abnormalities in the jaw joints themselves.
Genetic Factors
Genetic factors appear to play a role in predisposing people to recurrent tension headaches. One study of twins suggested that the chances of inheriting the susceptibility to recurring headaches (both migraine and tension) were about 70% in close relatives. The trait is equal in both boys and girls. Because such headaches tend to occur in females, however, other factors, such as hormonal, social, or psychological, must play a role in their development.
Psychologic Factors
Stress. Tension-type headache episodes are highly associated with stress and stressful events. (Sometimes the headache doesn’t even start until long after a stressful event is over.) Some research suggests that tension-type headache victims may actually have some biological predisposition for translating stress into muscle contraction.
Emotional Disorders. Although one study indicated that nearly half of those with chronic tension-type headaches had anxiety or depression disorder, people with such headaches do not often show signs of emotional problems. One study suggested that people with panic disorder had a very high risk for headaches, particularly migraine without auras and tension-type headaches. Having such headaches also increased the severity of the anxiety disorder. It is not clear whether the emotional disorders cause the headaches or are a result of them.
Causes of Other Chronic Daily Headaches
Transformed Migraines. In some cases, migraines naturally evolve into chronic, daily headaches referred to as transformed migraines.
Rebound Headache. Many persistent headaches are actually the result of the rebound effect caused by the overuse of migraine medications. In such cases, drugs have usually been taken for more than three days a week on an ongoing basis. If patients stop taking them, they experience rebound headaches, so they start taking the drugs again. Eventually the headache simply persists and medications are no longer effective. Medications implicated in rebound migraines include simple painkillers (eg, aspirin, ibuprofen), barbiturates, sedatives, narcotics, and migraine medications, particularly those that also contain caffeine. (Heavy caffeine use can also cause this condition.)
Head Injury. One study of patients who had chronic headaches after suffering an injury reported that the symptoms were similar to patients with chronic headaches of unknown cause. More men than women had post-traumatic headache, which is a reversal of the tension-headache gender ratio. Experts believe this might suggest actual changes in brain function. However, it is not known whether liability and worker’s compensation issues may have some effect on the persistence of some of these headaches.
Who Gets Tension And Chronic Daily Headaches?
Age, Gender, and Ethnicity
Tension-type headaches account for about two-thirds of all headaches. Almost 40% of Indians have episodes of tension-type headache each year, and virtually everyone experiences tension-type headache at some point in their life. International studies suggest that the prevalence is as high in any other developed country in both the East and the West. Surveys indicate that about up to 5% of people have chronic tension-type headaches, which can last up to several weeks. Tension-type headaches usually begin in adulthood, but can occur in childhood as well. Those at highest risk are middle-aged women, and people who are well educated.
Some Specific Risk Factors for Tension-Type Headaches
- Poor posture.
- Overwork.
- Intense physical exertion (including sexual activity). Athletes are at higher risk for headaches. (A sedentary lifestyle, however, may increase the risk for stress and thereby also be a risk factor for tension headaches.) Environmental assaults, such as noise, bright light, or weather changes. Upper respiratory tract infections, such as colds and flus, can produce tension-type headache. In fact, according to one 1999 study, tension-type headache in children is most often associated with such infections. Sleep disorders, such as insomnia or sleep apnea, may contribute to tension headache, particularly those that occur at night or early morning. (In one study, for example, treating people with chronic headaches for sleep apnea cured the headaches in many cases.)
- Hypothyroidism.
- Eyestrain.
- Dental problems.
- Allergies.
- Caffeine withdrawal.
- Substance or alcohol abuse also commonly causes headaches.
- The rapid consumption of ice cream or other very cold foods or beverages is a well-known trigger of sudden headache pain. It is worth mentioning because it can be easily prevented by warming the food or drink for a few seconds in the front of the mouth before swallowing.)
Ruling Out Other Common Headaches
Diagnosing the cause of persistent daily headache is a difficult one, even for expert physicians. Tension-type headache, although the most common chronic daily headache, is usually diagnosed after ruling out other types. [See Box Common Headaches and Their Symptoms, above.] It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.
Medical and Personal History
For an accurate diagnosis, the patient should describe the duration and frequency of headaches, recent changes in their character, the location of the pain, the type (eg, throbbing or steady pressure), the intensity, and any associated symptoms, such as visual disturbances or nausea and vomiting. To diagnose migraine headaches. The patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is very useful. The patient should report any chronic or recent illness or injuries, particularly head or back injuries, and their treatments. The physician should be told about uncharacteristic dietary changes, any current medications, or recent withdrawals from any drugs, including over-the-counter or so-called natural remedies. The patient should be honest about any history of caffeine, alcohol, or drug abuse. Patients should also discuss with the physician any serious stress, depression, and anxiety. The physician will also need a general medical and family history of headaches or diseases, such as epilepsy, that may increase their risk. Migraine, in particular, tends to run in families.
Physical Examination
In order to diagnose a chronic headache, the physician will examine the head and neck and will usually perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The physician may ask questions to test short-term memory and related aspects of mental function.
If the results of the history and physical examination suggest other or accompanying causes of headaches or serious complications, more extensive tests are performed. [See Box, Headache Symptoms of Serious Underlying Disorders.]
Imaging Tests
In general, imaging tests are expensive and not warranted in patients with tension-type headaches unless complications or serious causes are suspected. Indications for more advanced testing include the presence of seizures, changes in headache patterns, or abnormal neurologic signs or symptoms. Some experts also believe they should be used for patients who come to the emergency room with sudden headaches after exertion. A computed tomography (CT) scan may be ordered to rule out brain disorders or headaches caused by chronic sinusitis. X-Rays and other tests may also be used if sinusitis is strongly suspected. A neck X-Ray can reveal arthritis or spinal problems. Other tests include an MRI (magnetic resonance imaging), EEG (electroencephalogram), lumbar puncture, ultrasound testing, and cerebral angiography, which are only performed if there is reason to suspect an underlying disease.
Identifying Emergency or Serious Conditions
Headaches indicating a serious underlying problem, such as stroke or malignant hypertension, are uncommon. People with existing chronic headaches who experience changes in their pattern or intensity, however, might miss a more serious condition believing the pain to be one of their usual headaches. Such patients should call a physician promptly if they experience such changes. Everyone should call a physician for any sudden, severe headache that persists or increases in intensity over 24 hours or for chronic or severe headaches that begin after age fifty. In fact, in the elderly with persistent headaches, it is most important to rule out age-related disorders, including stroke, hypoglycemia, hydrocephalus, and head injuries (usually from falls). [See Table, Headache Symptoms of Serious Underlying Disorders.]
Headache Symptoms of Serious Underlying Disorders
- Very sudden, very severe headache, worse than any headache ever experienced (possibility of ruptured aneurysm in the brain).
- Headache begins very suddenly and evolves over several hours, accompanied by nausea, vomiting, sensitivity to light, and altered mental states (possibility of hemorrhagic stroke).
- Headaches accompanied by memory loss, confusion, loss of balance, changes in speech or vision, or loss of strength in or numbness or tingling in arms or legs (possibility of stroke from blockage of oxygen to the brain).
- Headaches after head injury, especially if drowsiness or nausea are present (possibility of internal bleeding or skull fracture).
- Headaches accompanied by fever, sensitivity to light, stiff neck, nausea and vomiting. Pain may be relieved by lying down (possibility of meningitis).
- Headaches that increase with coughing or straining (possibility of brain swelling).
- A throbbing pain around or behind the eyes or in the forehead accompanied by redness in the eye and perceptions of halos or rings around lights (possibility of acute glaucoma).
- A one-sided headache in the temple, the artery in the temple is firm and knotty and has no pulse, scalp is tender (possibility of temporal arteritis, a headache that is more likely in elderly people, particularly those with polymyalgia rheumatica. Untreated, it can cause blindness or even stroke).
- Sudden onset and then persistent, throbbing pain around the eye possibly spreading to the ear or neck unrelieved by pain medication (possibility of blood clot in one of the sinus veins of the brain).
- Headache accompanied by drowsiness, confusion, headache, nausea, and loss of vision in someone with high blood pressure (possibility of malignant hypertension).
- Headache may come and go but not throb. It is worse in morning or awakens sufferer at night. Double vision may occur. Headache follows other symptoms, including abnormal personality and mental functioning, vomiting, seizures (possibility of brain tumor). (Note that fear of brain tumor is common among people with headaches, but headache is almost never the first or only sign of a tumor.)
Given the very high prevalence of tension-type headaches, some experts express frustration over the dearth of serious scientific attention given to this problem. As a result, although simple over-the-counter pain relievers are sufficient for mild symptoms, there are few proven therapies for chronic tension-type headaches. Fortunately, most tension-type headaches resolve on their own without any treatments. Studies on remedies for prevention of chronic daily headaches are even weaker. Only antidepressants have been extensively studied; the value of most treatments is known only from anecdotal reports.
Over-the-Counter Medications
NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, substances that dilate blood vessels and cause inflammation. NSAIDs are usually the first drugs tried for almost any kind of headache. There are dozens of NSAIDs. Aspirin is the most common; others include ibuprofen (Brufen), indomethacin (Inmecin), naprosyn (Naprosyn), piroxicam (Pirox), and ketorolac (Ketanov).
Acetaminophen. Acetaminophen (Crocin,Metacin,Calpol) is a good alternative to these drugs when stomach distress, ulcers, or allergic reactions prohibit their use. COX-2 Inhibitors. Celecoxib (Celact), Etoricoxib(Ezact) are known as COX-2 (cyclooxygenase-2) inhibitors, the so-called super-aspirins. They may prove to be beneficial for chronic tension-type headache without incurring as high risk for ulcers and bleeding.
Antidepressants
Antidepressants may be useful in preventing tension-type headaches. Those known as the tricyclics and monoamine oxidase inhibitors are the gold-standard for prevention of severe chronic tension-type headaches. Others, known as SSRIs, are also sometimes used in milder cases.
Tricyclic Antidepressants. Tricyclics are useful not only for depression but appear to help relieve muscle pain and improve sleep as well. The tricyclic drug most commonly used is amitriptyline (Eliwel), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include doxepin (Spectra), imipramine (Tofranil), and nortriptyline (Sensiwal).
Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) work by increasing levels of serotonin in the brain. SSRIs include fluoxetine (Prodep), sertraline (Serta).
Antianxiety Agents
Mild antianxiety agents are occasionally used as an adjunct in treating chronic headaches to decrease muscle contraction or to treat anxiety symptoms during periods of extreme stress. They include alprazolam (Restyl) and clonazepam (Epitril). They tend to be highly addictive, however, and should therefore be used only on a short-term basis.
Botulism
Botulinum toxin A (Botox) injections are now widely used to relax muscles and reduce skin wrinkles. They are also being investigated for chronic headaches. (This potentially deadly toxin is very safe when minuscule amounts are injected into small muscles.)
Tizanidine
Tizanidine (Tizan) is an agent that helps prevent muscle spasms. In two studies of patients with chronic tension-type headache who took tizanidine for at least three months, nearly 70% of patients reported a reduction in headache days by 50% or more. Side effects are minor and include fatigue and dry mouth.
What Are Non Drug Treatments For Tension-Type Headaches?
Good Health Habits
Good health habits, including adequate sleep, healthy diet, regular exercise, and good stress management are important, along with the following specific measures for headache management. Quitting smoking is essential in reducing the risks for all headaches.
Healthy Diet
A healthy diet rich in fresh fruits and vegetables and whole grains and low in saturated fats (animal fats) is important to everyone. Fish (particularly oily fish such as salmon and tuna) and soy are protein sources that may be a good alternative to red meats.
Caffeine
In some people with headaches, caffeine appears to be an excellent companion to medications. One study found that the caffeine equivalent of two and a half of cups of coffee can help treat a tension-type headache by itself. Taking ibuprofen along with caffeine is even more effective than either substance alone. (It should be noted that in some people with migraines, the tannin found in coffee or tea may be a trigger for the headache.)
Trigger Point Needling
In trigger point needling, the physician uses an instrument called a pressure algometer, finds the source of the headache pain (the trigger point), and injects a pain reliever directly into the site. The needle is then used to break up any fluid or scar tissue in the area. The patient is required to perform therapeutic exercises after the procedure. This treatment may sound worse than the headache itself, but studies are reporting success with it in treating tension-type headaches and some migraines.
Spinal Manipulation
A number of small studies have suggested that spinal manipulation by chiropractors or osteopaths may have some benefits for people with tension-type headache. Although techniques vary, the basic approach is to manipulate and stretch the spine beyond an elastic barrier of resistance but not so far as to impair the structure. The vertebrae may be moved directly or by stretching a muscle, such as in the thigh. One 1998 study found that spinal manipulation had no benefit for patients with episodic tension-type headaches. Some practitioners argued that the specific techniques studied were not appropriate ones for tension-type headaches, that the study was too short (19 weeks), and only areas around the neck and upper body were manipulated in the study rather than the entire body, which may have provided more benefit. (Evidence is stronger, however, on benefits of spinal manipulation for patients with headaches originating from nerve or muscular problems in the neck. In fact, some experts believe that tension-type headaches relieved by spinal manipulation are probably really caused by neck problems.)
Side effects of spinal manipulation include local or radiating discomfort, headache, and fatigue; they rarely last longer than 24 hours. It should be noted that there have been reports of stroke or blood clots after spinal manipulation in the neck area, even in people without a previous history of these events. Although these complications are rare, people with risk factors for stroke should not use this approach.
Cervical Epidural Nerve Block
In cases where abnormalities or injuries in the cervical spine (the spinal bones in the neck) cause headaches, a cervical epidural nerve block may be beneficial in treating and preventing further pain. This procedure involves injecting small amounts of a corticosteroid and anesthetic into spaces between the vertebrae in the neck to block the nerves. Some patients have reported significant pain relief from this procedure.
Dental Adjustments
One interesting 1999 European study tested whether dental adjustment to help teeth bite down evenly might help some people with chronic headaches. The results indicated that those who underwent real dental adjustments had a better long-term response than those who had a mock adjustment. People with an uneven bite and chronic headaches might consider discussing this option with their dentists.
Treatment of Sleep Disorders
Headaches that occur during the night and early morning may be related to sleep disorders. One study reported that treating an underlying sleep disorder, such as sleep apnea or insomnia, in patients who also had headaches resulted in headache cure or improvement in all patients except those who suffered from restless legs syndrome.
What Are The Alternative Treatments Used For Tension-Type Headache?
Many alternative therapies are used for headache management, including meditation, acupuncture, acupressure, and yoga. Some have proven to be helpful and most are not harmful. A few are discussed below. Patients should always be wary, however, of methods that are unproven.
Relaxation and Related Stress Reduction Therapies
A number of stress-reduction methods are available that may help may help counteract the tendency for muscle contraction and uneven blood flow associated with some headaches. In choosing specific strategies for treating stress, several factors should be considered. First, no single method is uniformly successful: a combination of approaches is generally most effective. Second, what works for one person does not necessarily work for someone else. Third, stress can be positive as well as negative. Appropriate and controllable stress provides interest and excitement and motivates the individual to greater achievement, while a lack of stress may lead to boredom and depression. Among the stress reduction techniques that may be helpful are cognitive-behavioral therapy, muscle relaxation exercises, massage therapy, hypnosis, and biofeedback. One expert reported that correct breathing from the diaphragm relieved tension-type headaches in some of his patients. Hypnosis appears to be very effective in some people. Any of these therapies may be used in conjunction with drug therapy.
Acupuncture and Acupressure
An analysis of studies on acupuncture and tension-type headache suggest that they may have some benefit. In one study, more patients improved with relaxation methods than with acupuncture, but both treatments were helpful. However, evidence is still weak and better research is needed. One acupressure practitioner reports that pressing for 60 seconds on the web space between the forefinger and thumb of the dominant hand erases headache in patients with migraine and tension-type headaches. The specific spot pressed should be the most tender point in the web area. The patient should than lie down for about 15 minutes.
Ice Water
A novel treatment uses ice water that circulates for 15 minutes through metal tubes placed in the back of the jaw. In one small study, this procedure reduced pain in four out of six patients whose headaches were associated with neck problems.
Percutaneous Electrical Nerve Stimulation
A technique called percutaneous electrical nerve stimulation (PENS) uses low-level electrical pulses delivered through acupuncture needles into soft tissue. Patients are barely aware of the sensation. In a 2000 study, patients with chronic tension, migraine, and post-injury headache treated using either PENS or just needles. After six months of such treatments, those using PENS reported reductions in pain score of nearly 60% in migraine and tension-type headaches and 52% in injury-related headache, which were significantly greater than the needles alone. Energy levels and quality of sleep also improved.
Where Else Can Headache Sufferers Get Information?
National Headache Foundation, 428 West St. James Place , 2nd Floor, Chicago , Internet (http://www.headaches.org)
Publishes an excellent quarterly newsletter, Head Lines , containing news, research reports, book reviews, letters and other items.
American Headache Society (http://www.ahsnet.org/) and affiliated organization American Council for Headache Education (http://www.achenet.org/)
American Academy of Neurology, 1080 Montreal Avenue , St. Paul , Minnesota 55116 . Call (651-695-1940) or on the Internet (http://www.aan.com/)
Web site offers good information and provides names of neurologists for specific locations.
National Institute of Neurological Disorders and Stroke, PO Box 5801 , Bethesda , MD 20824 . Call (301-496-5751) or on the Internet (www.ninds.nih.gov)
