Ans. a. Chronic tension headache (Ref: Harrison 19/e p107t, p2587t, 2593-2594, 18/e p122, 2849)Tension-type Headache:Tension-type headache (TTH) is commonly used to describe a chronic head-pain syndrome characterized by bilateral tight, bandlike discomfortQ.Pain typically builds slowly, fluctuates in severity, and may persist more or less continuously for many daysQ.Headache maybe episodic or chronic (present >15 days per month)Q.A useful clinical approach is to diagnose TTH in patients whose headaches are completely without accompanying features such as nausea, vomiting, photophobia, phonophobia, osmophobia, throbbing, and aggravation with movementQ.Such an approach neatly separates migraineTemporal arteritis:Women account for 65% of casesMigraine:Pain often preceded by auraQFibromyalgia:Fibromyalgia (FM) is characterized by chronic widespread musculoskeletal pain and tenderness.Patients with FM have an increased prevalence of other syndromes associated with pain and fatigueQ.More common in womenQCommon Causes of HeadachePrimary HeadacheSecondary Headache* Tension-type (69%)* Migraine (16%)* Idiopathic stabbing (2%)* Exertional (1%)* Cluster (0.1%)* Systemic infection (63%)* Head injury (4%)* Vascular disorders (1%)* SAH (<1%)* Brain tumor (0.1%)Tension-Type Headache (TTH)Tension-type headache (TTH) is commonly used to describe a chronic head-pain syndrome characterized by bilateral tight, handlike discomfortQ.Pathophysiology:Pathophysiology is incompletely understoodQ.It seems likely that TTH is due to a primary disorder of CNS pain modulation alone, unlike migraine, which involves a more generalized disturbance of sensory modulation.Clinical Features:TTH: Chronic head-pain syndrome characterized by bilateral tight, bandlike discomfortQ.Pain typically builds slowly, fluctuates in severity, and may persist more or less continuously for many daysQ.Headache maybe episodic or chronic (present > 15 days per month)Q.A useful clinical approach is to diagnose TTH in patients whose headaches are completely without accompanying features such as nausea, vomiting, photophobia, phonophobia, osmophobia. throbbing, and aggravation with movementQ.Such an approach neatly separates migraine.Treatment: Tension-Type HeadacheAnalgesics (acetaminophen, aspirin, or NSAIDs).Behavioral approaches including relaxation can also be effective.Chronic TTH: Amitriptyline is the only proven treatmentQThere is no evidence for the efficacy of acupuncture.MigraineCluster Headache* LateralizedQ usually frontotemporal, can be generalized* All age groupsQ are affected* FemalesQ are affected more than males* Family history presentQPresentation:* Pain often preceded by auraQ* Builds up graduallyQ* May lasts for several hoursQ or longer* Usually throbbingQ but maybe dull* Onset is after awakeningQ and quietened by sleepQ* Lateralized, periorbitalQ or less commonly temporal* All ages >10 yearsQ with peak at 30-50 yrsQ* Male preponderanceQ (90%): Men affected 7-8 times more than females.* Hereditary factors usually absentQPresentation:* Pain (periodic attacks 1-2/day)* Begins without warningQ* Reaches crescendo within 5 minutesQ* Lasts for 45 minutesQAssociated symptoms:* Nausea, vomiting, diarrheaQ* Photophobia and visual disturbance in the form of photopsia and fortification spectraQ* Paraesthesia with tingling and numbnessQ* Other focal neurological symptoms such as clumsiness and weaknessQ.* Excruciating, deep, explosive pain but only rarely pulsatileQ* Commonly awakens patients from sleepQAssociated symptoms:* Homolateral lacrimationQ* Reddening of eyeQ* Nasal stuffinessQ* PtosisQ* NauseaQTemporal ArteritisAverage age of onset is 70 yearsQWomen account for 65% of cases.Typical presenting symptoms: Headache, polymyalgia rheumatica, jaw claudication, fever, and weight lossQ.Headache is the dominant symptom, often appears in association with malaise and muscle achesQ.Head pain maybe unilateral or bilateralQ and is located temporally in 50% of patients but may involve any and all aspects of the cranium.Pain usually appears gradually over a few hours before peak intensity is reached; occasionally, it is explosive in onset.The quality of pain is only seldom throbbing; it is almost invariably described as dull and boring, with superimposed episodic stabbing pains similar to the sharp pains that appear in migraine.Most patients can recognize that the origin of their head pain is superficial, external to the skull, rather than originating deep within the cranium (the pain site for migraineurs).Scalp tenderness is present, often to a marked degree; brushing the hair or resting the head on a pillow maybe impossible because of painQ.Headache is usually worse at night and often aggravated by exposure to coldQ.Additional findings may include reddened, tender nodules or red streaking of the skin overlying the temporal arteriesQ, and tenderness of the temporal or, less commonly, the occipital arteries.ESR is often, though not always, elevatedQ; a normal ESR does not exclude giant cell arteritis.A temporal artery biopsy followed by immediate treatment with prednisone 80 mg dailyQ for the first 4-6 weeks should be initiated when clinical suspicion is high.FibromyalgiaFibromyalgia (FM) is characterized by chronic widespread musculoskeletal pain and tenderness.Patients with FM have an increased prevalence of other syndromes associated with pain and fatigueQ.More common in womenQClinical Features:MC presenting complaint: "Pain all over."QPain is typically above and below the waist on both sides of the body and involves the axial skeletonQ (neck, back, or chest).Pain is poorly localized, difficult to ignore, severe in its intensity, and associated with a reduced functional capacity.QFibromyalgia classification criteriaHistory of chronic widespread pain > 3 monthsQ>11 of 18 tender pointsQNeuropsychological Symptoms: Fatigue, stiffness, sleep disturbance, cognitive dysfunction, anxiety, and depressionQ.