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fatigue, and depression in the trying times of life In the large series of Lance and Curran, about one-third of patients with persistent tension headaches had readily recognized symptoms of depression In our experience, chronic anxiety or depression of varying degrees of severity is present in the majority of patients with protracted headaches Migraine and traumatic headaches may be complicated by tension headache, which, because of its persistence, often arouses fears of a brain tumor or other intracranial disease However, as Patten points out, not more than one or two patients out of every thousand with tension headaches will be found to harbor an intracranial tumor, and in our experience, the discovery of a tumor has been most often accidental (see further on) In a substantial group of patients, the headache, when severe, develops a pulsating quality, to which the term tension-migraine or tension-vascular headache has been applied (Lance and Curran) This is particularly the case in patients with protracted and chronic daily headaches Observations such as these have tended to blur the sharp distinctions between migrainous and tension headaches in some cases For many years it was taught that tension headaches were due to excessive contraction of craniocervical muscles and an associated constriction of the scalp arteries However, it is not clear that either of these mechanisms contributes to the genesis of tension headache, at least in its chronic form Until recently it has been felt that in most patients with tension headache, the craniocervical muscles are quite relaxed (by palpation) and show no evidence of persistent contraction when measured by surface electromyographic (EMG) recordings Anderson and Frank found no difference in the degree of muscle contraction between migraine and tension headache However, using an ingenious laser device, Sakai et al have reported that the pericranial and trapezius muscles are hardened in patients with tension headaches Recently, nitric oxide has been implicated in the genesis of tension-type headaches, speci cally by creating a central sensitization to sensory stimulation from cranial structures The strongest support for this concept comes from several reports that an inhibitor of nitric oxide reduces muscle hardness and pain in patients with chronic tension headache (Ashina et al) At present, these are interesting but speculative ideas Treatment of Tension Headache Simple analgesics, such as aspirin or acetaminophen or other NSAIDs, may be helpful, but only for brief periods Tension headaches respond best to the cautious use of one of several drugs that relieve anxiety or depression, especially when these symptoms are present Stronger analgesic medication should be avoided Raskin reports success with calcium channel blockers, phenelzine, or cyproheptadine Ergotamine and propranolol are not effective unless there are symptoms of both migraine and tension headache Some patients respond to ancillary measures such as massage, meditation, and biofeedback techniques Relaxation techniques may be helpful in teaching patients how to deal with underlying anxiety and stress (Lance).

In several surveys of an elderly population, headache with onset in this age period was found to be a prominent symptom in as many as one of six persons and more often to have serious import than headache in a younger population In one series of such patients reported by Pascual and Berciano, more than 40 percent were classi ed as having tension headaches (women more than men), and there was a wide variety of diseases in the others (posttraumatic

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headaches, cerebrovascular disease, intracranial tumors, cranial arteritis, severe hypertension) Cough-induced headaches and cluster headaches were present in some of the men New-onset migraine in this age group is a rarity Raskin has described a headache syndrome in older patients that shares with cluster headache a nocturnal occurrence (hypnic headache) It may occur with daytime naps as well However, it differs in being bilateral and unaccompanied by lacrimation and rhinorrhea Also, it differs from migraine Raskin has successfully treated a number of his patients with 300 mg of lithium carbonate at bedtime The nosologic position of this hypnic headache syndrome is undetermined Despite these considerations, the most treacherous and neglected cause of headache in the elderly is temporal (cranial) arteritis with or without polymyalgia rheumatica, as discussed further on

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As mentioned several times in the above discussions, in our clinics the most common cause of generalized persistent headache, both in adolescents and adults, is depression or anxiety in one of its several forms The authors have also noted that many seriously ill psychiatric patients complain of frequent headaches that are not typically of the tension type These patients report unilateral or generalized throbbing cephalic pain lasting for hours every day or two The nature of these headaches, which in some instances resemble common migraine, is unsettled Others have delusional symptoms involving physical distortion of cranial structures As the psychiatric symptoms subside, the headaches usually disappear Odd cephalic pains, eg, a sensation of having a nail driven into the head (clavus hystericus), may occur in hysteria and raise perplexing problems in diagnosis The bizarre character of these pains, their persistence in the face of every known therapy, the absence of other signs of disease, and the presence of other manifestations of hysteria provide the basis for correct diagnosis Older children and adolescents sometimes have peculiar behavioral reactions to headache: screaming, looking dazed, clutching the head with an agonized look Usually, migraine is the underlying disorder, the additional manifestations responding to therapeutic support and suggestion

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