Page 230 Guide to Pain Management in Low-Resource Settings

218 Arnaud Fumal and Jan Schoenen

What is essential to know about of amitriptyline at bedtime. Many patients will be satis-
tension-type headache? fi ed by such a low dose. Th e average dose of amitripty-
line in chronic TTH, however, is 75–100 mg per day. If
Tension-type headache (TTH) is an ill-defi ned and a patient is insuffi ciently improved on this dose, a trial of
heterogeneous syndrome, of which diagnosis is mainly higher doses of amitriptyline is warranted. If the head-
based on the absence of features found in other head- ache has improved by at least 80% after 4 months, it is
ache types such as migraine (see Tables 4 and 5 for diag- reasonable to attempt discontinuation of the medication.
nostic criteria). It is thus above all a “featureless” head- Decreasing the daily dose by 20–25% over 2–3 days may
ache, characterized by nothing but pain in the head. avoid rebound headache. Th e best results are obtained
Th e diagnostic problem most often encountered is to by combining tricyclics with relaxation therapy.
discriminate between TTH and mild migraines. TTH
is the most common form of headache, but it receives What is essential to know about
much less attention from health authorities, clinical re- cluster headache and other
searchers, or industrial pharmacologists than migraine. trigeminal autonomic cephalalgias?
Th at is because most persons with infrequent or fre-
quent TTH never consult a doctor; treat themselves, if Trigeminal autonomic cephalalgias (TACs) are a group
necessary, with over-the-counter analgesics. Howev- of rare primary headache syndromes that include clus-
er, chronic TTH, which causes headache ≥15 days per ter headache, paroxysmal hemicrania, SUNCT (short-
month represents a major health problem with an enor- lasting unilateral neuralgiform headache attacks with
mous socioeconomic impact. In a population-based conjunctival injection and tearing), and SUNA (short-
study, the lifetime prevalence of tension-type headache lasting unilateral neuralgiform headache attacks with
was 79%, with 3% suff ering from chronic TTH, i.e., cranial autonomic symptoms). Although rare, they are
headache ≥15 days per month. important to recognize because of their excellent but
It still is a matter of debate whether the pain in highly selective response to treatment. Th ey share the
TTH originates from myofascial tissues or from central same features in their phenotype of headache attacks,
mechanisms in the brain. Research progress is ham- which is a severe unilateral orbital, periorbital, or tem-
pered by the diffi culty in obtaining homogeneous pop- poral pain, with associated ipsilateral cranial autonomic
ulations of patients because of the lack of specifi city symptoms, such as conjunctival injection, lacrimation,
of clinical features and diagnostic criteria. Th e present nasal blockage, rhinorrhea, eyelid edema, and ptosis.
consensus, nonetheless, is that peripheral pain mecha- Th e distinction between the syndromes is made on du-
nisms are most likely to play a role in infrequent epi- ration and frequency of attacks.
sodic TTH and frequent episodic TTH, whereas central As cluster headache (CH) is the commonest of
dysnociception becomes predominant in chronic TTH. the TACs, we will describe only this kind of headache in
Simple analgesics (i.e., ibuprofen 600 to 1200 the present chapter. CH has a prevalence of about 0.3%,
mg/d) are the mainstay of treatment of episodic TTH. and male-female ratio of 3.5–7:1. Th e attacks of CH
Combination analgesics, triptans, muscle relaxants, are stereotypical, being severe or excruciating, lasting
and opioids should not be used, and it is crucial to even 15–180 minutes, occurring once every other day up to
avoid frequent and excessive use of simple analgesics to eight times per day, and associated with ipsilateral au-
prevent the development of medication overuse head- tonomic symptoms. In most patients, CH has a striking
ache. Prophylactic pharmacotherapy should be consid- circannual and circadian periodicity. Diagnosis is based
ered in patients with headaches for more than 15 days on IHS criteria for the phenotype of attacks, but an MRI
per month (chronic TTH). A prophylactic treatment is of the brain with contrast should be performed in order
useful to prevent the transformation of episodic TTH to rule out a secondary/symptomatic CH.
into medication overuse headache. Th e tricyclic antide- Cluster headache patients should be advised to
pressant amitriptyline is the drug of fi rst choice for the abstain from taking alcohol during the cluster period.
prophylactic treatment of chronic TTH, but nonphar- Because the pain of CH builds up so rapidly, abortive
macological management strategies (relaxation, bio- agents have to act quickly to be useful. By far the most
feedback, physical therapy) are equally eff ective. Th e effi cient one is a subcutaneous injection of sumatriptan
initial dosage of tricyclics should be low: 10–25 mg 6 mg. Inhalation of 100% oxygen, at 10 to 12 L/minute