Case - Tension Type Headache
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Transcript of Case - Tension Type Headache
CASE REPORT
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
heart sound without murmur.
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.
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There was pericranial tenderness, positive invisible pillow sign, and positive
arm chair sign.
SUMMARY
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.
CLINICAL DIAGNOSIS
Frequent episodic tension type headache associated with pericarnial
tenderness
TOPIC DIAGNOSIS
Intracranial
ETIOLOGY
Idiopatic
SECONDARY DIAGNOSIS
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THERAPY
a. Medicinal therapy
- Paracetamol 500 mg + Caffeine 65 mg 4 times a day
- Topiramate 50 mg twice daily
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b. Supportive therapy
- Perfect the posture
- Prevent stress
- Massage
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BAB III
DISKUSI
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.
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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
you're caught in a stressful situation, consider stepping back and allowing
emotions to settle.
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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.
BIBLIOGRAPHY
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.
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