A 24-year-old woman has a slowly building headache with a bilateral, tight "bandlike" distribution. The pain fluctuates in intensity for the next 4 hours before subsiding. She experiences similar headaches on average once per month for the next 40 years.

Questions:

9.1 What is the most likely diagnosis?

Tension-type headache is characterized by bilateral tight "bandlike" pain or as dull, deeply located, and aching pain. Patients may report that the head feels as if it is in a vise or that the posterior neck muscles are tight. The pain typically builds slowly, fluctuates in severity, and may persist more or less continuously for hours to many days. Exertion does not usually worsen the headache. The headache may be episodic or chronic (i.e., present more than 15 days per month). Tension-type headache is common in all age groups, and more common in women. In some patients, anxiety or depression coexist with tension headache.

Entrapment of the spinal accessory nerve (cranial nerve XI) is associated with spasm and pain in the trapezius and sternocleidomastoid muscles.

9.2 What therapy is indicated?

Rest and relaxation will relieve tension headaches. However, patients who want immediate relief can use just about any over-the-counter analgesic. Low dosages of amitriptyline at bedtime may provide prophylaxis for persons with chronic tension-type headache.