What are the treatments for Chronic Tension Headache combined with Migraine?

[Keith__0]

  I am a male 43 years old. Normal weight, normal blood pressure, low blood cholesterol, no known illness of disease. Never hospitalized and never had any head trauma. History of lower back problems (nothing serious), that is occasionally accompanied by moderate to severe muscle splinting (often which is far more painful that the back injury). No known family history of migraines or head pain (diabetes and high blood pressure does run in the family).
  I suffer from daily muscle contraction head pain for the past 6 months that are bilateral from the temples to the back of the head. It usually starts in the morning after I wake up (I usually have no problems before rising). Vigorous massage of these head muscles often reduces the tension.  About 50% of the time this is accompanied by moderate tension (and sometime swelling) in the neck (primarily in an occipital location) with some restriction in head movement and is usually dominated with moderate to severe tinnitus and a feeling of slight head congestion.  At its worse, the tinnitus is often so bad it is hard to concentrate or sleep. Head movement sometimes makes the tinnitus increase. The tension in these more severe headaches is more focused on the back of the head and often lasts throughout the night. During the day the headaches will get better or worse depending on what I do. Things that may make the tension increase (and often start a period of tinnitus) are driving, reading, teaching class, computer games, and up-close work. The level of tension is propotional to the length of time I drive, read etc. Low dosage of over the counter analgesics (Excedrin) often help when used on the worse days (less than once a week).  I am currently taking 375mg (bid) of naproxen for my back.  I have had a three weeks period when I have not been on any medication, and still suffered from tinnitus.  I have had periods of tinnitus since I was a teenager, but they have always been mild and were not accompanied by neck swelling.
  Combined with these tension headaches are headaches that follow more traditional migraine patterns. These include no aura, no photophobia, no phonophobia, no nausea and no vomiting. The prodome phase lasts one to four days and is dominated by metal slowness, fatigue and sometime a stiff neck and is often worse than the headache phase. Impaired concentration and stiff neck dominate the headache phase. Over the past six months I have isolated the triggers to be primarily exertional in nature; intense exercise bursts such as: running up flights of stairs, straining to defecate, sex, and long periods of driving, teaching class and computer games. I have been controlling these migraines through severe restriction of activities that may trigger a migraine (I was forced to quit my teaching position, as I am unable to lecture; I limit my driving and activities). Carefully controlled exercise (slow start up and cool down, but not for too long) seems to help the tension headaches, but if I push too hard I can trigger a migraine attack.
  This all started six months ago with a severe migraine attach triggered by running up 6 flights of stairs. I had over two weeks of mental slowness and impaired concentration. I was still teaching at the time and with each lecture, the headache got worse (muscle contraction). After 5 weeks from the first migraine I had to quit my teaching job as I was suffering from constant head pain similar to a cluster headache: Nasal conjection, forehead and facial sweating, sharp pain around my left eye, severe restriction in head movement, extreme tenderness in the occipital muscles, inability to concentrate, unable to drive and had some loss of balance. I had two CT scans (with and without contrast enhancement) and both were clear. My doctor tried butalbital, but that did not help. Out of desperation and pain I went to the emergency room. Luckily the emergency room doctor was able to break this cluster like headache pattern with an injection of Toradol and a two-day treatment with vicodin. While I get occasional minor pain around my left eye, this form of headache seems to be gone (for about 6 weeks now).  I suspect that the naproxen I am taking currently for my back helps with the tension headaches, but of this I cannot be sure.
  My question is what is a reasonable course of treatment for my condition? What tests etc should I be looking for to help figure out what is going on. As I can no longer function in my profession (I was a university engineering professor), and my health plan severely limits my access to a neurologist, any pointers on what to do or ask for (medication, treatment, etc) would be appreciated.
Dear Keith,
From your description, it sounds as if the majority of your headaches are of a tension type. The fact that you have had 2 negative CT scans is reassuring. Yes, Naprosyn will help with tension headaches.  Other options include tricyclics class of medications (especially Elavil) which can be used as prophalaxis. Iff exacedrin helps to abort a severe headache, I would recommend that you continue the medication. Midrin is another good alternative.  Biofeedback and relaxation techniques  have  proven beneficial in some patients. Muscle relaxers may help for a short term. I do not recommend the use of frequent narcotics use for the treatment of this type of headache.  If you are interested in getting an evaluation at the headache center at CCF, call 1-800-CCf-CARE; otherwise, discuss these treatment options with your doctor. Good Luck.