Tension-type Headache

Tension-type headache is characterized as a diffuse, dull pain or tightness around the forehead also called muscle contraction headache or stress headache. ICHD diagnostic criteria should be used to categorize the headache. Chronic tension-type headache at baseline, coexisting migraine disorder, and sleep disorders are associated with poor outcomes. A physician needs proper insight into provoking and preventing factors to best educate the patients.

Primary Category
Headache & Pain
P-Category
Secondary Category
S-Category

Introduction

  • Characterized as a diffuse, dull pain or tightness around the forehead.
  • Can also involve the back of the head and neck.
  • Not associated with any other symptom; nausea and vomiting.
  • Also called muscle contraction headache or stress headache.
  • Most commonly leads to fatigability, irritability and sleep disturbance amongst patients.

Classification

  • It is classified into 2 main types based on the frequency of headache
    • Episodic tension-type headaches (ETTH)

    • Can be an infrequent or frequent episodic headache.
    • Infrequent type occurs once or twice a month.
    • Frequent type occurs less than 15 days per month.
    • It usually starts slowly and progresses throughout the day.
    • It can last from 30 minutes to a week.
    • Chronic tension-type headaches (Chronic TTH)

    • Occurs more than 15 days a month for at least 3 months consecutively.
    • It starts slowly and lasts for days. The pain can exacerbate or ease as the day progresses, but it is always there.
    •  
      ☝️
      Tension-type Headache Infrequent ETTH
      • Less than 12 days/year
      Frequent ETTH
      • More than 12 days and less than 180 days/year
      • At least 10 episodes occurring more than 1 day and less than 15 days per month for at least 3 months
      Chronic TTH
      • More than 180 days/year
      • More than 15 days per month for at least 3 months
      Source: Tension type headache. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444224/

Epidemiology

  • Most common type of headache and second most prevalent disorder worldwide.
  • Has a lifetime prevalence of 30% to 78% among the general population according to many different studies.
  • Occurs during the teenage years and persists as long as into the 6th decade of life.
  • More common in women, affecting them in a ratio of 3 women to every 2 men.

Pathophysiology

  • An important mechanism of headache in patients with TTH is the increased sensitivity of the pericranial facial muscles to pain.
  • Continuous nociceptive input from peripheral myofascial structures may induce central sensitization and thereby chronification of the headache.
  • Sensitization of second-order neurons at the level of the spinal dorsal horn or trigeminal nucleus play a major role in the pathophysiology of chronic tension-type headache.
  • The sensitization of supraspinal neurons is also seen.
  • There is decreased descending inhibition from supraspinal structures.
  • Chronic tension headaches lasting longer than 5 years tend to have a lower cortisol level.
  • Another mechanism of pain is decreased antinociception or inability of the body to stop painful stimuli to the supraspinal structures.

Etiology and Common Precipitating Factors

  • Stress due to sustained contraction of the face, scalp and neck muscles is the most important cause.
  • It can be triggered by;
    • Alcohol
    • Smoking
    • Squinting
    • Poor posture
    • Fatigue
    • Anxiety
    • Dehydration
    • Missing meals
    • Bright sunlight
    • Certain smells
    • Noise
    • Flu or cold
    • Sinusitis
    • Caffeine
    • Low iron levels

Diagnostic Criteria

☝️
International Classification of Headache Disorders Diagnostic Criteria for Tension-Type Headache
Criteria A:
  • <1 day/month (for Infrequent) or ≥1 but <15 days/month for ≥3 months (for frequent), and fulfilling criteria B-D.
Criteria B:
  • Headache lasting from 30 minutes to 7 days.
Criteria C:
  • At least 2 of the following characteristics:
    • Bilateral location
    • Pressing or tightening (non pulsating) quality
    • Mild or moderate intensity
    • Not aggravated by routine physical activity
Criteria D:
  • Both of the following:
    • No nausea or vomiting.
    • No more than 1 of photophobia or phonophobia.
Source: Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808. doi: 10.1177/0333102413485658. PMID: 23771276.

Differential Diagnosis

  • Acute Angle-Closure Glaucoma
  • Acute Subdural Hematoma
  • Brain Abscess
  • Acute Otitis Media
  • Subarachnoid Hemorrhage
  • Encephalitis
  • Cluster Headache
  • Meningitis
  • Migraine Headache
  • Sinusitis (Rhinosinusitis)
  • Ischemic and Hemorrhagic Stroke
  • Temporal Arteritis
  • Temporomandibular Joint Syndrome
  • Trigeminal Neuralgia

Evaluation

  • Refer to

    Treatment and Management

    • Treatment is directed at the cause.
    • Depends on the type, cause and frequency of headache.

    Home remedies for all types include:

    • Applying heat or cold packs to the head.
    • Doing stretching exercises.
    • Massaging the head, neck or back.
    • Resting in a dark and quiet room.
    • Taking a walk.

    Non-pharmacological

    • Physical therapy
    • Cognitive Behavioral Therapy
    • Acupuncture
    • Various Local Injections
    • Relaxation Techniques
      • Deep breathing exercises
      • Yoga
      • Meditation
      • Progressive muscle relaxation
    • Biofeedback Method
      • Monitoring body functions such as muscle tension, heart rate and blood pressure and giving feedback.
    • Lifestyle Modifications
      • Improved sleep hygiene.
      • Smoking cessation.
      • Regular exercise.
      • Balanced diet.
      • Hydrate.
      • Decrease use of alcohol and caffeine.

    Abortive Therapy

    • Simple and compound OTC analgesics containing caffeine.

    Preventive Therapy

    • Tricyclic Antidepressants
      • Amitriptyline; 10-100 mg nightly
      • Nortriptyline; 25-75 mg nightly
      • Imipramine; 25-50 mg daily
    • Muscle Relaxants
      • Baclofen; 5-20 mg tid–qid
      • Carisoprodol; 350 mg bid (short-term use, subject to abuse)
      • Cyclobenzaprine; 5-10 mg bid
      • Tizanidine; 2 mg qid
    • Others
      • Memantine; 20-40 mg daily
      • SSRI/SNRI - Banzi 2015 Cochrane review showed none of these worked

    Complications

    • Over-reliance on non-prescription caffeine-containing analgesics
    • Dependence on/addiction to narcotic analgesics
    • GI bleed from use of NSAIDs
    • Risk of epilepsy 4 times greater than that of the general population
    • Medication overuse headache
    • Overall quality of life is compromised
    • Absence from school and work
    • Decreased productivity at work
    • Inability to take part in physical activities

    Prognosis

    • The prognosis is favourable in the general population.
    • 45% of adults with chronic headache were in remission when examined 3 years later.
    • Poor outcome was associated with
      • Chronic tension-type headache at baseline
      • Coexisting migraine disorder
      • Sleep disorders
      • Being single
    • Factors associated with remission were
      • Old age
      • Absence of chronic tension-type headache

    Further Reading

    Bibliography

    1. Tension headaches - Symptoms, causes, and treatment. (2002, March 27). WebMD. https://www.webmd.com/migraines-headaches/tension-headaches
    1. Tension headaches: Symptoms, causes, & treatments. (n.d.). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8257-tension-type-headaches
    1. Tension headache - Symptoms and causes. (2019, June 11). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/tension-headache/symptoms-causes/syc-20353977
    1. Tension-type headache. (2020, September 21). American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/tension-type-headache/
    1. Tension headache: Background, pathophysiology, etiology. (2021, July 12). Diseases & Conditions - Medscape Reference. https://emedicine.medscape.com/article/792384-overview#a6
    1. Tension type headache. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444224/
    1. Tension-type headache. AAFP American Academy of Family Physicians. https://www.aafp.org/afp/2002/0901/p797.html
    1. UpToDate. (n.d.). https://www.uptodate.com/contents/tension-type-headache-in-adults-pathophysiology-clinical-features-and-diagnosis
    1. The effect of autogenic relaxation on chronic tension... : Indian Journal of anaesthesia. (n.d.). LWW.https://journals.lww.com/ijaweb/Abstract/2005/49060/THE_EFFECT_OF_AUTOGENIC_RELAXATION_ON_CHRONIC.5.aspx
    1. 2.3 chronic tension-type headache. (n.d.). ICHD-3. https://ichd-3.org/2-tension-type-headache/2-3-chronic-tension-type-headache/
    1. Tension-type headache. (n.d.). Physiopedia. https://www.physio-pedia.com/Tension-type_headache#cite_note-:0-2
     
     
    Muhammad Roshan Asghar MD

    ECFMG Certified. Research Fellow at NeuroCare.AI Academy and Postdoc Intern at Global Innervation LLC.

    Muhammad Umair MD

    ECFMG Certified. Research Associate at NeuroCare.AI Academy

    Junaid Kalia MD

    Written by

    Junaid Kalia MD

    Founder NeuroCare.AI, Practicing Neurologist, sub-specialized in the field of Neurocritical Care, Stroke & Epilepsy

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