Tension-type Headache

Primary Category

Headache & Pain

P-Category

Secondary Category

S-Category

Authors:

Muhammad Roshan Asghar MD,
Muhammad Umair MD,
Junaid Kalia MD

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

Bibliography

Tension headaches - Symptoms, causes, and treatment. (2002, March 27). WebMD. https://www.webmd.com/migraines-headaches/tension-headaches

Tension headaches: Symptoms, causes, & treatments. (n.d.). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8257-tension-type-headaches

Tension headache - Symptoms and causes. (2019, June 11). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/tension-headache/symptoms-causes/syc-20353977

Tension-type headache. (2020, September 21). American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/tension-type-headache/

Tension headache: Background, pathophysiology, etiology. (2021, July 12). Diseases & Conditions - Medscape Reference. https://emedicine.medscape.com/article/792384-overview#a6

Tension type headache. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444224/

Tension-type headache. AAFP American Academy of Family Physicians. https://www.aafp.org/afp/2002/0901/p797.html

UpToDate. (n.d.). https://www.uptodate.com/contents/tension-type-headache-in-adults-pathophysiology-clinical-features-and-diagnosis

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

2.3 chronic tension-type headache. (n.d.). ICHD-3. https://ichd-3.org/2-tension-type-headache/2-3-chronic-tension-type-headache/

Tension-type headache. (n.d.). Physiopedia. https://www.physio-pedia.com/Tension-type_headache#cite_note-:0-2

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