Table of Contents
- Introduction
- Classification
- Epidemiology
- Pathophysiology
- Etiology and Common Precipitating Factors
- Diagnostic Criteria
- Differential Diagnosis
- Evaluation
- Treatment and Management
- Home remedies for all types include:
- Non-pharmacological
- Abortive Therapy
- Preventive Therapy
- Complications
- Prognosis
- Further Reading
- Bibliography
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
- 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.
- 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.
- Less than 12 days/year
- 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
- More than 180 days/year
- More than 15 days per month for at least 3 months
Episodic tension-type headaches (ETTH)
Chronic tension-type headaches (Chronic TTH)
Tension-type Headache
Infrequent ETTH
Frequent ETTH
Chronic TTH
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
- 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.). Physiopedia. https://www.physio-pedia.com/Tension-type_headache#cite_note-:0-2
- Tension-type headache. (n.d.). Physiopedia. https://www.physio-pedia.com/Tension-type_headache#cite_note-:0-2
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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