Tension-type headache

This page was originally based on the International Classification of Headache Disorders from the International Headache Society

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Introduction

This is the most common type of primary headache: its lifetime prevalence in the general population ranges in different studies from 30 to 78%. At the same time, it is the least studied of the primary headache disorders, despite the fact that it has the highest socio-economic impact.

Whilst this type of headache was previously considered to be primarily psychogenic, a number of studies have appeared after the first edition of The International Classification of Headache Disorders that strongly suggest a neurobiological basis, at least for the more severe subtypes of tension-type headache.

Tension-type headaches are divided into infrequebt, frequent and chronic. The chronic subtype is a serious disease causing greatly decreased quality of life and high disability. The infrequent subtype has very little impact on the individual and does not deserve much attention from the medical profession. However, frequent sufferers can encounter considerable disability that sometimes warrants expensive drugs and prophylactic medication.

The exact mechanisms of tension-type headache are not known. Peripheral pain mechanisms are most likely to play a role in Infrequent episodic tension-type headache and Frequent episodic tension-type headache whereas central pain mechanisms play a more important role in Chronic tension-type headache.

Increased pericranial tenderness recorded by manual palpation is the most significant abnormal finding in patients with tension-type headache. The tenderness increases with the intensity and frequency of headache and is further increased during actual headache. Pericranial tenderness is easily recorded by manual palpation by small rotating movements and a firm pressure (preferably aided by use of a palpometer) with the second and third finger on the frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius and trapezius muscles. A local tenderness score from 0-3 on each muscle can be summated to yield a total tenderness score for each individual. It has been demonstrated that, using a pressure sensitive device that allows palpation with a controlled pressure, this clinical examination becomes more valid and reproducible. However, such equipment is not generally available to clinicians and it is advised that clinicians simply perform the manual palpation as a traditional clinical examination. Palpation is a useful guide for the treatment strategy. It also adds value and credibility to the explanations given to the patient.

Infrequent episodic tension-type headache

Infrequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present.

Diagnostic criteria

1. At least 10 episodes occurring on <1 day per month on average (<12 days per year) and fulfilling criteria 2-4
2. Headache lasting from 30 minutes to 7 days
3. Headache has at least two of the following characteristics:
   • bilateral location
   • pressing/tightening (non-pulsating) quality
   • mild or moderate intensity
   • not aggravated by routine physical activity such as walking or climbing stairs
4. Both of the following:
   • no nausea or vomiting (anorexia may occur)
     
   • no more than one of photophobia or phonophobia
5. Not attributed to another disorder

Frequent episodic tension-type headache

Frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present.

Frequent tension-type headache often coexists with migraine without aura. Coexisting tension-type headache in migraineurs should preferably be identified by a diagnostic headache diary. The treatment of migraine differs considerably from that of tension-type headache and it is important to educate patients to differentiate between these types of headaches in order to select the right treatment and to prevent medication-overuse headache.

Diagnostic criteria

1. At least 10 episodes occurring on ≥1 but <15 days per month for at least 3 months (≥12 and <180 days per year) and fulfilling criteria 2-4
2. Headache lasting from 30 minutes to 7 days
   
3. Headache has at least two of the following characteristics:
   • bilateral location
   • pressing/tightening (non-pulsating) quality
   • mild or moderate intensity
   • not aggravated by routine physical activity such as walking or climbing stairs
4. Both of the following:
   • no nausea or vomiting (anorexia may occur)
   • no more than one of photophobia or phonophobia
5. Not attributed to another disorder

Chronic tension-type headache

A disorder evolving from episodic tension-type headache, with daily or very frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There may be mild nausea, photophobia or phonophobia.

Differentiation between this and Chronic migrane can be difficult. It should be remembered that some patients with chronic tension-type headache develop migraine-like features if they have severe pain and , conversely, some migraine patients develop increasingly frequent tension-type-like interval headaches, the nature of which remains unclear.

Diagnostic criteria

1. Headache occurring on ≥15 days per month on average for >3 months (≥180 days per year)1 and fulfilling criteria 2-4
2. Headache lasts hours or may be continuous
3. Headache has at least two of the following characteristics:
   • bilateral location
   • pressing/tightening (non-pulsating) quality
   • mild or moderate intensity
   • not aggravated by routine physical activity such as walking or climbing stairs
4. Both of the following:
   • no more than one of photophobia, phonophobia or mild nausea
   • neither moderate or severe nausea nor vomiting
5. Not attributed to another disorder