Tension-type headache

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

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Definition/Description

Tension-type headache is a neurological disorder characterized by a predisposition to attacks of mild to moderate headache with few associated symptoms.(level of evidence 1A)1 The criteria for tension-type headache outlined in the IHS classification will be mentioned in the subtitle ‘Diagnostic Procedures’.
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.
Tension-type headaches are divided into infrequent episodic, frequent episodic and chronic tension-type headaches. The infrequent subtype has episodes less than once per month and has very little impact on the individual. The pain is typically bilateral, pressing, or tightening in quality and mild to moderate intensity. It does not worsen with physical activity. There is no nausea, but photophobia or phonophobia may be present. However, frequent sufferers(between one and fifteen days a month) can encounter considerable disability that sometimes warrants expensive drugs and prophylactic medication. This frequent form is a physiologic response to stress, anxiety, depression, emotional conflicts, fatigue or repressed hostility. The chronic subtype evolves over time from episodic tension-type headache and causes greatly decreased quality of life and high disability. It is diagnosed if headaches occur 15 days a month (180 or more days a year).2,18
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. 1,2

Clinically Relevant Anatomy

The underlying cause of tension-type headache is uncertain. The most probably explanation for Infrequent episodic tension-type headache is activation of hyperexcitablehyper excitable peripheral afferent neurons from head and neck muscles. Muscle tenderness and psychological tension are associated with and aggravate tension-type headache but are not clearly its cause. Abnormalities in central pain processing and generalisedgeneralized increased pain sensitivity are present in some patients with tension-type headache, often the chronical type. Susceptibility to tension-type headache is influenced by genetic factors. (level of evidence 1A)1

Epidemiology /Etiology

The patient can either be given only the tension-type headache diagnosis or be given both the tension-type headache diagnosis and a secondary headache diagnosis, according to another disorder that is causing the headache with characteristics of tension type headache. Factors that characterize the secondary headache diagnosis are: a very close temporal relation to the disorder, a marked worsening of the tension-type headache, very good evidence that the disorder can cause or aggravate tension-type headache and improvement or resolution of tension-type headache after relief from the disorder.
TTH is the most common type of primary headache. Lifetime prevalence in the general population ranges in different studies from 30 to 78%. 3 (level of evidence 2A)
Loder et al summarizes that the mean lifetime prevalence of tension-type headache in adults, based on pooled results from five population based studies, is 46%. The prevalence peaks at age 40-49 years in both sexes. The female to male ratio is about 5:4.1 (level of evidence 1A)
In a review of Stovner J. L. et al from 2010, nineteen studies have reported the prevalence of current tension type headache in Europe. Among 66,000 adults, 62.6% had episodic TTH, and 3,3% had chronic TTH. Prevalence of children and youth is less, about 15.9% TTH and 0.9% chronic TTH. The studies where done in Croatia, Denmark, Georgia, Germany, Norway, Portugal, Turkey, Finland, Serbia and Sweden. 4(level of evidence 2A)Data on TTH is still too scarce in Europe.
The female preponderance of chronic TTH is greater than that of episodic, but lower than that of migraine. The prevalence of CTTH increases with age, according to Schwartz BS et al (1998)5 (level of evidence 2A) The prevalence of episodic tension type headache increases with educational level.1 (level of evidence 1A)
The International Classification of Headache Disorders (ICHD) is a detailed hierarchical classification of all headache-related disorders published by the International Headache Society. It was in 1988, in the ICHD-1, that tension-type headache was divided into episodic and chronic subtypes.

The first edition arbitrarily separated patients with and without disorder of the pericranial muscles. The only really useful feature to subdivide all three subtypes of tension-type headache is tenderness on manual palpation and not, as suggested in the first edition, evidence from surface EMG or pressure algometry.
In the second edition of this classification(2004) there was an attempt to precise the diagnostic criteria for tension-type headache, with the hope to exclude migraine patients whose headache phenotypically resembles tension-type headache. 3 (level of evidence 2A)

Characteristics/Clinical Presentation

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.

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.

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 migranemigraine 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.3 (level of evidence 2A)

Recent Related Research (from Pubmed)

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References

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