Tension-type headache

Rashmi B Halker Singh MD (Dr. Halker Singh of the Mayo Clinic in Phoenix, Arizona, has no relevant financial relationships to disclose.)
Stephen D Silberstein MD, editor. (Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.)
Originally released December 30, 1993; last updated October 8, 2017; expires October 8, 2020

This article includes discussion of tension-type headache, anxiety headache, conversion headache, CTTH, depressive headache, essential headache, idiopathic headache, muscle contraction headache, near-daily headache, ordinary headache, psychogenic headache, psychomyogenic headache, somatoform disorder headache, stress headache, tension headache, chronic tension-type headache, episodic tension-type headache, phenotypic tension-type headache, and pure tension-type headache. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

The author outlines the clinical manifestations, etiology, differential diagnosis, diagnostic evaluation, and management of tension-type headache. Updated diagnostic criteria from the International Classification of Headache Disorders (ICHD-3) from the International Headache Society on tension-type headache, migraine, and medication-overuse headache are reviewed.

Key points

 

• Tension-type headache is bland and characterized as head pain devoid of migrainous characteristics.

 

• The fundamental difference between tension-type headache and migraine is that tension-type headache lacks features of sensory sensitivity of any description and lacks the usual triggering associations of migraine.

 

• Because of the nonspecific clinical features of tension-type headache, virtually any and all structural and metabolic diseases may cause a phenotypic tension-type headache.

 

• First-line acute therapies are simple analgesics and nonsteroidal anti-inflammatory drugs.

 

• Preventive medications should be used for chronic tension-type headache when attacks occur more than 2 days a week; first-line preventive therapy is amitriptyline.

 

• Electromyography biofeedback has a documented effect; cognitive-behavioral therapy and relaxation training are most likely effective.

Historical note and terminology

Tension-type headache is the most common primary headache, and perhaps because of this, it has been called by several different names over the years. Prior terminology has included tension headache, psychogenic headache, muscle contraction headache, depressive headache, anxiety headache, stress headache, ordinary headache, essential headache, idiopathic headache, conversion headache, psychomyogenic headache, and somatoform disorder headache (Schulman 2001; Headache Classification Subcommittee of the International Headache Society 2004). In the current International Classification of Headache Disorders (ICHD-3), the International Headache Society divides tension-type headache into episodic and chronic types, based on the frequency of attacks (See Tables 1 and 2) (Headache Classification Subcommittee of the International Headache Society 2013). Episodic tension-type headache is classified as either infrequent (fewer than 1 day per month or 12 days per year) or frequent (1 to 14 days per month or 12 to 179 days per year) (See Table 1 and Table 2). Chronic tension-type headache occurs on 15 or more days per month or 180 or more days per year (See Table 3). The ICHD-3 further classifies each type of tension-type headache based on the presence or absence of associated pericranial tenderness on manual palpation. As outlined in Tables 3 and 9, with the updated ICHD-3, chronic tension-type headache can now be diagnosed when patients overuse acute medication (simple analgesics 15 or more days a month or ergotamine, triptans, opioids, or combination analgesics on 10 or more days a month); previously, such patients could not be diagnosed with chronic tension-type headache until the overused medication had been discontinued and it was demonstrated that the headache still persisted. Now, with the updated guidelines, such patients are diagnosed with both chronic tension-type headache and medication-overuse headache (a separate ICHD-3 diagnosis). The ICHD-3 also comments that chronic tension-type headache must be separated from new daily persistent headache. New daily persistent headache can phenotypically resemble chronic tension-type headache, but it is daily and unremitting from onset (ie, it starts 1 day and never goes away). In contrast, chronic tension-type headache evolves from episodic tension-type headache in most cases (Lipton et al 2004).

Table 1. ICHD-3 Beta Diagnostic Criteria for Infrequent Episodic Tension-Type Headache

(A) At least 10 episodes occurring on less than 1 day per month on average (fewer than 12 days per year) and fulfilling criteria B to D.

(B) Headache lasting from 30 minutes to 7 days

(C) Headache has at least 2 of the following characteristics:

 

(1) Bilateral location
(2) Pressing or tightening (nonpulsating) quality
(3) Mild or moderate intensity
(4) Not aggravated by routine physical activity such as walking or climbing stairs

(D) Both of the following:

 

(1) No nausea or vomiting (anorexia may occur)
(2) No more than 1 of photophobia and phonophobia

(E) Not attributed to another disorder

Note: May or may not be associated with pericranial tenderness (Headache Classification Subcommittee of the International Headache Society 2013).

Table 2. ICHD-3 Beta Diagnostic Criteria for Frequent Episodic Tension-Type Headache

(A) At least 10 episodes occurring 1 to 14 days per month for at least 3 months (or 12 to 179 days per year ) and fulfilling criteria B to D.

(B) Headache lasting from 30 minutes to 7 days

(C) Headache has at least 2 of the following characteristics:

 

(1) Bilateral location
(2) Pressing or tightening (nonpulsating) quality
(3) Mild or moderate intensity
(4) Not aggravated by routine physical activity such as walking or climbing stairs

(D) Both of the following:

 

(1) No nausea or vomiting (anorexia may occur)
(2) No more than 1 of photophobia and phonophobia

(E) Not attributed to another disorder

Note: May or may not be associated with pericranial tenderness (Headache Classification Subcommittee of the International Headache Society 2013).

Table 3. ICHD-3 Beta Diagnostic Criteria for Chronic Tension-Type Headache

(A) Headache occurring on 15 or more days per month on average for more than 3 months (180 or more days per year) and fulfilling criteria B through D*

(B) Headache lasts hours or may be continuous

(C) Headache has at least 2 of the following characteristics:

 

(1) Bilateral location
(2) Pressing or tightening (nonpulsating) quality
(3) Mild or moderate intensity
(4) Not aggravated by routine physical activity such as walking or climbing stairs

(D) Both of the following:

 

(1) No more than 1 of photophobia, phonophobia, or mild nausea
(2) Neither vomiting nor moderate or severe nausea

(E) Not attributed to another disorder**

*Chronic tension-type headache evolves over time from episodic tension-type headache. When criteria A through E are fulfilled by headache that, unambiguously, is daily and unremitting within 3 days of its first onset, physicians should code it as new daily persistent headache. When the manner of onset is not remembered or is otherwise uncertain, code as chronic tension-type headache.

**When medication overuse is present, the patient should be diagnosed with both chronic tension-type headache and medication-overuse headache.

Note: May or may not be associated with pericranial tenderness (Headache Classification Subcommittee of the International Headache Society 2013).

The ICHD-3 criteria for tension-type headache allow certain migrainous features. In 1994, Silberstein and colleagues offered useful criteria for chronic daily headache in general, including chronic tension-type headache (Silberstein et al 1994). These criteria stated that the diagnosis of chronic migraine (previously termed transformed migraine) takes precedence over chronic tension-type headache.

Table 4. 1994 Silberstein-Lipton Criteria for Chronic Tension-Type Headache

(A) Average headache frequency more than 15 days/month (180 days/year) with average duration of 4 hours/day (if untreated) for 6 months fulfilling criteria B to D
(B) At least 2 of the following pain characteristics:

 

(1) Pressing or tightening quality
(2) Mild or moderate severity (may inhibit but does not prohibit activities)
(3) Bilateral location
(4) No aggravation by walking stairs or similar routine physical activity

(C) History of episodic tension-type headache in the past
(D) History of evolutive headaches that gradually increased in frequency over at least a 3-month period
(E) Both of the following:

 

(1) No vomiting
(2) No more than 1 of nausea, photophobia, or phonophobia

(F) Does not meet criteria for hemicrania continua, new daily persistent headache, or transformed migraine
(G) Is not associated with any systemic or intracranial disorder

Note: Can occur with or without medication overuse (Silberstein et al 1994)

As many migraineurs suffer from not only migraine headaches but also tension-type headache (Lipton et al 2000), authors have long suggested that the variety of headaches endured by migraineurs might be a manifestation of the same underlying pathophysiologic substrate (Lipton et al 2000). In 1988 Raskin wrote that "the similarities between migraine and tension headache appear to be more striking than the differences," and “current evidence supports a biological mechanism of tension headache that is qualitatively similar to that of migraine” (Raskin 1988). The Spectrum Study examined the effectiveness of sumatriptan in treating the range of headaches seen in migraine patients. In a double-blind, placebo-controlled, multiple-attack study, Lipton and colleagues investigated migraineurs who also had phenotypic tension-type headache and patients with exclusive tension-type headache. Oral sumatriptan was equally effective in tension-type headache for the group of patients who had migraine and tension-type headache, but ineffective for the patients who had tension-type headache without any other headache types (Lipton et al 2000). The authors of the Spectrum Study suggest that the attacks of episodic tension-type headache and the attacks of migraine are pathophysiologically related, even though their symptom profiles vary (Lipton et al 2000).

The results of the Spectrum Study also raise the question of whether patients with chronic tension-type headache and episodic migraine really have a single unifying disorder: chronic migraine. This is not a new question. The renowned Queen Square neurologist James Collier raised this issue in 1922:

In some cases of long standing, the [migraine] attacks become less severe towards middle life, and a persistent aggravating headache may develop between the attacks. When such a persistent headache is complained of alone, it is very important to inquire about preceding migraine, for the same treatment is applicable to the two conditions (Collier 1922).

Some headache specialists feel that it is often not clinically rewarding to diagnose both episodic migraine and chronic tension-type headache (as the 2013 ICHD classification would recommend if the headaches with migrainous features occurred fewer than 15 days per month) if a patient presents with a chronic, persistent, fluctuating headache with migrainous features because many of these patients, and certainly the most disabled group, can be usefully described as having chronic migraine (Boes et al 2001). In 1996, Silberstein and colleagues suggested criteria for transformed migraine (now referred to as chronic migraine).

Table 5. Silberstein-Lipton Criteria for Transformed Migraine

(A) Daily or almost daily (more than 15 days/month) head pain for more than 1 month
(B) Average headache duration of more than 4 hours/day (if untreated)
(C) At least 1 of the following:

 

(1) A previous history of International Headache Society migraine
(2) History of increasing headache frequency with decreasing severity of migrainous features over at least 3 months

 

(3) Current superimposed attacks of headaches that meet all the International

Headache Society criteria for migraine except duration
(D) Does not meet criteria for new daily persistent headache or hemicrania continua
(E) Is not associated with any systemic or intracranial disorder

Note: Can occur with or without medication overuse (Silberstein et al 1996).

In the Silberstein-Lipton criteria for transformed migraine, there were no definite headache phenotypic requirements as long as the patient had a history of episodic migraine. The headache had to occur more than 15 days per month for more than 1 month, and the average headache duration had to be greater than 4 hours per day. Transformed migraine could be associated with or without acute medication overuse. A patient with daily or near-daily headache could fit the transformed migraine criteria in several ways. The patient could have (1) migraine headaches meeting 1988 ICHD criteria fewer than 15 days per month associated with phenotypic chronic tension-type headache; (2) migrainous headaches more than 15 days per month meeting all 1988 ICHD criteria aside from duration, associated with phenotypic episodic tension-type headache; (3) migrainous headaches alone meeting all 1988 ICHD criteria aside from duration occurring more than 15 days per month; or (4) phenotypic ICHD chronic tension-type headache as long as the patient had a past history of 1988 ICHD migraine, as the diagnosis of transformed migraine precluded the diagnosis of either episodic migraine or chronic tension-type headache (Silberstein et al 1996).

The Silberstein-Lipton criteria for transformed migraine are different from the current ICHD-3 beta criteria for chronic migraine and medication-overuse headache.

Table 6. ICHD-3 Beta Criteria for Chronic Migraine

(A) Headache fulfilling (tension-type-like and/or migraine-like) on 15 or more days per month for more than 3 months and fulfilling criteria B and C
(B) Occurring in a patient who has had at least 5 attacks fulfilling criteria B to D for migraine without aura and/or criteria B and C for migraine with aura
(C) On at least 8 days per month for more than 3 months, fulfilling any of the following:

 

(1) Criteria C and D for migraine without aura
(2) Criteria B and C for migraine with aura
(3) Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative

(D) Not better accounted for by another ICHD-3 diagnosis
(Headache Classification Subcommittee of the International Headache Society 2013)

Table 7. ICHD-3 Beta Criteria for Migraine without Aura

(A) At least 5 attacks fulfilling criteria B to D
(B) Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
(C) Headache has at least 2 of the following 4 characteristics:

 

(1) Unilateral location
(2) Pulsating quality
(3) Moderate or severe pain intensity
(4) Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

(D) During headache at least 1 of the following:

 

(1) Nausea and/or vomiting
(2) Photophobia and phonophobia

(E) Not better accounted for by another ICHD-3 diagnosis

Table 8. ICHD-3 Beta Criteria for Migraine with Aura

(A) At least 2 attacks fulfilling criteria B and C
(B) One or more of the following fully reversible aura symptoms:

 

(1) Visual
(2) Sensory
(3) Speech and/or language
(4) Motor
(5) Brainstem
(6) Retinal

(C) At least 1 of the following characteristics:

 

(1) At least 1 aura symptom spreads gradually over at least 5 minutes, and/or 2 or more symptoms occur in succession
(2) Each individual aura symptom lasts 5 to 60 minutes
(3) The aura is accompanied, or followed within 60 minutes, by headache

(D) Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded

Table 9. ICHD-3 Beta Criteria for Medication-Overuse Headache (MOH)

(A) Headache occurring on 15 or more days per month in a patient with a preexisting headache disorder

(B) Regular overuse for greater than 3 months of 1 or more drugs that can be taken for acute and/or symptomatic treatment of headache

(C) Not better accounted for by another ICHD-3 diagnosis

Medication-overuse headache can occur in patients using ergot derivatives, triptans, combination analgesics, or opioids more than 10 days per month, or simple analgesics (including acetaminophen, acetylsalicylic acid, and other nonsteroidal antiinflammatory drugs) more than 15 days per month.

(Silberstein et al 2005; Olesen 2007; Headache Classification Subcommittee of the International Headache Society 2013)

Chronic migraine was noticeably absent from the 1988 International Headache Society classification, and medication-overuse headache was referred to as headache induced by chronic substance use or exposure (Headache Classification Committee of the International Headache Society 1988). In the current International Headache Society classification, chronic migraine is felt to be a complication of migraine (Headache Classification Subcommittee of the International Headache Society 2013). Furthermore, giving a patient the diagnosis of chronic migraine effectively excludes the diagnosis of tension-type headache, as tension-type headache is contained within the criteria for chronic migraine.

If a patient with a history of episodic migraine without aura presented with a greater than 3-month history of chronic daily headache meeting criteria for migraine on 15 days per month or more but was presently overusing acute medication, the patient would be given 3 diagnoses per the current ICHD-3 guidelines. The first diagnosis would be migraine without aura, which is the antecedent migraine subtype. The second diagnosis is chronic migraine, and the third is medication-overuse headache. The overused acute medication is then withdrawn, and the diagnosis is reassessed at 2 months. If the patient still meets criteria for chronic migraine 2 months after medication withdrawal, medication-overuse headache is removed from the list, and the patient is left with 2 diagnoses: migraine without aura (the antecedent migraine subtype) and chronic migraine. If the patient improves with acute medication withdrawal and no longer meets the criteria for chronic migraine, the diagnosis of chronic migraine is discarded, and the patient is left with 2 diagnoses: migraine without aura and medication-overuse headache.

Given that phenotypic tension-type headache in migraineurs may have a migrainous biology and given that the ICHD criteria do not require a strictly featureless headache, one wonders how many patients who have contributed to the tension-type headache literature have migrainous biology. The realization that some or perhaps many of the patients with previously reported chronic tension-type headache may be better classified as having chronic migraine makes prior studies of chronic tension-type headache somewhat difficult to interpret.

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