Tension-type headache

Jennifer Robblee MD MSc FRCPC (

Dr. Robblee of Barrow Neurological Institute 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 September 23, 2019; expires September 23, 2022

Tension-type headache is a primary headache disorder but can be a common phenotype of secondary headache disorders. This article includes discussion of tension-type headache, previously known by multiple terms including: 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, and tension headache. The article will refer to the condition as tension-type headache, further divided into episodic tension-type headache and chronic tension-type headache. Other discussions include the difference between phenotypic versus 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 are the focus, with some discussion on other conditions like migraine and medication-overuse headache when relevant.

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 (eg, photophobia and phonophobia) and lacks the usual triggers associated with migraine.

 

• Due to 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.

 

• Biofeedback has a documented effect; cognitive-behavioral therapy and relaxation training are most likely effective. Other nonpharmacologic strategies could also be considered.

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 (Schulman 2001; Headache Classification Subcommittee of the International Headache Society 2004). In the current International Classification of Headache Disorders (ICHD-3), based on the frequency of attacks, the International Headache Society (IHS) divides tension-type headache into episodic tension-type headache and chronic tension-type headache types. Tables 1 and 2 include diagnostic criteria of episodic tension-type headache, and table 3 details criteria for chronic tension-type headache (Headache Classification Subcommittee of the International Headache Society 2018). 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). Chronic tension-type headache occurs on greater than or equal to 15 days per month or greater than or equal to 180 days per year. The ICHD-3 further classifies each type of tension-type headache based on the presence or absence of associated pericranial tenderness on manual palpation. The pericardial tenderness is assessed using small rotating movements with index and middle fingers or with a palpometer in the following muscles: frontal, temporal, master, pterygoid, sternocleidomastoid, splenius, and trapezius. A score of 0 to 3 can be used for degree of tenderness.

The updated ICHD-3 allows chronic tension-type headache to be diagnosed in the presence of overuse of acute medication(s) (simple analgesics greater than or equal to 15 days a month; ergotamine, triptans, opioids, or combination analgesics on greater than or equal to 10 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 persisted. Now, with the updated guidelines, such patients are diagnosed with both chronic tension-type headache and medication-overuse headache, which is a separate ICHD-3 diagnosis.

According to the ICHD-3, 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 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 2018).

Table 2. ICHD-3 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 2018).

Table 3. ICHD-3 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**

Note: May or may not be associated with pericranial tenderness (Headache Classification Subcommittee of the International Headache Society 2018).

*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. If onset is gradual or not recalled, it should be coded 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.

Patients can have both migraine and tension-type headache (Lipton et al 2000). Authors have long suggested that the variety of headaches in those with migraine might be a manifestation of the same underlying pathophysiology (Lipton et al 2000). The Spectrum Study examined the effectiveness of sumatriptan in treating the range of headache attacks seen in migraine patients. In a double-blind, placebo-controlled, multiple-attack study, Lipton and colleagues investigated migraine with associated phenotypic tension-type headache and patients with pure tension-type headache. Oral sumatriptan was equally effective for phenotypic tension-type headache and clear migraine attacks in the group of patients who had migraine with tension-type headache but was ineffective for the patients with only tension-type headache (Lipton et al 2000). The authors of the Spectrum Study suggest that the attacks of phenotypic tension-type headache in the setting of migraine are pathophysiologically related to migraine, even though their symptom profiles vary (Lipton et al 2000).

The results of the Spectrum Study also raised the question of whether patients with chronic tension-type headache and episodic migraine really have a single unifying disorder: chronic migraine.

In the ICHD-3, chronic migraine is the diagnosis if there is headache on 15 days or more per month with at least 8 days meeting migraine criteria. The other headache days can be phenotypically tension-type headache, but the overall diagnosis is still coded as chronic tension-type headache (Headache Classification Subcommittee of the International Headache Society 2018). Table 4 outlines the chronic migraine criteria, and tables 5 and 6 show supplement differentiation between migraine with and without aura.

The criteria do not require a truly featureless headache for tension-type headache as mild nausea, photophobia, or phonophobia may be allowed, but even this detail varies on whether tension-type headache is considered chronic or episodic. Given that phenotypic tension-type headache in migraine may have a migrainous biology and given that the ICHD-3 criteria do not require a strictly featureless headache, one wonders how many patients who have contributed to the tension-type headache literature in fact have migraine. The realization that some or perhaps many of the patients with previously reported chronic tension-type headache may be better classified as chronic migraine makes prior studies of chronic tension-type headache somewhat difficult to interpret.

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

(A) Headache (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, fulfills any of the following:

 

(1) Criteria C and D for migraine without aura (see table 7)

 

(2) Criteria B and C for migraine with aura (see table 8)

 

(3) Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative

(D) Not attributed to another disorder**

Table 5. Silberstein-Lipton Criteria for Transformed Migraine

(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) Aggravated 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 attributed to another disorder

Table 6. ICHD-3 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 3 of the following 6 characteristics:

 

(1) At least 1 aura symptom spreads gradually over at least 5 minutes
(2) Two or more aura symptoms occur in succession
(3) Each individual aura lasts 5 to 60 minutes
(4) At least 1 aura symptoms is unilateral
(5) At least 1 aura symptom is positive
(6) 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.
(Headache Classification Subcommittee of the International Headache Society 2018)

Note: The maximum duration of the entire aura is 60 minutes multiplied by the number of aura symptoms. Aphasia can be considered as unilateral, but dysarthria may not be. Positive aura symptoms include scintillations and paresthesia (Headache Classification Subcommittee of the International Headache Society 2018).

Table 7. ICHD-3 Criteria for Medication-Overuse Headache (MOH)

(A) Headache occurring on at least 15 days a month in a patient with a pre-existing headache disorder
(B) Regular overuse for greater than 3 months of 1 or more drugs that can be taken for acute or symptomatic treatment of headache
(C) Not attributed to another disorder

Note: The ICHD-3 includes further subdivides into ergotamine-overuse headache, triptan-overuse headache, nonopioid analgesic over-use headache, opioid-overuse headache, combination-analgesic overuse headache, and multiple medications. The nonopioid analgesic subdivision includes further divisions for acetaminophen/paracetamol and nonsteroidal anti-inflammatory drugs, including a further subdivision for acetylsalicylic acid (Headache Classification Subcommittee of the International Headache Society 2018).

To further clarify how to diagnosis headache based on these various headache types, consider these scenarios:

 

(1) A patient with at least 15 headache days per month, of which at least 8 meet criteria for migraine: this patient would be diagnosed with chronic migraine, even though the other headache days are consistent with tension-type headache.

 

(2) If this patient also had medication overuse, they would receive an additional diagnosis of medication overuse headache (see table 7).

 

(3) If a patient has at least 15 headache days per month of headache in which none of the days meet migraine criteria, chronic tension-type headache is diagnosed. Technically, if 7 or less days meet migraine criteria, the ICHD-3 would not consider this presentation chronic migraine, although opinion among headache specialists may vary regarding whether the pathophysiology in this case would actually represent chronic migraine.

 

(4) If a patient presents with both chronic tension-type headache and medication overuse, they receive both diagnoses.

 

(5) If a patient meets criteria for chronic tension-type headache but had an onset of headache over 3 months ago with no previous headache history, then the diagnosis of new daily persistent headache is given if it became daily within 1 to 3 days. They are not given the diagnosis of chronic tension-type headache in this case. Medication overuse headache can only be added to new daily persistent headache if the headache predates the medication overuse, otherwise chronic tension-type headache or chronic migraine should be considered.

To further complicate the distinction, there is also the diagnosis of probable migraine, which allows for a headache that is essentially in-between criteria for migraine and tension-type headache (Headache Classification Subcommittee of the International Headache Society 2018). This headache type is diagnosed, with assumed underlying migraine pathophysiology, if 1 of the migraine criteria are not met. For example, a patient with 7 headaches a month meets all criteria for migraine except that it is not pulsatile, but bilateral, mild, and not aggravated by activity, and it is accompanied by nausea. This patient would be considered to have probable migraine, not tension-type headache.

Unfortunately, the diagnosis of primary headache disorders continues to be an issue for physicians and allied health. Incorrect diagnosis means incorrect enrollment for research studies, incorrect headache counselling, incorrect workup, and most importantly, incorrect treatment. Even when diagnosed correctly as migraine or tension-type headache, understanding of medication overuse headache is limited, with 1 study showing that one third of physicians would not prescribe prophylactic medications due to incorrect thinking that it would cause medication overuse headache (Kristoffersen et al 2019). Another study showed poor knowledge that opioids and butalbital-containing products can cause medication overuse (Minen et al 2016). A further example includes a study of physiotherapists where only 26.4% self-identified as being moderately or very familiar with the criteria for headache disorders (Dale et al 2019). A major issue is that headache medicine is still undertaught in neurology programs; in a study of 133 program directors in neurology, 96% of directors stated that their residents are not prepared for headache management (Ahmed and Faulkner 2016).

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