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  • Updated 12.02.2023
  • Released 12.30.1993
  • Expires For CME 12.02.2026

Tension-type headache

Introduction

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 differentiation from other conditions like migraine and medication-overuse headache where 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 severe throbbing pain.

• Virtually any and all structural and metabolic diseases may cause a phenotypic tension-type headache.

• First-line acute treatments for tension-type headache are aspirin or acetaminophen, whereas second-line are NSAIDs and caffeine combinations.

• Nonpharmacologic management should be first-line for tension-type headache preventive treatment before medications. These nonpharmacologic treatments include cognitive behavioral therapy, biofeedback, relaxation, physical therapy, occupational therapy, and optimization of sleep hygiene.

• Preventive medications should be considered when attacks occur more than 2 days a week, with a goal of 50% reduction. After 6 months response, consider stopping the preventive treatment to assess for maintained benefit.

• First, second, and third-line preventive medications are amitriptyline, mirtazapine, and venlafaxine, respectively.

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 (119; 54). 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 (55). Episodic tension-type headache is classified as either infrequent (less 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. A retrospective pediatric study that included 250 cases of tension-type headache found that 11 had concurrent medication overuse headache (50).

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 (77).

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 two 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 one of photophobia and phonophobia

(E) Not attributed to another disorder


Note: May or may not be associated with pericranial tenderness (55).

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 two 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 one of photophobia and phonophobia

(E) Not attributed to another disorder


Note: May or may not be associated with pericranial tenderness (55).

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 two 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 one 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 (55).

*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 (78). Authors have long suggested that the variety of headaches in those with migraine might be a manifestation of the same underlying pathophysiology (78). 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 (78). 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 (78).

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 (55).

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.

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.

(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 fewer 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 (55). This headache type is diagnosed, with assumed underlying migraine pathophysiology, if one of the migraine criteria are not met. For example, a patient with seven headaches a month meets all criteria for migraine except that it is bilateral, mild, not pulsatile, 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 one study showing that one third of physicians would not prescribe prophylactic medications due to incorrect thinking that it would cause medication overuse headache (66). Another study showed poor knowledge that opioids and butalbital-containing products can cause medication overuse (87). 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 (26). A major issue is that headache medicine is still under taught 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 (01). Eventually we may have biomarkers to help differentiate primary headache disorders. For example, a study comparing episodic tension-type headache (n=32) to healthy controls (n=32) using resting state functional MRI found altered functional connectivity of the insula and posterior cingulate (142). Unfortunately, the use of biomarkers is still at the level of research study and is not used clinically.

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