AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Tension-type headache (TTH) represents one of the most costly diseases because of its very high prevalence. TTH is the most common type of headache, and it is classified as episodic (ETTH) or chronic (CTTH). It had various ill-defined names in the past including tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, and psychogenic headache. See Medscape's Headache Resource Center for more information.

The International Headache Society (IHS) defines TTH more precisely and differentiates between the episodic and the chronic types. The following is a modified outline of the IHS diagnostic criteria:

Episodic tension-type headache

• At least 10 previous headaches fulfilling the following criteria; number of days with such headache fewer than 15 per month
• Headaches lasting from 30 minutes to 7 days
• At least 2 of the following pain characteristics:
  • Pressing/tightening (nonpulsating) quality
  • Mild or moderate intensity (may inhibit but does not prohibit activities)
  • Bilateral location
  • No aggravation from climbing stairs or similar routine physical activity
• Both of the following:
  • No nausea or vomiting
  • Photophobia and phonophobia absent or only one present
• Secondary headache types not suggested or confirmed

Chronic tension-type headache

• Average headache frequency of more than 15 days per month for more than 6 months fulfilling the following criteria
• At least 2 of the following pain characteristics:
  • Pressing/tightening (nonpulsating) quality
  • Mild or moderate intensity (may inhibit but does not prohibit activities)
  • Bilateral location
  • No aggravation from climbing stairs or similar routine physical activity
• Both of the following:
  • No vomiting
  • No more than one of the following: nausea, photophobia, or phonophobia
• Secondary headache types not suggested or confirmed

Pathophysiology

Pathogenesis of TTH is complex and multifactorial, with contributions from both central and peripheral factors. In the past, various mechanisms including vascular, muscular (ie, constant overcontraction of scalp muscles), and psychogenic factors were suggested. The more likely cause of these headaches is believed now to be abnormal neuronal sensitivity and pain facilitation, not abnormal muscle contraction.

Various evidence suggests that, like migraine, TTH is associated with exteroceptive suppression (ES2), abnormal platelet serotonin, and decreased cerebrospinal fluid beta-endorphin. In one study, plasma levels of substance P, neuropeptide Y, and vasoactive intestinal peptide were found to be normal in patients with CTTH and unrelated to the headache state.

Several concurrent pathophysiologic mechanisms may be responsible for TTH; according to Jensen, extracranial myofascial nociception is one of them. Headache is not related directly to muscle contraction, and possible hypersensitivity of neurons in the trigeminal nucleus caudalis has been suggested.

Bendtsen described central sensitization at the level of the spinal dorsal horn/trigeminal nucleus due to prolonged nociceptive inputs from pericranial myofascial tissues.¹² The central neuroplastic changes may affect regulation of peripheral mechanisms and can lead to increased pericranial muscle activity or release of neurotransmitters in myofascial tissues. This central sensitization may be maintained even after the initial eliciting factors have been normalized, resulting in conversion of ETTH into CTTH.

Further research is necessary to understand and clarify the mechanisms of TTH. Research may lead to the development of more specific and effective management in the future.

Frequency

United States

TTH is the most common primary headache syndrome.

International

Rasmussen et al reported a lifetime prevalence of TTH of 69% in men and 88% in women in the Danish population.¹ The patient may experience more than one primary headache syndrome. In one study by Ulrich et al, the 1-year prevalence of TTH was the same among individuals with and without migraine.²

Sex

Women are slightly more likely to be affected than men.

• The female-to-male ratio for TTH is approximately 1.4:1.
• In CTTH, female preponderance is 1.9:1.

Age

TTH can occur at any age, but onset during adolescence or young adulthood is common. It can begin in childhood.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Tension-type headaches (TTHs) are characterized by pain that is usually mild or moderate in severity and bilateral in distribution. Unilateral pain may be experienced by 10-20% of patients. Headache is a constant, tight, pressing, or bandlike sensation in the frontal, temporal, occipital, or parietal area (with frontal and temporal regions most common).

• Ulrich et al reported that 82% of TTHs last less than 24 hours.²
• The deep steady ache differs from the typical throbbing quality of migraine headache.
• • Prodrome and aura are absent.
  • Occasionally, the headache may be throbbing or unilateral, but most patients do not report photophobia, sonophobia, or nausea, which commonly are associated with migraine.
• Some patients may have neck, jaw, or temporomandibular joint discomfort.

Physical

• Patients with TTH have normal findings on general and neurologic examinations.
• Some patients may have tender spots or taut bands in the pericranial or cervical muscles (trigger points).

Causes

Various precipitating factors may cause TTH in susceptible individuals. One half of patients with TTH identify stress or hunger as a precipitating factor.

• Stress - Usually occurs in the afternoon after long stressful work hours
• Sleep deprivation
• Uncomfortable stressful position and/or bad posture
• Irregular meal time (hunger)
• Eyestrain

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Chronic daily headache
Transformed migraine
New daily persistent headache
Hemicrania continua
Posttraumatic headache
Cervical spine disorders
Intracranial vascular and nonvascular disorders associated with headache
Overuse of symptomatic analgesic medication
Fibromyalgia
Myofascial pain syndrome
Depression

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The diagnosis of tension-type headache (TTH) is clinical. As with the other primary headaches, no specific diagnostic test is available for TTH.
• Occasionally, studies may be required to exclude secondary headache disorders.

Imaging Studies

• Neuroimaging studies are important to rule out secondary causes of headache, including neoplasms and cerebral hemorrhage.
• MRI imaging shows the greatest detail of cerebral structures and is especially useful in evaluating the posterior fossa.
• CT scan with contrast is a viable alternative but is inferior to MRI for viewing structures in the posterior fossa.
• Neuroimaging is indicated if the headaches are atypical in any way or if they are associated with abnormalities in the neurologic examination.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Management of TTH consists of pharmacotherapy, psychophysiologic therapy, and physical therapy.
  • Treatment of headache must be tailored for individual patients.
  • Recognition of comorbid illness is essential. Migraine may be associated with TTH, and management overlaps. Other associated conditions may include depression, anxiety, and emotional or adjustment disorders.
  • Management of CTTH with a combination of tricyclic antidepressant medication and stress management therapy may result in a better outcome than monotherapy.³
• Pharmacotherapy consists of abortive therapy (to stop or reduce severity of the individual attack) and long-term preventive therapy. Preventive drugs are the main therapy for CTTH, but they seldom are needed for ETTH.
• • These headaches (especially ETTH) generally respond to simple over-the-counter (OTC) analgesics such as paracetamol (ie, acetaminophen), ibuprofen, aspirin, or naproxen.
  • If treatment is unsatisfactory, the addition of caffeine or use of prescription drugs is recommended. If possible, avoid use of barbiturates or opiate agonists.
  • Also discourage overuse of all symptomatic analgesics because of the risk of dependence, abuse, and development of chronic daily headache.
  • Fiorinal with codeine is generally significantly more effective than placebo or Fiorinal alone. The combination is also significantly better than codeine alone in relieving pain and maintaining ability to perform daily activities. However, Fiorinal with codeine is not first-line therapy and carries a significant risk of abuse.
• Consider preventive medications if the headaches are frequent (>2 attacks per wk), of long duration (>3-4 h), or severe enough to cause significant disability or overuse of abortive medication.
  • Amitriptyline (Elavil) and nortriptyline (Pamelor) are the most frequently used tricyclic antidepressants.
  • The selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also are used commonly by many physicians. In a double-blind placebo-controlled trial conducted by Saper et al of fluoxetine in patients with chronic daily headache and migraine, it was reported to be helpful.⁴⁶
  • Other antidepressants such as doxepin, desipramine, protriptyline, and buspirone also can be used. According to Cohen, protriptyline may be comparable in effectiveness to amitriptyline in CTTH without producing drowsiness and weight gain.
  • As reported by Bendtsen et al, in one double-blind trial that compared citalopram to amitriptyline and a placebo, patients on citalopram demonstrated lower headache scores than those on placebo, but amitriptyline was significantly more effective.⁴
  • Tizanidine may improve inhibitory function in the central nervous system and can provide pain relief. One recent study by Saper et al provides support for the efficacy of tizanidine in the prophylaxis of chronic daily headache.⁴⁷ Currently the use of tizanidine remains investigational in the treatment of this disorder.
• Physical therapy techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations.
• • Heat, massage, and stretching can be used to alleviate excess muscle contraction and pain.
  • Cranial electrotherapy stimulation is different from TENS, is safe, and may be effective in alleviating the pain intensity of TTH. It may be considered as an alternative to long-term analgesic use.
• Psychophysiologic therapy includes reassurance, counseling, relaxation therapy, stress management programs, and biofeedback techniques. With these modalities of treatment, both frequency and severity of chronic headache may be reduced.
  • In a few studies, such as that by Holroyd et al, benefits from cognitive-behavioral therapy and biofeedback therapy have been reported.³
  • Biofeedback may be helpful in some patients when combined with medications.
  • One prospective study of TTH in an elderly population suggested that relaxation therapy may be an effective intervention.
• The following various minimally invasive techniques may provide pain relief:
• • Trigger point injections
  • Greater or lesser occipital nerve blocks
  • Auriculotemporal nerve block
  • Supraorbital nerve block
  • Botulinum toxin injection in the pericranial muscle
  • Other alternative treatments: In one study, Biondi and Portuesi suggested that acupuncture results are difficult to assess and that acupuncture should be reserved for selected patients.⁵

Consultations

Psychiatry consultations: CTTH can mask or be associated with comorbid conditions such as depression, anxiety, or other serious emotional disorders.

Diet

Balanced meals

Activity

• Regular exercise
• Adequate sleep: The patient should maintain a regular sleep schedule.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy for tension-type headaches (TTHs) are to relieve the headache, reduce morbidity, and prevent complications.

Drug Category: Analgesics

These agents can be used for abortive therapy.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. They generally are used in mild to moderately severe headaches; however, they also may be effective for severe headaches.

Drug Category: Antidepressants

These drugs increase the synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake by the presynaptic neuronal membrane.

Cymbalta can also be helpful for patients who have coexisting depression.

Drug Category: Serotonin reuptake inhibitors

These agents specifically inhibit presynaptic reuptake of serotonin. May be considered as an alternative to TCAs.

Drug Category: Electrolyte supplements

Electrolytes such as magnesium may help in the treatment of tension headache.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Patient Education

Advise the patient with tension-type headaches (TTHs) to take the following actions:

• Avoid stressful situations if possible
• Maintain a regular sleep schedule
• Exercise regularly
• Eat balanced meals
• Avoid uncomfortable stressful positions and bad posture
• Avoid eyestrain
• Try biofeedback and relaxation techniques

For excellent patient education resources, visit eMedicine's Headache Center and Muscle Disorders Center. Also, see eMedicine's patient education articles, Causes and Treatments of Migraine and Related Headaches, Tension Headache, and Chronic Pain.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

Appropriate studies should be performed to exclude secondary headache disorders.

Special Concerns

Special concerns include treatment of the pregnant patient with tension-type headaches.

• The use of medication during pregnancy is not contraindicated, but limit and justify it carefully.
• Headache may improve after the first trimester, and initially it should be managed with nonpharmacologic measures such as reassurance, rest, hot or cold applications, positioning, stretching exercises, massage, ultrasound therapy, relaxation therapy, and biofeedback.
• If headaches do not respond to a nonpharmacologic approach, symptomatic drugs may be used carefully. Acetaminophen and codeine (alone or in combination) can be used during pregnancy.
• Nonsteroidal anti-inflammatory drugs (eg, ibuprofen, aspirin) may be considered during the first trimester of pregnancy, but avoid their use generally, especially during the last trimester. They may constrict or close the fetal ductus arteriosus and may cause maternal and fetal bleeding.
• Limit benzodiazepine and barbiturate use. Do not use ergotamine, dihydroergotamine, or sumatriptan.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Sep 18, 2008