Practice Essentials
The International Headache Society (IHS) began developing a classification system for headaches in 1985. Now in its third edition, this system includes a tension-type headache (TTH) category, further defined as either episodic (frequent and infrequent) or chronic. In infrequent episodic TTH, headache episodes occur less than one day a month, whereas in frequent episodic TTH, headache episodes occur 1 to 14 days a month. In chronic TTH, headaches occur 15 or more days a month.
Diagnosis
Laboratory work should be unremarkable in cases of tension-type headache. Specific tests should be obtained if the history or physical examination suggests another diagnostic possibility.
Head CT scan or MRI is necessary only when the headache pattern has changed recently, the headache cannot be clearly defined by the clinician as a common primary headache disorder (that is not a cluster, migraine, or tension-type of headache), or neurologic examination reveals abnormal findings. [11]
Signs and symptoms
Pain onset in tension-type headache can have a throbbing quality and is usually more gradual than onset in migraines. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.
IHS diagnostic criteria for tension-type headaches states that two of the following characteristics must be present: [1]
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Pressing or tightening (nonpulsatile quality)
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Frontal-occipital location
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Bilateral - Mild/moderate intensity
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Not aggravated by physical activity
Management
Various modalities are used in the treatment of tension headaches. These include hot or cold packs, ultrasound, electrical stimulation, improvement of posture, trigger point injections, occipital nerve blocks, stretching, and relaxation techniques.
Non-pharmacological treatments for headache include behavioral treatments such as cognitive-behavioral therapy, relaxation, biofeedback as well as acupuncture and massage. These treatments are options for patients who prefer non-pharmacological treatments or cannot take medications such as pregnant patients. [13]
Background
The International Headache Society (IHS) began developing a classification system for headaches in 1985. Now in its third edition, this system includes a tension-type headache (TTH) category, further defined as either episodic (frequent and infrequent) or chronic. In infrequent episodic TTH, headache episodes occur less than one day a month, whereas in frequent episodic TTH, headache episodes occur 1 to 14 days a month. In chronic TTH, headaches occur 15 or more days a month.
Headache categories also are defined by whether they are associated with pericranial muscle disorders. [1]
Episodic tension headache usually is associated with a stressful event. This headache type is of moderate intensity, self-limited, and usually responsive to nonprescription drugs.
Chronic tension headache often recurs daily and is associated with contracted muscles of the neck and scalp. This type of headache is bilateral and usually occipitofrontal.
TTH is the most common type of chronic recurring head pain. In the past, pain etiology was presumed to be the muscular contraction of pain-sensitive structures of the cranium, but the IHS intentionally abandoned the terms muscular contraction headache and tension headache because no research supports muscular contraction as the sole pain etiology.
Pathophysiology
The pathogenesis of tension type headaches is multifactorial. Given the wide variation in frequency and intensity in TTH, not only between individuals but also within individuals over time, it is likely that the underlying pain mechanisms in TTH are dynamic. It is suggested that the mechanisms vary from one individual to another, and potentially from one attack to another in the same individual. [3] These factors include environmental and genetic factors. Environmental factors influence the development of episodic TTH more than chronic TTH, while genetic factors appear to play an important role in the development of chronic TTH. [4, 5, 6]
It is postulated that peripheral activation or sensitization of myofascial nociceptors play a major role in episodic TTH. Extended nociceptive stimuli from pericranial myofascial tissues seems to be responsible for the conversion of episodic to chronic TTH. [3, 7, 8, 9, 10, 11] In chronic THH, stimuli that are normally painless are misinterpreted as pain. This continuous painful input induces central sensitization. The increased nociceptive stimulation of supraspinal structures results in increased facilitation and decreased inhibition of pain transmission at the level of the spinal dorsal horn/trigeminal nucleus, and in increased pericranial muscle activity. [7] This was shown in a study of women with frequent episodic tension-type headaches (FETTH). They had widespread pressure pain hypersensitivity over both nerve trunks and musculoskeletal structures suggesting this central altered nociceptive processing. This pain was not restricted to musculoskeletal areas, but also pain evoked from directly provoking the nerve trunks by pressure. [22]
A study by Kiran et al indicated that patients with chronic tension headaches for longer than 5 years tended to have lower cortisol levels. [2] This was postulated to be due to hippocampus atrophy resulting from chronic stress, a cause of chronic tension headaches. More recently it is believed that there is increased myofascial pain sensitivity caused by central factors such as sensitization of neurons in the supraspinal region as well as second order neurons in the spinal dorsal horn/trigeminal nucleus. [3] Another mechanism of pain is decreased antinociception or inability of the body to stop painful stimuli to the supraspinal structures. [4]
Etiology
Stress may cause contraction of neck and scalp muscles, although no evidence confirms that the origin of pain is sustained muscle contraction. Other triggers [23, 24] of headache include:
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Stress (physical or emotional) and/or anxiety
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Alcohol use
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Caffeine (too much or withdrawal)
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Colds, flu, sinus infection
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Dental problems
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Eye strain
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Excessive smoking
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Poor posture
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Depression
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Fatigue
One study showed that patients with tension-type headache (TTH) have relatively weak neck extension muscles. According to results, these patients are 26% weaker than controls with respect to neck extension muscles, they have a 12% smaller extension/flexion ratio, and they have a borderline significant difference in the ability to generate muscle force over the shoulder joint. [5, 6]
Epidemiology
Statistics
Headaches account for 1–4% of all emergency department (ED) visits and are in the top most common reasons for a patient to consult a physician. Tension-type headaches (TTH) are common, with a lifetime prevalence in the general population ranging between 30% and 78% in different studies. They affect approximately 1.4 billion people or 20.8% of the population. [7, 8] Of concern is that in 2010, opioids were administered in 35% of ED visits for headache compared to triptans, which were given in only 1.5% of visits. [9]
TTH onset often occurs during the teenage years and affects three women to every two men. Previous studies in the United States had shown that tension type headaches peaked in the fourth decade. However, European studies show that these headaches persist occurring even into the 6th decade of life. [10]
Prognosis
Tension-type headaches (TTH) may be painful, but are not harmful. Most cases are intermittent and do not interfere with work or normal life span. However, they may become chronic if life stressors are not changed.
