Tension headache overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sabeeh Islam, MBBS[2]
Overview
A common primary headache disorder, characterized by a dull, non-pulsatile, diffuse, band-like (or vice-like) pain of mild to moderate intensity in the head, scalp or neck. The subtypes are classified by frequency and severity of symptoms. There is no clear cause even though it has been associated with muscle contraction and stress.
Historical Perspective
Tension headaches, which were renamed tension-type headaches by the International Headache Society in 1988, are the most common type of primary headaches.
Classification
Tension-type headaches can be episodic or chronic. Episodic tension-type headaches are defined as tension-type headaches occurring less than 15 days a month, whereas chronic tension headaches occur 15 days or more a month for at least 6 months. Tension-type headaches can last from minutes to days or even months, though a typical tension headache lasts 4-6 hours.
Pathophysiology
Causes
The exact cause of tension-type headaches is still unknown. Multiple pathophysiologic mechanisms explain the possible etiologies or causative factors.
Epidemiology and Demographics
Tension headache is one of the most common type of headaches. Tension-type headache (TTH) is the most prevalent headache in the general population. Tension-type headache (TTH) is the second-most prevalent disorder in the world. A Danish Registry showed 1 year prevalances of infrequent episodic, frequent episodic and and chronic TTH were 63.5, 21.6 and 0.9% respectively. A United States study showed that the 1 year prevalences of episodic and chronic TTH were 38.3 and 2.2%. Females have a higher prevalence compared to males. Limited data suggests TTH to be more prevalent in whites compared to black in the US, irrespective of sex. A recent study showed that TTH prevalence peaking in the 4th decade. A Danish study showed decreasing prevalence of TTH with increasing age.
Natural History, Complications and Prognosis
Tension headaches that do not occur as a symptom of another condition may be painful, but are not harmful. It is usually possible to receive relief from treatment. Tension headaches that occur as a symptom of another condition are usually relieved when the underlying condition is treated. Frequent use of pain medications in patients with tension-type headache may lead to the development of medication overuse headache or rebound headache.
Diagnosis
History and Symptoms
Tension-type headache pain is often described as a constant pressure, as if the head were being squeezed in a vise. The pain is frequently bilateral which means it is present on both sides of the head at once. Tension-type headache pain is typically mild to moderate, but may be severe. In contrast to migraine, the pain does not increase during exercise.
Physical Examination
Laboratory Findings
CT
MRI
Treatment
Medical Therapy
Episodic tension-type headaches generally respond well to over-the-counter analgesics, such as paracetamol, ibuprofen or aspirin. Simple analgesic monotherapy such as NSAIDS or aspirin are recommended (Grade 1A) for episodic TTH treatment requiring patients. Simple analgesic monotherapy is used in combination with caffeine for TTH patients who are unresponsive or have a poor response to analgesic monotherapy (Grdae 2A). Combination therapies including opioids or butalbital are not recommended as first line agents for TTH Rx (Grade 1C). Inpatient treatment for severe TTH can be treated in addition to the above mentioned treatment with chlorpromazine, metoclopramide, combination of metoclopramide and diphenhydramine and intramuscular ketorolac.
Prevention
TTH prevention and prophylactic treatment is generally indicated for chronic TTH and frequent episodic TTH. Data regarding pharmacologic prevention and prophylactic treatment is limited and not well established. Drugs that can be used are; TCA (amitriptyline), SSRI (mirtazapine, venlafaxine), and anticonvulsants (gabapentin, topiramate). Behavioral treatments include; relaxation, biofeedback, and CBT. For patients with frequent episodic or chronic TTH, combined Rx with TCA plus stress management therapy is recommended rather than alone therapy with TCA or behavioral therapy alone. (Grade 2B). For patients with frequent episodic or chronic TTH, having preference for pharmacologic therapy rather than behavioral therapy, TCA with amitriptyline is recommended. (Grade 2B). For patients with frequent episodic or chronic TTH, not needing pharmacologic therapy, electromyography biofeedback combined with relaxation therapy is recommended. (Grade 2B). For patients with frequent episodic or chronic TTH, who cannot tolerate or require more effective treatments such as amitriptyline and biofeedback, accupuncture (Grade 2B) or physical therapy (Grade 2C) is recommended.