Tension-type Headache

Headaches are a major cause of morbidity. Tension-type headaches are a significant cause of sickness absence and impaired ability at work.¹ Tension-type headache (TTH) is classified as a primary headache according to the International Classification of Headache Disorders.² It is a very common form of headache and can be:

• Episodic TTH (affects 78% of the population). This occurs on less than 15 days each month. It can evolve into the chronic variety.
• Chronic TTH (affects 3% of the population). This occurs on more than 15 days each month and has all the features of the episodic tension-type headache.

As with many headache disorders, a good history (see box below) is essential to make the diagnosis. There are both physical and psychological aetiological factors. With the correct diagnosis effective treatment and advice can be offered.

• Tension-type headache is the most common type of chronic recurring head pain.
• It is one of the most common conditions for which patients seek medical advice.
• It is more common in women than men (ratio 1.4 to 1).
• It is most common in young adults with about 60% occurring in people over 20 years of age. Onset over age 50 years is unusual.
• Lifetime prevalence of episodic tension-type headache is between 30% and 78%.
• Care should be taken when diagnosed in the elderly because more secondary headache disorders occur in the elderly.³

Typically, TTH is described as pressure or tightness, like a vice or tight band around the head. There is often a relationship to the neck, with pain into or from the neck. TTH can be disabling for a few hours but lacks the specific features and associated symptoms of migraine (although photophobia and exacerbation by movement are common to many headaches).² When compared to migraine, tension-type headaches are:

• More gradual in onset
• More variable in duration (usually shorter)
• More constant in quality
• Less severe
• Usually respond to 'over-the-counter' medication (in episodic variety)

Diagnosis of tension-type headache requires 2 of the following in at least 10 previous headaches:²

• Bilateral or generalised, and of mild-to-moderate intensity (interfering with, but not preventing activities)
• Frontal-occipital
• Non-pulsatile in quality (pressing or tightening)
• Not aggravated by routine physical activity

History

• Time questions:
  • There will have been 10 previous headache episodes or more to make the diagnosis.
  • 'Infrequent' is considered to mean fewer than 180 days per year with headache.
  • Often present at, or soon after, getting up in the morning.
  • It may be chronic with a duration of more than 5 years in 75% of patients with the chronic variety.
  • Duration will range from 30 minutes to 7 days.
• Character questions:
  • Pain is mild to moderate in intensity.
  • The pain is described as:
    • 'Fullness'
    • 'Tightness'
    • 'Squeezing'
    • 'Pressure'
    • 'Like a skullcap'
    • 'Band or vice-like'
  • Pain is bilateral and occipitonuchal or bifrontal.
  • Associated symptoms:
    • Muscular tightness or stiffness in neck, occipital or frontal regions
    • Difficulty concentrating
    • Symptoms of stress and anxiety
    • Insomnia
    • Usually no photophobia or phonophobia (may be one or both of these symptoms)
    • No nausea or vomiting
    • No prodrome
• Cause questions:
  • Anxiety⁴
  • Depression⁴
  • Poor posture
  • Poor sleep
  • Stress
  • Muscular tightness (as above)
  • Usually relieved by simple analgesics
• Response questions:
  • Patients can usually do normal activities
  • Simple analgesics will have been tried usually with good effect
• State between attacks:
  • Well between attacks
  • May be anxious about the headaches

Examination²

This will be normal in tension-type headache and is performed to exclude other causes and to reassure the patient. There may be some tenderness in the scalp or neck (especially the upper cervical muscles, with occipital headache). Examination should include:

• Head and neck
• Blood pressure
• Optic fundi

The following may be worthy of consideration:

• Migraine
• Temporal arteritis
• Trigeminal neuralgia
• Temporomandibular joint dysfunction
• Subarachnoid haemorrhage
• Sinusitis
• Encephalitis
• Cervical spondylosis
• Carbon monoxide poisoning

These do not generally contribute anything to the diagnosis of tension-type headache. They may be required if history or examination suggest the headache is secondary to another condition. Cervical spine X-rays and eye tests are unlikely to contribute to the diagnosis.

Episodic tension-type headache

This has the features described above. Headaches occur on fewer than 15 days each month.
Management should incorporate:

• An explanation and discussion of the diagnosis.
• Reassurance that the condition is self-limiting and not serious.
• Attention to any stress, anxiety or depression.^{4 7}
• Appropriate advice on exercise and posture.
• Advice on medication: opioids including codeine should be avoided because of the risk of medication-overuse headache (MOH). Recommended drug treatment is:
  • Ibuprofen:
    • This is the first choice.
    • From age 16 years the dose is from 400 mg to 800 mg 3 times daily with food.
  • Diclofenac:
    • This is an alternative to ibuprofen but has an intermediate risk of gastrointestinal (GI) side-effects.
    • From age 16 years the dose is 25 mg to 50 mg 3 times daily.
  • Naproxen:
    • This is another alternative to ibuprofen but also with intermediate risk of GI side-effects.
    • From age 16 years the dose is 250 mg to 500mg twice daily.
  • Paracetamol:
    • This is recommended for those intolerant of non-steroidal anti-inflammatory drugs (NSAIDS).
    • Dosage is 500 mg, 2 tablets every 4 to 6 hours.

Chronic tension-type headache

• What is the potential for treatments other than medication? It can be difficult to access the different modalities of treatment on offer. Reports on efficacy are mixed. Some patients may be driven to use ineffective and expensive treatments.⁸ However, some of the treatments on offer are attractive to patients and promising in some clinical trials. The following might be broadly considered:
  • Relaxation therapies
  • Physical treatments
  • Psychological therapies
  Specific therapies may incorporate elements of all three. For example yoga, therapeutic massage, acupuncture,^9,10 and osteopathy.¹¹ Spinal manipulation for episodic TTH was not beneficial in a randomised controlled trial of chiropractic treatment.¹² Another study compared spinal manipulation with amitriptyline in chronic TTH and found amitriptyline more effective.¹³ Spinal manipulation has been shown to be more effective than massage for chronic headache.¹⁴ There are methodological problems with these studies¹⁵ but, in well-motivated patients, a variety of treatment modalities could reasonably be tried, preferably with medication,¹⁶ particularly for the chronic variety of headache.^16,17 A Cochrane review of a wide range of physical treatments concluded that they were safe, often as effective as prophylactic treatments but in need of further investigation.¹⁸
• Medication:
  • Amitriptyline is the treatment of choice.
  • Warn of side-effects (dry mouth for example).
  • Start at 10 to 15 mg at night, increased up to as much as 150 mg at night. Usually requires no more than 20-30 mg. If higher doses are required, this may suggest an alternative diagnosis (for example depression).
  • Reduce once improvement is maintained for between 4 and 6 months.
  • Reduce gradually, but be prepared to hold the reduction if headaches recur.

Tension-type headache in the episodic form is particularly common and causes minimal disability or discomfort. However, if it evolves into the chronic TTH, then the morbidity escalates dramatically. It seems to improve over age 60 years but appears to remain a problem for most sufferers throughout their lives.¹⁹

It is important to beware of creating cases of MOH. Those at risk are patients using analgesics (or triptans) for more than 17 days a month.

1. Jensen R; Diagnosis, epidemiology, and impact of tension-type headache. Curr Pain Headache Rep. 2003 Dec;7(6):455-9. [abstract]
2. Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache, BASH (2007)
3. Kaniecki RG; Tension-type Headache in the Elderly. Curr Treat Options Neurol. 2007 Jan;9(1):31-7. [abstract]
4. Holroyd KA, Stensland M, Lipchik GL, et al; Psychosocial correlates and impact of chronic tension-type headaches. Headache. 2000 Jan;40(1):3-16. [abstract]
5. Headache - tension-type, Clinical Knowledge Summaries (August 2009)
6. Diagnosis and management of headache in adults, SIGN (November 2008)
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11. Anderson RE, Seniscal C; A comparison of selected osteopathic treatment and relaxation for tension-type headaches. Headache. 2006 Sep;46(8):1273-80. [abstract]
12. Bove G, Nilsson N; Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998 Nov 11;280(18):1576-9. [abstract]
13. Boline PD, Kassak K, Bronfort G, et al; Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther. 1995 Mar-Apr;18(3):148-54. [abstract]
14. Bronfort G, Assendelft WJ, Evans R, et al; Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001 Sep;24(7):457-66. [abstract]
15. Fernandez-de-las-Penas C, Alonso-Blanco C, San-Roman J, et al; Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache. J Orthop Sports Phys Ther. 2006 Mar;36(3):160-9. [abstract]
16. Biondi DM; Physical treatments for headache: a structured review. Headache. 2005 Jun;45(6):738-46. [abstract]
17. Biondi DM; Noninvasive treatments for headache. Expert Rev Neurother. 2005 May;5(3):355-62. [abstract]
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• Loder E, Rizzoli P; Tension-type headache. BMJ. 2008 Jan 12;336(7635):88-92.