Tension Headache

Headaches are a major cause of morbidity. Tension headaches are a significant cause of sickness absence and impaired ability at work.¹ Tension type headache 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 tension-type headache (affects 78% of the population). This occurs on less than 15 days each month. It can evolve into the chronic variety.
• Chronic tension-type headache (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 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 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

When compared to migraine, tension headaches are:

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

Diagnosis of tension 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
• Nonpulsatile 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 vicelike'
  • 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 headache and is performed to exclude other causes and reassure the patient. There may be some tenderness in scalp or neck (especially upper cervical muscles with occipital headache). Examination should include:

• Examination of head and neck
• Blood pressure
• Optic fundi

The following may be worthy of consideration:

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

These do not generally contribute anything to the diagnosis of tension 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 less 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 medicines overuse headache (MOH). Recommended drug treatment is:
  • Ibuprofen
    • This is the first choice
    • From age 16 years the dose is from 400mg to 800mg three times daily with food.
  • Diclofenac
    • This is an alternative to ibuprofen but has an intermediate risk of gastrointestinal side effects.
    • From age 16 years the dose is 25mg to 50mg three times daily.
  • Naproxen
    • This is another alternative to ibuprofen but also with intermediate risk of gastrointestinal side effects.
    • From age 16 years the dose is 250mg to 500mg twice daily.
  • Paracetamol.
    • This is recommended for those intolerant of NSAIDS.
    • Dosage is 500mg, two 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 broadly be 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 tension-type headache was not beneficial in a randomised controlled trial of chiropractic treatment.¹² Another study compared spinal manipulation with amitriptyline in chronic tension-type headaches 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.^{17 16} 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 15mg at night, increased up to as much as 150mg at night. Usually requires no more than 20-30mg. 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 headache in the episodic form is particularly common and causes minimal disability or discomfort. However if it evolves into the chronic tension-type headache 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 medication overuse headache. Those at risk are patients using analgesics (or triptans) for more than 17 days a month.