Tension Headache

Aka: Tension Headache, Occipital Headache, Tension Type Headache, Episodic TTH, Chronic TTH

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II. Epidemiology

  1. Most common Primary Headache
    1. Accounts for 46 to 78% of Primary Headaches (contrast with 14 to 16% for Migraine Headaches)
  2. Prevalence
    1. Lifetime: 78%
    2. Annual: 38% of adults
  3. Age
    1. Peaks 30 to 39 years old
  4. Gender
    1. Slightly more common in women

III. Pathophysiology

  1. Pain associated with myofascial (muscular) cause

IV. Causes

  1. Stress or worry
  2. Anxiety
  3. Major Depression
  4. Overwork
  5. Lack of sleep
  6. Incorrect Posture
  7. Marital and family dysfunction
  8. Post-Concussion (<3 months)
  9. Conversion
  10. Malingering

V. Types

  1. Episodic Tension Headache (Episodic TTH)
    1. Recurrent Tension Headaches may progress to chronic Tension Headache (due to Headache Central Sensitization)
    2. Increased risk of chronic Tension Headache with longer duration Headaches and associated Nausea
    3. Frequent episodic Headaches occur on at least one day, and up to 14 days per month
    4. Infrequent episodic Headaches occur less than once per month
  2. Chronic Tension Headache (Chronic TTH)
    1. See Chronic Daily Headache
    2. Present at least half the days of the month
    3. Persists for 6 months or more
    4. Associated with high disease burden
      1. Days of work missed per year averages 27
      2. Contrast with 9 days per year in episodic Tension Headache
      3. Schwartz (1998) JAMA 279(5): 381-3 [PubMed]

VI. Symptoms

  1. Characteristics
    1. Pressing, tightening or vice-like gripping Headache
  2. Location
    1. Band of pain extending from forehead back to occiput
    2. Usually affects bilateral forehead
    3. Radiation into trapezius Muscle and posterior neck
  3. Timing
    1. Mild to moderate intensity for more than 30 minutes
  4. Provocative
    1. Not provoked by low level activity
  5. Migraine Headache symptoms absent
    1. No Nausea or Vomiting
    2. No photophobia and phonophobia
    3. Headache is not pulsating

VII. Evaluation

  1. See Headache History
  2. See Headache Examination
  3. See Headache Diagnostic Testing

VIII. Diagnosis (ICHD or International Headache Society Diagnostic Criteria 3)

  1. Characteristics: All must be present
    1. Headache lasts 30 minutes to 7 days
    2. No significant Nausea and no Vomiting (although Anorexia may be present)
    3. Photophobia OR phonophobia (but not both)
    4. Headache has at least 2 of the following features
      1. Bilateral distribution
      2. Pressing or tightening (non-pulsating quality)
      3. Mild to moderate intensity
      4. Not worse with routine Physical Activity (e.g. walking, climbing stairs)
  2. Timing
    1. Infrequent, Episodic Tension Type Headache
      1. Ten episodes or more AND
      2. Episodes occur <1 day per month on average (<12 per year)
    2. Frequent Tension Type Headache
      1. Ten episodes or more AND
      2. Episodes occur 1-14 days per month for at least 3 months (12 to 180 episodes per year)
    3. Chronic Tension Type Headache
      1. Episodes occur >15 days per month for at least 3 months (>180 episodes per year)
  3. References
    1. (2018) Cephalgia 38(1):1-211 [PubMed]

IX. Management: General Measures

  1. See Nonpharmacologic Headache Treatment
  2. Reassurance
  3. Tobacco Cessation
    1. Headache is related to amount of Tobacco used
    2. Headaches increase with Cigarette use per day
  4. Modify or eliminate stressors
  5. Biofeedback
  6. Relaxation Therapy
  7. Yoga
  8. Coping strategies
  9. Counseling (Psychotherapy)
  10. Acupuncture
    1. Growing evidence of benefit (see Acupuncture)
    2. Vickers (2004) BMJ 328:744 [PubMed]
  11. Spinal Manipulation
  12. Physical Therapy
    1. Hammill (1996) Headache 36:149-53 [PubMed]

X. Management: Medications

  1. Myofascial injections
    1. Trigger Point Injection at affected occiput or
    2. Lower Cervical Intramuscular Injection
  2. Selective C1-C2 lateral Joint Injection
    1. Aprill (2002) Cephalalgia 22:15-22 [PubMed]
  3. Analgesics
    1. Tylenol
    2. NSAIDs
    3. Aspirin
    4. Avoid Opioids
  4. Consider Antidepressants for Headache prophylaxis
    1. Tricyclic Antidepressants (e.g. Amitriptyline)
      1. Gobel (1994) Pain 59:241-9 [PubMed]
      2. Jackson (2017) J Gen Intern Med 32(12):1351-8 +PMID: 28721535 [PubMed]
    2. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Adelman (2000) Headache 40:572-80 [PubMed]

XI. References

  1. Millea (2002) Am Fam Physician 66(5):797-805 [PubMed]
  2. Redillas (2000) Headache 40(2): 83-102 [PubMed]
  3. Ryan (1996) Am Fam Physician 54(3):1051-7 [PubMed]
  4. Stevens (1993) Am Fam Physician 47(4):799-804 [PubMed]
  5. Trachtenbarg (1994) Postgrad Med 95(6):44-56 [PubMed]
  6. Hainer (2013) Am Fam Physician 87(10): 682-7 [PubMed]
  7. Viera (2022) Am Fam Physician 106(3): 260-8 [PubMed]

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Related Studies

Ontology: Tension Headache (C0033893)

Definition (MSH) 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. (International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004: suppl 1)
Definition (MSHCZE) Problém s běžnou základní bolestí hlavy charakterizovanou jako BOLEST tupá, nepulzatilní, prostupující, svíravá ("mít hlavu v kleštích"), a to od mírné až po střední intenzitu právě v oblasti HLAVY, SKALPU nebo KRKU. Podtypy jsou klasifikovány podle četnosti a závažnosti symptomů. Příčina není zřejmá, je však spojována se svalovou kontrakcí (SVALY-KONTRAKCE) a zátěží. (International Classification of Headache Disorders, 2. vyd. Cephalalgia 2004: suppl. 1)
Concepts Disease or Syndrome (T047)
MSH D018781
ICD9 339.1, 339.10, 307.81
ICD10 G44.2 , G44.209, G44.20
SnomedCT 230469006, 154931007, 192028000, 193035000, 66551002, 398057008
LNC LA15136-7, LA15139-1
English Headache, Tension, Headache, Tension-Type, Headaches, Tension, Headaches, Tension-Type, Tension Headache, Tension Headaches, Tension Type Headache, Tension-Type Headaches, tension-type headache (diagnosis), tension-type headache, Tension type headache, Tension type headache, unspecified, Headache tension, Tension headaches, Headache, Stress, Headaches, Stress, Stress Headache, Stress Headaches, Tension headache NOS, Tension-type headache, unspecified, Tension-Type Headache [Disease/Finding], headaches tensions, headaches tension, muscle tension headache, stress headache, stress headaches, tension-type headaches, Headache;tension, headache tension, headaches muscle tension, tension type headache, headache stress, tension headache, tension headaches, headaches stress, headaches tension type, headaches tension-type, Stress headaches, Psychogenic headache, Tension headache, Tension-type headache, Stress headache, Psychogenic headache (finding), Tension-type headache (disorder), headache; tension, tension; headache, Tension-Type Headache, Headache, Psychogenic, Headaches, Psychogenic, Psychogenic Headache, Psychogenic Headaches, Headache, Idiopathic, Headaches, Idiopathic, Idiopathic Headaches, Idiopathic Headache
Spanish cefalea de tipo tensional, Cefaleas de tensión, Cefalea de Tipo Tensional, cefalea tensional (trastorno), Cefalalgia de Tipo Tensional, Cefalea debida a Tensión, cefalea de tipo tensional (trastorno), cefalea por tensión, cefalea psicógena (hallazgo), cefalea psicógena, cefalea tensional, dolor de cabeza psicógeno, Cefalea de tensión, Cefalea Psicogénica, Dolor de Cabeza Tensional
Italian Cefalea muscolotensiva, Cefalee muscolotensive, Cefalea idiopatica, Cefalea psicogenica, Cefalea da stress, Cefalea muscolo-tensiva, Cefalea tensiva
Dutch spanningshoofdpijnen, hoofdpijn; spanning, spanning; hoofdpijn, spanningshoofdpijn, Spanningshoofdpijn, Hoofdpijn, spannings-, Stresshoofdpijn
French Céphalées de tension, Céphalée de tension, Céphalée par tension nerveuse, Céphalée psychogène
German Spannungskopfschmerzen, Spannungskopfschmerz, Kopfschmerz, Spannungs-, Kopfschmerz durch Streß
Portuguese Cefaleias tipo tensão, Cefaleia de tensão, Cefaleia Psicogênica, Cefaleia por Estresse, Cefaleia do Tipo Tensional, Cefaleia Tensional, Cefalalgia Tensional, Cefalgia Psicogênica, Cefalalgia do Tipo Tensional, Cefalgia do Tipo Tensional, Cefalalgia Psicogênica, Cefalgia Tensional, Cefaleia Tensional Vascular, Cefaleias de tensão
Swedish Spänningshuvudvärk
Japanese ｷﾝﾁｮｳｾｲｽﾞﾂｳ, 筋収縮性頭痛, 緊張性頭痛, 頭痛-筋緊張性, 筋緊張性頭痛, 頭痛-緊張性
Czech idiopatická bolest hlavy, hlava - bolest tenzní, hlava - bolest tenzního typu, psychogenní bolest hlavy, stresová bolest hlavy, Tenzní typ bolesti hlavy, Bolest hlavy tenzní, Tenzní bolesti hlavy, hlava - bolesti tenzního typu, tenzní bolesti hlavy, tenzní cefalea
Finnish Jännityspäänsärky
Russian GOLOVNAIA BOL' NAPRIAZHENIIA, GOLOVNAIA BOL' OT NERVNOGO NAPRIAZHENIIA, ГОЛОВНАЯ БОЛЬ НАПРЯЖЕНИЯ, ГОЛОВНАЯ БОЛЬ ОТ НЕРВНОГО НАПРЯЖЕНИЯ
Korean 긴장형 두통
Polish Ból głowy napięciowy, Ból głowy spowodowany ze stresem, Napięciowy ból głowy
Hungarian Tensiós fejfájás, Tensiós fejfájások, Fejfájás tensiós
Norwegian Spenningshodepine, Spenningshodeverk, Stresshodepine, Stresshodeverk, Tensjonshodepine, Tensjonshodeverk
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Occipital headache (C0231613)

Concepts Sign or Symptom (T184)
SnomedCT 139574005, 330007
English Headache Occipital, headache at back of head (occipital), occipital headache (symptom), occipital headache, Headache, occipital, headaches occipital, Occipital headache, Occipital headache (finding)
Dutch occipitale hoofdpijn
French Mal de tête occipital
German okzipitaler Kopfschmerz
Italian Cefalea occipitale
Portuguese Cefaleia occipital
Spanish Dolor de cabeza occipital, cefalea occipital (hallazgo), cefalea occipital, dolor de cabeza occipital
Japanese 後頭部痛, ｺｳﾄｳﾌﾞﾂｳ
Czech Týlní bolest hlavy
Hungarian Occipitalis fejfájás
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Headache Disorders

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