Tension Headache

Aka: Tension Headache, Occipital Headache

1. See Also
   1. Headache
   2. Headache Causes
   3. Acute Generalized Headache
   4. Acute Localized Headache
   5. Acute Recurrent Headache
   6. Chronic Progressive Headache
2. Pathophysiology
   1. Pain associated with myofascial (muscular) cause
3. 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
4. Types
   1. Acute Tension Headache
   2. Chronic Tension Headache
      1. See Chronic Daily Headache
      2. Present at least half the days of the month
      3. Persists for 6 months or more
5. 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
6. Evaluation
   1. See Headache History
   2. See Headache Examination
   3. See Headache Diagnostic Testing
7. Diagnosis
   1. Characteristics: All must be present
      1. Headache lasts 30 minutes to 7 days
      2. No Nausea or Vomiting (although Anorexia may be present)
      3. Photophobia or phonophobia
      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
         1. Ten episodes or more and
         2. Episodes occur <1 day per month on average (<12 per year)
      2. Frequent
         1. Ten episodes or more and
         2. Episodes occur 1-15 days per month for at least 3 months
8. 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]
9. 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. Selective Serotonin Reuptake Inhibitors (SSRI)
         1. Adelman (2000) Headache 40:572-80 [PubMed]
10. 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]