Tension Headache

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

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. 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
3. Pathophysiology
   1. Pain associated with myofascial (muscular) cause
4. 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
5. 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]
6. 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
7. Evaluation
   1. See Headache History
   2. See Headache Examination
   3. See Headache Diagnostic Testing
8. Diagnosis
   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]
9. 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]
10. 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]
11. 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]