Tension-type headache

Diagnostic approach

• Evaluate for signs of high-risk headache.
• Rule out red flags for headache.
• Evaluate for diagnostic criteria for tension-type headaches.
• Neurological exam
• Palpation of pericranial muscles
• Symptom diary (if recurrent)

Red flag features

• Sudden onset (i.e., thunderclap headache)
• Systemic symptoms (e.g., fever)
• Neurological deficits
• Age > 50 years at onset
• Pattern change or recent onset
• Positional headache
• Signs of increased ICP (e.g., papilledema)
• Posttraumatic onset

Management checklist

• NSAIDs (e.g., ibuprofen , naproxen , diclofenac )
• Aspirin
• Acetaminophen
• Counsel against medication use > 15 days/month.
• Lifestyle modifications (e.g., stress reduction, sleep hygiene)
• Consider prophylactic amitriptyline for chronic and/or frequent episodic TTH.

Tension-type headache (TTH) is a primary headache disorder and the most common type of headache overall. TTHs are characterized by a dull, nonpulsating, band-like pain that is often bilateral. Autonomic symptoms such as photophobia, phonophobia, or nausea are usually not present. Depending on the frequency and duration of episodes, TTHs are classified as episodic or chronic. Infrequent episodic TTHs are treated with NSAIDs or acetaminophen, while chronic and frequent episodic forms may benefit from prophylactic amitriptyline. Nonpharmacological treatment options include lifestyle modification (e.g., stress reduction) and cognitive behavioral therapy. In children, nonpharmacological interventions for headache are preferred over pharmacological prophylaxis for headache prevention.

• Occurrence
  • Most common type of headache
  • ∼ 86% of the population will have had at least one episode in their lifetime. ^[1][2]
• Sex: : ♀ > ♂ ^[2]
• Peak incidence: 30–39 years ^[3]

Epidemiological data refers to the US, unless otherwise specified.

• The exact pathophysiology of tension headaches remains unknown.
• Exacerbating factors: fatigue, lack of sleep, poor posture, anxiety, stress, depression ^[4]

• Episodic nature
• Headaches last 30 minutes to a couple of days. ^[4]
• Holocranial or bifrontal, band-like headache (mild to moderate intensity)
• Dull, pressing, nonpulsating ("vise-like”) quality
• Headache does not increase with exertion.
• Maximum of one autonomic symptom (phonophobia or photophobia)
• No nausea, vomiting, or aura
• Palpation of muscles of the head may reveal increased pericranial tenderness.
• Normal neurological examination ^[5]
• For clinical features in children, see "TTH in children."

TTH is primarily a clinical diagnosis based on a history of typical features and normal neurological examination. Severe underlying conditions should be ruled out (see "Red flags for headache" and “Diagnostic workup for headache”). A headache diary can be helpful to establish the diagnosis and guide management. ^[6]

Diagnostic criteria for TTH ^[4][6]

• At least two of the following:
  • Dull, pressing, nonpulsating quality
  • Mild to moderate intensity
  • Bilateral
  • No increase in intensity with exertion
• Not better explained by any other headache disorder
• Categorized into three entities (which guide treatment); all criteria have to be fulfilled for the diagnosis ^[4]

Classification of TTH

TTHs may be difficult to differentiate from mild forms of migraine without aura, and some patients may have both disorders. ^[4]

See “Primary headaches” in “Differential diagnosis of headache.”

The differential diagnoses listed here are not exhaustive.

General principles ^[4]

Both pharmacological and nonpharmacological strategies can be used for the treatment of TTH. In addition, any underlying conditions (e.g., depression) should be identified and treated. See "TTH in children" for pediatric management.

• Pharmacological treatment
  • Episodic TTH: NSAIDs (e.g., ibuprofen, aspirin) or acetaminophen
  • Chronic TTH; and frequent episodic type: consider prophylactic therapy (e.g., with amitriptyline).
  • All types of TTH:
    • Triptans are not indicated for the treatment of isolated TTH. ^[6]
    • Opioids should be avoided. ^[6]
• Nonpharmacological treatment: Consider if there is a significant decrease in the patient's quality of life.
  • Lifestyle and behavioral modification (e.g., exercise, weight reduction)
  • Psychobehavioral treatments (e.g., cognitive behavioral therapy, relaxation training)

Avoid prolonged use (> 15 days/month) of NSAIDs for chronic tension headache, as this may cause medication overuse headaches. ^[4]

Pharmacological treatment

Episodic TTH ^[6][7]

• One of the following NSAIDs:
  • Ibuprofen
  • Naproxen
  • Diclofenac
  • Aspirin
  • Ketorolac IM ^[6]
• Acetaminophen
• Caffeine can be used in combination with ibuprofen or acetaminophen to augment the analgesic effect. ^[6]
• Counsel patient against taking acute pain medication for more than 15 days/month to avoid medication overuse headache.

Opioids are not recommended for TTHs and increase the risk of developing medication overuse headache. ^[6]

Prophylactic therapy for chronic TTH and frequent episodic TTH ^[6][7]

• First-line: amitriptyline (off-label)
• Second-line ^[6]
  • Mirtazapine
  • Venlafaxine

Nonpharmacological treatment ^[6][8]

• Lifestyle and behavioral changes (identification and management of triggers)
  • Reduction of caffeine intake
  • Smoking cessation
  • Stress reduction
  • Sleep hygiene
  • Physical activity
• Treatment of underlying conditions (e.g., depression)
• Additional nonpharmacological therapies include: ^[6]
  • Biofeedback
  • Relaxation training (e.g., progressive muscle relaxation)
  • Cognitive behavioral therapy
  • Physical therapy (including posture training, massage, spinal manipulation)
  • Acupuncture

• Epidemiology
  • Most common primary headache disorder in children (occurs in up to 60% of children) ^[9]
  • Average age of onset: 7 years ^[10]
• Etiology: same as adults; usually unknown, but may be triggered by fatigue, lack of sleep, poor posture, anxiety, stress, and/or depression ^[4]
• Clinical features ^[4][9][10]
  • Same clinical features of TTH as in adults (e.g., bilateral, nonpulsating, mild to moderate intensity)
  • In children, symptoms are often:
    • Inferred from behaviors
    • Described in developmentally appropriate terms ^[11]
    • Present toward the end of school days; absent or rare on nonschool days
  • It may be difficult to distinguish TTH from migraine in children without aura. ^[10]
• Diagnosis ^[4][10][12]
  • Diagnosed clinically if:
    • The diagnostic criteria for TTH are met.
    • No headache red flags are present.
  • The classification of TTH in adults is the same as in children.
• Differential diagnoses: See “Primary headaches” in “Differential diagnosis of headache.”
• Management ^[13][14]
  • Acute pain: nonopioid oral analgesia in children
  • Offer the following preventive measures sequentially:
    • Lifestyle modifications for headaches
    • Behavioral interventions (e.g., relaxation techniques, cognitive behavioral therapy, biofeedback)
    • Refractory symptoms: Consider pediatric neurology referral for management, e.g., prophylactic amitriptyline (off-label).
  • Screen children with chronic TTH for coexisting psychiatric conditions (e.g., depression, ADHD, and other neurodevelopmental disorders). ^[4][10]
  • Caution patients about medication overuse headache. ^[14]

Avoid aspirin in children < 15 years of age because of the risk of Reye syndrome. ^[15][16]

Prevention of pediatric TTH focuses on nonpharmacological management for headaches rather than long-term pharmacological prophylaxis. ^[13]