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Tension Headache
Essentials
- Tension headache (or tension-type headache, TTH) includes headaches caused by both muscle tension and mental stress.
- Tension headache may occur concomitantly with migraine.
- Physical activity and relaxation alleviate symptoms.
- Unlike in migraine, physical exertion does not exacerbate symptoms.
- Non-pharmacological treatment methods have a central role.
Symptoms
- The headache is steady and worsens gradually towards the evening.
- There is a tight, squeezing pain in the head, like a band around the head.
- Localized to the temples, occiput or top of the head; may be unilateral.
- Tingling, stabbing, excruciating pains may be felt on the top of the head.
- Muscular tension in the neck area may be associated with pain in the nuchal muscles and night-time numbness of the upper extremities.
- There may be dizziness and a sense of loss of balance.
Diagnosis
- Based on typical symptoms and clinical examination (ICHD-3 Classification: Tension-type headache http://ichd-3.org/2-tension-type-headache/).
- Neurological status is normal.
- On palpation, tenderness may be detected in the temporal or occipital areas as well as in the neck and shoulders.
- Tension headache is divided to episodic (< 15 headache days/month) and chronic (> 15 headache days/month) types.
Differential diagnosis
- Keeping a headache diary helps to make the right diagnosis, especially in the case of suspected mixed headache.
- Migraine without aura where physical exertion typically makes the headache worse, and where prodromal symptoms and associated symptoms occur
- Malocclusion (bruxism) Bruxism
- Occipital nerve compression, where trigger tenderness can be found at the point where the nerve exits the cranial base and the pain follows its innervation boundaries
- SinusitisAcute Maxillary Sinusitis
- Giant cell arteritis where a palpable temporal artery can be found in physical examination, often unilateral Giant Cell (Temporal) Arteritis, in laboratory tests SR often elevated.
- Endocrinological cause, such as hyperthyroidism Hyperthyroidism or hyperparathyroidism Hypercalcaemia and Hyperparathyroidism
- Brain tumour, the symptoms and signs of which often include morning nausea, progressively worsening headache, abnormal findings in physical examination Brain and Spinal Cord Tumours
Imaging
- Imaging of the head is indicated only if the neurological status is abnormal or if a suspicion of a severe disease arises.
- Indications for head computed tomography or magnetic resonance imaging in headache
- Suspicion of subarachnoidal haemorrhage
- Progressively worsening headache
- Recurring or continuous vomiting associated with the headache
- Abnormal neurological status in association with headache
- Headache occurring only in connection with coughing or physical exertion
- An episode of unconsciousness associated with the headache
- Position-dependent headache
- An endocrine disturbance associated with the headache
- Neurofibromatosis in the patient's history or in his/her family history
Episodic tension headache
Chronic tension headache
- Stopping excess use (continuous > 15 days per month) of analgesics
- Physical exercise, avoiding exercise forms that increase symptoms
- Muscle care and relaxation
- Check ergonomics: sleep and workplace ergonomics
- Identification of stress factors
- Physiotherapy, orthopaedic manual physical therapy (OMT)
- Acupuncture Acupuncture for Tension-Type Headache
- Injections of local anaesthetics and/or glucocorticoids to trigger points
- Pharmacotherapy
References
- Stephens G, Derry S, Moore RA. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev 2016;(6):CD011889. [PubMed]
- Linde K, Allais G, Brinkhaus B et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev 2016;(4):CD007587. [PubMed]
- Veys L, Derry S, Moore RA. Ketoprofen for episodic tension-type headache in adults. Cochrane Database Syst Rev 2016;(9):CD012190. [PubMed]
- Banzi R, Cusi C, Randazzo C et al. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults. Cochrane Database Syst Rev 2015;(5):CD011681. [PubMed]