Editors

Marja-LiisaSumelahti

Tension Headache

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.

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.

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.

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) Malocclusion and Headache
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 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

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]