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Marja-LiisaSumelahti

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) 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

  • 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

Treatment Ssris and Snris for Preventing Tension-Type Headaches and Migraine, Biofeedback for Tension-Type Headache

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]

Evidence Summaries