2008

TENSION TYPE HEADACHE

Diagnostic criteria

At least 10 episodes fulfilling following criteria

Headache lasting 30 mins to 7 days
Has 2 at least 2 of the following
Bilateral location
Pressing/tightening (non-pulsating) quality
Mild or moderate intensity
Not aggravated by physical activity such as walking or
climbing stairs
No nausea or vomiting
< 2 episodes of photophobia or phonophobia
Not attributable to another disorder
Categories

Infrequent episodic tension type headache

Occurs < 1 day per month ( < 12 days/year)
Frequent episodic tension type headache
Occurs > 1 and < 15 days/month ( > 12 and <180
days/year)
Chronic tension type headache
Occurs > 15 days/month ( 180 or more days/year)
Causes

Uncertain
? Activation of hyper excitable peripheral
afferent neurons from head and neck muscles
Associated with and aggravated by muscle
tenderness and psychological tension but do not
cause it
Abnormalities in central pain processing and
generalised increased pain sensitivity are found
in some individuals
Genetic factors
People at risk

Prevalence peaks at age 40-49 in both sexes

Mean life time prevalence is 46%
Chronic tension type headache affects 3% of
general population
Female to male ratio is 4:5
Prevalence increases with educational level
Can occur in children
Presentation

Mild to moderate bilateral pain

Sensation of muscle tightness or pressure
Lasts hours to days
Not associated with constitutional or
neurological symptoms
People with chronic tension headache more
likely to seek help often have a history of
episodic headache but delayed until
frequency and disability are high
Differential diagnosis

Migraine in chronic form characteristic

features disappear and pain is less severe
Neck problems muscle tenderness of
tension type headache may involve the neck
Medication overuse headache consider in
patients taking opioid or combination
analgesics for an average of 10 days/month
Examination and
investigation
Examination
Neurological examination
Manual palpation of pericranial muscles ( frontal,
temporal, masseter, pterygoid, sternomastoid,
splenius and trapezius.
Fundoscopy for papilloedema
Investigations
If neuro examination normal none needed
Investigation

Neuroimaging should be arranged if

Atypical pattern of headache
History of seizures
Neurological signs or symptoms
Symptomatic illness acquired immunodeficiency
syndrome, tumours or neurofibromatosis
Treatment

Infrequent headache
Good results from non prescription medication
May need reassurance
If require drugs on more than 2-3 days/week
then medical treatment is indicated to
prevent medication misuse headache
Treatment

Acute therapy for individual attacks

Simple analgesia
Aspirin 500 1000mg
NSAIDS
Paracetamol more effective than placebo less
effective than NSAIDS
Combination drugs containing simple analgesics and
caffeine are helpful
Opioids or sedatives should not be used as impair
alertness and can cause overuse and dependence
Treatment

Preventive treatment
Consider when headaches are frequent or acute
attacks dont respond to abortive treatment
Best evidence is for Amitriptyline 75- 150mg/day. It
helps both pain and muscle tenderness. Works best
when started at low dose and increased weekly
Mirtazipine 15-30mg/day
Unhelpful
SSRIs
Botulinium toxin
Treatment

Preventive treatment
Should be considered when at least 2
headaches/month as risk of chronic headache
goes up exponentially when frequency reaches
1/week as does severity of pain
Benefit or preventive treatment is diminished
when patients are simultaneously overusing
abortive treatments. Withdrawal of medication is
advised before starting preventative therapy
Treatment

Education, lifestyle and non-pharmacological

treatment
Little evidence exists to support or refute most
dietary or lifestyle recommendations for tension
type headache.
Treatment

Referral
Diagnosis is unclear
Does not respond to treatment
Complicated by medication overuse
Require neuroimaging
Prognosis

45% of adults with frequent or chronic

tension type headache will go into
remission
39% will carry on with frequent
headaches
16% will carry on with chronic
headache
Poor prognosis

Associated with
Presence of chronic headache at
baseline
Co-existing migraine
Not being married
Sleep problems
Good prognosis

Associated with
Older age
Absence of chronic tension type
headache at baseline

Important message intervene early

before headaches become chronic