Tension headache

Tension-type headache (TTH)
Other names	Tension headache, stress headache
A woman experiencing a tension-type headache
Specialty	Neurology
Differential diagnosis	Migraine

Tension headache, stress headache, or tension-type headache (TTH), is the most common type of primary headache. The pain usually radiates from the lower back of the head, the neck, eyes or other muscle groups in the body typically affecting both sides of the head. Tension-type headaches account for nearly 90% of all headaches.

Pain medications, such as

The 2016 Global Burden of Disease study revealed that TTHs affect about 1.89 billion people and are more common in women than men (30.8% to 21.4% respectively).[6] TTH was most prevalent between ages 35 and 39. Despite its benign character, tension-type headache, especially in its chronic form, can impart significant disability on patients as well as burden on society at large. In 2016, the global burden of TTH was reported to be 7.2 million years of life lived with disability (YLDs). The YLD was calculated using TTH prevalence and average time spent with TTH multiplied by percentage health loss caused by TTH (3.7%).

Signs and symptoms

According to the third edition of the International Classification of Headache Disorders,^[7] the attacks must meet the following criteria:

• A duration of between 30 minutes and 7 days.
• At least two of the following four characteristics:
  • bilateral location
  • pressing or tightening (non-pulsating) quality
  • mild or moderate intensity
  • not aggravated by routine physical activity such as walking or climbing stairs
• Both of the following:
  • no nausea or vomiting
  • no more than one of photophobia (sensitivity to bright light) or phonophobia (sensitivity to loud sounds)

Tension-type headaches may be accompanied by tenderness of the scalp on manual pressure during an attack.^{[citation needed]}

Risk factors

Various precipitating factors may cause tension-type headaches in susceptible individuals:^[8]

• Anxiety
• Stress
• Sleep problems
• Young age
• Poor health

Mechanism

Although the musculature of the head and neck and psychological factors such as stress may play a role in the overall pathophysiology of TTH, neither is currently believed to be the sole cause of the development of TTH.

Regarding synaptic level changes, homosynaptic facilitation and heterosynaptic facilitation are both likely to be involved in central sensitization.[8] Homosynaptic facilitation occurs when synapses normally involved in pain pathways undergo changes involving receptors on the post-synaptic membrane as well as the molecular pathways activated upon synaptic transmission. Lower pain thresholds of CTTH result from this homosynaptic facilitation. In contrast, heterosynaptic facilitation occurs when synapses not normally involved in pain pathways become involved. Once this occurs innocuous signals are interpreted as painful signals. Allodynia and hyperalgesia of CTTH represent this heterosynaptic facilitation clinically.^[8]

Stress

In the literature, stress is mentioned as a factor and may be implicated via the adrenal axis. This ultimately results in downstream activation of NMDA receptor activation,

With TTH, the physical exam is expected to be normal with perhaps the exception of either pericranial tenderness upon palpation of the cranial muscles, or presence of either photophobia or phonophobia.^[13]

Classification

The International Headache Society's most current classification system for headache disorders is the International Classification of Headache Disorders 3rd edition (ICHD-3) as of 2018. This classification system separates tension-type headache (TTH) into two main groups: episodic (ETTH) and chronic (CTTH). CTTH is defined as fifteen days or more per month with headache for greater than three months, or one-hundred eighty days or more, with headache per year.^[14] ETTH is less than fifteen days per month with headache or less than one-hundred eighty days with headache per year.^[15][16] However, ETTH is further sub-divided into frequent and infrequent TTH.^[17] Frequent TTH is defined as ten or more episodes of headache over the course of one to fourteen days per month for greater than three months, or at least twelve days per year, but less than one-hundred eighty days per year.^[16] Infrequent TTH is defined as ten or more episodes of headache for less than one day per month or less than twelve days per year.^[15] Furthermore, all sub-classes of TTH can be classified as having presence or absence of pericranial tenderness, which is tenderness of the muscles of the head.^[17] Probable TTH is utilized for patients with some characteristics, but not all characteristics of a given sub-type of TTH.^[18]

Differential diagnosis

Extensive testing is not needed as TTH is diagnosed by history and physical examination. However, if symptoms indicative of a more serious diagnosis are present, a

• Migraine
• Oromandibular dysfunction
• Sinus disease
• Eye disease
• Cervical spine disease
• Infection in immunocompromised
• Intracranial mass
• Idiopathic intracranial hypertension
• Medication overuse headache
• Secondary headache (headache due to other disorder)
• Giant cell arteritis
  (≥50 years of age)
• Dermatochalasis

Prevention

Lifestyle

Good posture might prevent headaches if there is neck pain.^[19]

Drinking alcohol can make headaches more likely or severe.^[19]

Drinking water and avoiding dehydration helps in preventing tension headache.^[19]

People who have jaw clenching might develop headaches, and getting treatment from a dentist might prevent those headaches.^[19]

Using stress management and relaxing often makes headaches less likely.^[19]

Biofeedback techniques may also help.^[20]

Medications

People who have 15 or more headaches in a month may be treated with certain types of daily antidepressants which act to prevent continued tension headaches from occurring.

Evidence supports simple neck and shoulder exercises in managing ETTH and CTTH for headaches associated with neck pain. Exercises include stretching, strengthening and range of motion exercises. CTTH can also benefit from combined therapy from stress therapy, exercises and postural correction.[22]

Medications

Episodic

Analgesic/caffeine combinations are popular such as the aspirin-caffeine combination or the aspirin, paracetamol and caffeine combinations.[10] Frequent use (daily or skipping just one day in between use for 7–10 days) of any of the above analgesics may, however, lead to medication overuse headache.^[2][21][10]

Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations, analgesic/barbiturate combinations such as Fiorinal).^[2][21]

Muscle relaxants are typically used for and are helpful with acute post-traumatic TTH rather than ETTH.^[10] Opioid medications are not utilized to treat ETTH.^[10] Botulinum toxin does not appear to be helpful.^[24]

Chronic

Classes of medications involved in treatment of CTTH include tricyclic antidepressants (TCAs), SSRIs, benzodiazepine (Clonazepam in small evening dose), and muscle relaxants. The most commonly utilized TCA is amitriptyline due to the postulated role in decreasing central sensitization and analgesic relief. Another popular TCA used is Doxepine. SSRIs may also be utilized for management of CTTH. For patients with concurrent muscle spasm and CTTH, the muscle relaxant Tizanidine can be a helpful option.^[10]

These medications however, are not effective if concurrent overuse of over the counter medications or other analgesics is occurring.^[10] Stopping overuse must occur prior to proceeding with other forms of treatment.^[10]

Manual therapy

Current evidence for acupuncture is slight. A 2016 systematic review suggests better evidence among those with frequent tension headaches, but concludes that further trials comparing acupuncture with other treatment options are needed.^[25]

People with tension-type headache often use

As of 2016 tension headaches affect about 1.89 billion people [6] and are more common in women than men (23% to 18% respectively).^[32] Despite its benign character, tension-type headache, especially in its chronic form, can impart significant disability on patients as well as burden on society at large.^[33]

References