Tension-type headache (TTH) is the most common type of primary headaches. It is also sometimes referred to as muscle contraction headache, stress headache, or psychomyogenic headache. TTH occurs repetitively and can be categorized into episodic TTH (with frequent and infrequent subtypes) and chronic TTH. This activity outlines the evaluation and treatment of tension headaches and highlights the role of the healthcare team in evaluating and treating patients with this condition.
Objectives:Identify the etiology of tension headaches.Review the evaluation steps for assessing tension headaches.Summarize the management strategies available for tension headaches.Describe some interprofessional team strategies for improving care coordination and communication to advance tension headaches and improve outcomes.Access free multiple choice questions on this topic.
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Tension-type headache (TTH) is the most common type of primary headaches. It is also sometimes referred to as muscle contraction headache, stress headache, or psychomyogenic headache. TTH occurs repetitively and can categorize into episodic TTH (with frequent and infrequent subtypes) and chronic TTH. The differentiating factor for these is the frequency of headache episodes.[1]
Environmental and muscular factors are also possible etiology of tension headaches. Stress and posture appear to be the two significant factors.[4] The exact pathophysiology of both is not entirely understood. However, poor posture, such as excessive neck flexion while playing video games and/or watching the computer screen, leads to more stress placed on the atlantoaxial joint-upper cervical vertebrae. The shoulders attempt to compensate by stooping forward to reduce the stress that leads to muscular imbalances, with some areas tightening to create the tension headache.
TTH is the most common type of primary headache disorder and one of the most prevalent conditions in the world, affecting about one-fifth of the world population. A Danish epidemiologic study revealed that about 78% of the adult population has at least one episode of TTH in their lives. TTH is also more common in women as compared to men (female-to-male 3 to 1).[5][6] TTH is also the most common headache type in children.[2] However, the average age remains between 25 to 30 years. While the exact incidence is difficult to ascertain, a Danish study revealed an incidence of 14.2 per 1000 person-years for frequent episodic TTH.[7]
There is also a hypothesis that autonomic dysfunction may also play a role in the pathophysiology of TTH, especially due to sleep disturbance. Sleep loss can lead to an increase in fatigue that can lead to a greater sympathetic overdrive, which would subsequently worsen or cause a headache. TTHs may also occur due to dysfunction within the brain's cortical matter. The trigeminal nucleus caudalis contains the nociceptive pathways of the face, which transmits pain signals to the ventral posteromedial thalamus. When stimulated with a molecule known as orexin, the nociceptive pathways within the trigeminal nucleus caudalis become inhibited. With inconsistent sleep, researchers postulate that the release of orexin becomes reduced, and therefore, less blocking of the trigeminal nucleus caudalis results in headaches.[10]
There is also a role for NO-mediated mechanisms for a chronic tension-type headache. Part of this is due to the treatments, which have shown that the inhibition of NO is effective in the treatment of a chronic-tension-type headache. This area is under further investigation at this time.[11]
The most important question in the evaluation of headache history is to ascertain whether the headache is of primary or secondary type. Primary headaches are recurrent headaches. The new-onset headache should undergo assessment for the secondary causes. In cases of recurrent headaches, the next important question is if the current episode is similar to the previous headaches. If this headache is similar to the previous headaches, a primary headache disorder is the most likely possibility. If the current headache is different from the previous headache episodes, an evaluation for the secondary causes is necessary (e.g., a patient with migraine or TTH may suffer from subarachnoid hemorrhage or meningitis and may present with a headache different from the usual headaches).
Physical examination is normal in primary headache disorders, including the TTH. Although the transient trigeminal cranial features of ptosis, conjunctivitis, or orbital swelling may occur with the trigeminal autonomic cephalgias (TACs). Physical examination is vital in excluding the secondary causes, such as nuchal rigidity seen in meningitis and subarachnoid hemorrhage, focal neurological deficits seen in the space-occupying lesion, and/or papilledema in idiopathic intracranial hypertension, etc.
The above is a general ICHD-3 diagnostic criterion for the TTH. If one of the above ICHD-3 features for TTH is missing and not fulfilling the criteria for another headache disorder, a diagnosis of probable tension-type headache is possible. These patients with probable TTH should undergo evaluation over time, and the clinician usually makes a diagnosis of TTH in these patients. TTHs are further subdivided into three subtypes based on the frequency of headache episodes.[13]
processing.... Drugs & Diseases > Neurology Tension Headache Updated: Nov 15, 2022 Ā Author: Michelle Blanda, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...Ā Ā Share Print FeedbackĀ CloseĀ Facebook Twitter LinkedIn WhatsApp EmailĀ webmd.ads2.defineAd({id: 'ads-pos-421-sfp',pos: 421}); Sections Tension HeadacheĀ Sections Tension HeadacheĀ OverviewĀ Practice Essentials Background Pathophysiology Etiology Epidemiology Prognosis Show AllĀ PresentationĀ History Physical Examination Complications Show AllĀ DDx Workup TreatmentĀ Medical Care Alternative Medicine Show AllĀ MedicationĀ Medication Summary Nonsteroidal anti-inflammatory drugs (NSAIDs) Acetylsalicylic acids Barbiturates Analgesics Analgesic/antiemetic or sedatives Ergot alkaloids and derivatives Show AllĀ Questions & Answers ReferencesĀ Overview Practice Essentials The International Headache Society (IHS) began developing a classification system for headaches in 1985. Now in its third edition, this system includes a tension-type headache (TTH) category, further defined as either episodic (frequent and infrequent) or chronic. In infrequent episodic TTH, headache episodes occur less than one day a month, whereas in frequent episodic TTH, headache episodes occur 1 to 14 days a month. In chronic TTH, headaches occur 15 or more days a month.
Head CT scan or MRI is necessary only when the headache pattern has changed recently, the headache cannot be clearly defined by the clinician as a common primary headache disorder (that is not a cluster, migraine, or tension-type of headache), or neurologic examination reveals abnormal findings. [11]
Pain onset in tension-type headache can have a throbbing quality and is usually more gradual than onset in migraines. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.
Various modalities are used in the treatment of tension headaches. These include hot or cold packs, ultrasound, electrical stimulation, improvement of posture, trigger point injections, occipital nerve blocks, stretching, and relaxation techniques.
The International Headache Society (IHS) began developing a classification system for headaches in 1985. Now in its third edition, this system includes a tension-type headache (TTH) category, further defined as either episodic (frequent and infrequent) or chronic. In infrequent episodic TTH, headache episodes occur less than one day a month, whereas in frequent episodic TTH, headache episodes occur 1 to 14 days a month. In chronic TTH, headaches occur 15 or more days a month.
TTH is the most common type of chronic recurring head pain. In the past, pain etiology was presumed to be the muscular contraction of pain-sensitive structures of the cranium, but the IHS intentionally abandoned the terms muscular contraction headache and tension headache because no research supports muscular contraction as the sole pain etiology.
The pathogenesis of tension type headaches is multifactorial. Given the wide variation in frequency and intensity in TTH, not only between individuals but also within individuals over time, it is likely that the underlying pain mechanisms in TTH are dynamic. It is suggested that the mechanisms vary from one individual to another, and potentially from one attack to another in the same individual. [3] These factors include environmental and genetic factors. Environmental factors influence the development of episodic TTH more than chronic TTH, while genetic factors appear to play an important role in the development of chronic TTH. [4, 5, 6]
It is postulated that peripheral activation or sensitization of myofascial nociceptors play a major role in episodic TTH. Extended nociceptive stimuli from pericranial myofascial tissues seems to be responsible for the conversion of episodic to chronic TTH. [3, 7, 8, 9, 10, 11] In chronic THH, stimuli that are normally painless are misinterpreted as pain. This continuous painful input induces central sensitization. The increased nociceptive stimulation of supraspinal structures results in increased facilitation and decreased inhibition of pain transmission at the level of the spinal dorsal horn/trigeminal nucleus, and in increased pericranial muscle activity. [7] This was shown in a study of women with frequent episodic tension-type headaches (FETTH). They had widespread pressure pain hypersensitivity over both nerve trunks and musculoskeletal structures suggesting this central altered nociceptive processing. This pain was not restricted to musculoskeletal areas, but also pain evoked from directly provoking the nerve trunks by pressure. [22] be457b7860
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