Tension Headache

Criteria for tension-type headaches includes the following [4] [8] [9] :

• Pressing or tightening pain (non-pulsating)
• Muscular tightness or stiffness in neck
• Frontal-occipital location
• Bilateral, occipitonuchal or bifrontal pain
• Mild to moderate intensity
• Not aggravated by physical activity
• Duration of 30 minutes to several days
• No nausea or vomiting (anorexia may occur) [9] 
• Often occurs during emotional distress or intense worry
• May be associated with insomnia
• Often occurs upon rising or shortly thereafter
• Difficulty concentrating
• No prodromal or aura

The physical examination to exclude the possibility of other causes [9]:

• Vital signs normal
• Normal neurologic assessment
• Tenderness in the scalp or neck
• Acute tenderness when upper cervical muscles are palpated
• Pain with neck flexion and stretching differentiated from nuchal rigidity associated with meningeal irritation

The differential diagnosis between tension headache and migraine is based on the clinical characteristics of the headache. Migraines are of moderate to severe intensity, have a pulsating quality are aggravated by physical activity and include photophobia and nausea. The characteristics of tension-type headache are pain of mild or moderate intensity, no photophobia, no nausea, not aggravated by physical activity, and a non-pulsating quality [7].

The history is the most important diagnostic component for evaluation and treatment of headache. This relies on recall by the patient that is often unreliable. History should include information about the presentation, onset, and duration of symptoms, as well as social and psychological information [2].

Laboratory tests

In tension headache laboratory work will be unremarkable. Specific blood work is only useful if the history or physical examination suggests another possible diagnosis [2].

Other procedures

Head computed tomography or magnetic resonance imaging scans are required, if neurologic examination is abnormal, to rule out other diagnoses: tumor, stroke, or swelling. They may also be useful when headache pattern changed [6] [9]. A lumbar puncture and examination of cerebrospinal fluid may be needed to rule out infection or meningitis [6].

Medications can be highly effective in the treatment of chronic tension headaches, both prescription and non-prescription. Medications, however, are not always effective or well tolerated and have associated adverse effects [8]. Some medications may also cause medication dependency in some patients. Commonly used medications include [2] [4]:

Non-prescription drugs

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Acetylsalicylic acids
• Acetaminophen 

Barbiturates

• Fiorinal (Butalbital, aspirin, caffeine) 
• Fioricet (Acetaminophen, butalbital, and caffeine) 

Analgesics

• Acetaminophen with codeine (Tylenol #3)
• Acetaminophen and oxycodone (Percocet)

Ergot alkaloids and derivatives direct vasoconstrictors 

• Ergotamine tartrate (Cafergot, cafatine, cafetrate)
• Dihydroergotamine (Migranal nasal spray)

Current research advocated behavioral headache management to be effective in the management of chronic tension headache. These techniques include [4] [8]:

• Relaxation training
• Biofeedback
• Stress management training
• Cognitive behavior therapy
• Meditation [9]

Exercise is another treatment option to be considered in the treatment of tension-type headaches. Researchers has shown an association between decreased physical activity and increased incidence of headaches[8].

Optimum treatment of tension headaches should include a variety of techniques [5] [6]:

• Preventive measures such as avoidance of triggers and stress management.
• Alternative therapies such as meditation, acupuncture, and biofeedback.
• Pharmacological intervention. 

Psychological stress is the most frequent trigger of tension headache, and treatments that reduce stress and increase the ability to cope with stress are the best means of preventing and treating their occurrence [9]. Stress is thought cause tension headache by [9]:

• Increasing pain perception
• Activating and sensitizing neurorecepters
• Increasing disability and decreasing quality of life

Most tension headaches are intermittent and do not interfere with daily life to any substantial degree. However, these headaches may become chronic if life stressors are not changed [10].
One possible complication of chronic headache is an over dependence on non-prescription and prescription pain relievers [9].

The prognosis for individuals with coexisting migraine and tension-type headache has poorer long term outcomes [2].
Thirty percent of individuals who have childhood headaches develop chronic headache as adult [2].

The progression from intermittent to almost daily headaches, from episodic tension-type headache to chronic migraine occurs in many individuals over an average of 10.7 years [10].

Tension headaches are felt to be the result of muscle contraction primarily in the cervical region [2]. Chronic contraction of neck and scalp muscles may be the result of [4]:

• Stress and/or anxiety
• Poor posture
• Depression

About 2% of the adult population have a history of chronic episodic tension-type headaches [6]. The prevalence of tension-type headache in children and adolescents is increasing and is now a significant health problem [7]. Tension-type headache accounts for 42% of cases of headache once underlying neurologic or cancerous causes have been eliminated [1] [7].

Headache disorders rank among the 10 most disabling conditions, according to the World Health Organization and among the top five for women [1]. Recurrent headaches negatively affect family life, work productivity, and absenteeism, and increase emergency room visits and use of prescription and non-prescription medications [8].

The age of onset of tension headaches ranges from as young as 6 years to over 70 years with a mean of 35 years [4] [6]. In 15 percent of patients symptoms begin before age 10 [4]. They are more common in women with a female to male ratio of 2:1 in adults and children [2] [4] [6].

A family history of some form of headache occurs in 40 percent of individuals with chronic tension-type headache. However, a genetic component is not thought to be a factor [4]. The incidence of headache worldwide is estimated to be 4% of the general population, with half of these classified as tension-type headache [2] [3].

The exact mechanism causing tension headache is not known. However, it is assumed that excessive, sustained muscle contraction of the head, neck, and jaw are at fault. The association with psychosocial factors as well as environmental factors is well documented. The triggers for headache include stress, hormonal factors (such as menstruation and pregnancy), ingested substances, bright light, florescent lights, and computers [5].

The extent of psychological factors on the development of tension-type headache is not known [3]. However, it is assumed that factors like copying skills, avoidance behaviors, anxiety and depression play a role [3]. These factors have been associated with higher levels of stress [3].

Other aggravating factors to the occurrence of tension headache are poor quality and duration of sleep, poor nutrition, and lack of exercise [9].

The high frequency of crossover between subtypes of headache suggests that the distinction between is not proven [2] [10]. This supports the theory that the various headache types are part of the same continuum with common symptoms and causes [2] [7][10].

The most significant differences between the headache types are severity and character of the pain, aggravating factors, and duration of symptoms. Tension headaches were generally characterized by the absence of photophobia and nausea and positive for bilateral presentation [7].

A diagnosis of the specific type of headache is important for appropriate treatment, but is difficult because of the overlap in the symptomatology [7].

Perhaps the most effective preventive measures for tension headaches, after stress management, are life style changes including regular exercise, balanced diet, adequate sleep, and avoidance of excessive intake of caffeine, alcohol, or nicotine [2][10].

Tension headache is a primary subgroup of the disorder chronic headache. Headaches, including tension-type headache, migraine, cluster headache and chronic daily headache syndromes, are the most common disorder of the nervous system [1]. Although classified as separate entities there is significant crossover among the subtypes and shared symptomatology. Some current theories propose that they are the connected disorders along a common continuum [2].

It is estimated that approximately 4% of the population worldwide suffer chronic headache [3]. It accounts for 10% of all emergency room visits and is the ninth most common reason for physician visits [1]. One half of all headaches fall in the category of tension-type headache [2]. They occur more frequently in women than men with a ratio of 2 to 1 [4].

Headache has a significant impact on morbidity and economics worldwide. The direct effects of headache upon the individual are related to the severity of pain, frequency of occurrence and extent of disability [5]. The economic impact includes the costs of medical care, and lost work time and productivity [2] [5]. It is estimated that headaches costs American employers over $13 billion annually [5]. Despite the cost, headache is underestimated, under-recognized, and under-treated throughout the world [1].

What is tension headache?

Tension headache is one of the most common forms of headache worldwide, occurring in approximately 2% of the general population. Headache can be a symptom of another, more serious diagnosis, so any chronic headache should be evaluated to exclude other diagnoses.

What are the symptoms?

The symptoms of tension headache are:

• Pressing or tightening pain(non-pulsating)
• Muscular tightness or stiffness in neck
• Mild to moderate intensity
• Not aggravated by physical activity
• Lasting 30 minutes to several days
• Often occurs during emotional distress or intense worry
• Often occurs upon rising or shortly thereafter
• Difficulty concentrating
• No nausea, vomiting, or preceding visual or sensory symptoms 

What causes tension headache?

The cause of tension headache varies from person to person, however, emotional stress seems to be the most common trigger. The exact physical component is believed to be tightening of the muscles of the neck, head, jaw and upper shoulders.

Who gets tension headache?

Anyone may get tension headache. It has been reported in individuals from 6 years old to over 70 years of age. It occurs in approximately 2 % of the population at some time in their lives.
Those experiencing stress in their lives are at higher risk.

How is it diagnosed?

Tension headache is diagnosed by the clinical symptoms of the headache. There are no specific tests for this disorder. Your healthcare provider may order some tests or procedures to exclude other, more serious diagnoses. A complete and through history, of the headache symptoms and psychosocial history is of prime importance.

How is tension headache treated?

Tension headache is treated by multiple techniques. These include:

• Non-prescription medications like ibuprophin aspirin, acetaminophen
• Prescription medications
• Relaxation training
• Biofeedback
• Frequent regular exercise 
• Stress management training
• Cognitive behavior therapy
• Meditation

How can tension headache be prevented?

Since stress appears to be the most common trigger prevention and relief of stress or anything that reduces it may be the best way to prevent the disorder.

What are the complications?

Complications of tension headache are related to how it affects daily life, absenteeism from work, interference with family relationships, and decreasing quality of life.

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