Diagnosis

Tension headache

Etiology

Cause [opr]

• Unknown

• Trigger:

  • Stress

  • Sleep disturbances

  • Poor posture (excessive neck flexion)

  • Muscle tension

  • Nutritional factors: vitamin B12/D deficiency

  • Environmental factors

  • Genetic conditions

Pathophysiology [opr]

1. Episodic headache: Peripheral sensitization (higher levels of peripheral excitability)

2. Chronic headache: Central sensitization

3. Myofascial trigger points: the pericranial musculature is the presumed trigger point

4. Excessive pericranial muscle contractions

5. Autonomic dysfunction due to sleep disturbances

   • Sleep loss --> fatigue --> sympathetic overdrive --> headache

6. Clinical manifestation according to International Headache Society:

   • Pain quality: Nonpulsatile, pressing, or tightening pain

   • Location: Frontal-occipital (band-like) and bilateral

   • Severity: Mild/moderate intensity

   • Provoked by: Not aggravated by physical activity

   • Associated symptoms: Muscle tightness in the head, scalp, or neck

   • Duration: 30 minutes to 7 days

Classification

• Episodic: <15 times per month

• Chronic: >15 times per month or on a consistent basis over longer stretches of time

Red flags for secondary disorders [opr]

• Sudden onset of headache

• Age > 50 years

• Severe headache

• New onset of headache in the presence of an underlying medical condition

• Headache with concomitant systemic illness

• Focal neurologic signs or symptoms

• Papilledema

• History of head trauma

• Systemic symptoms, including fever

• History of neoplasm

Epidemiology

Incidence per 100.000 [vdk][uic][z8e][sw7][pvm][sus]

Approach

• Neurological examination

• MRI caput

3rd edition of the International Classification of Headache Disorders [sus][img]

Infrequent episodic tension-type headache

1. At least 10 episodes of headache occurring on < 1 day/month on average

2. Lasting from 30 min to 7 days

3. 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

4. Both of the following:

   • No nausea or vomiting

   • No more than one of photophobia or phonophobia

Frequent episodic tension-type headache

1. At least 10 episodes of headache occurring on 1–14 days/month on average for > 3 months (≥ 12 and < 180 days/year)

2. Lasting from 30 min to 7 days

3. 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

4. Both of the following:

   • No nausea or vomiting

   • No more than one of photophobia or phonophobia

Chronic tension-type headache

1. Headache occurring on ≥ 15 days/month on average for > 3 months (≥ 180 days/year), fulfilling criteria B-D

2. Lasting hours to days, or unremitting

3. 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

4. Both of the following:

   • No nausea or vomiting

   • No more than one of photophobia or phonophobia

Treatment

1. NSAIDs [sus][opr]

2. Paracetamol

3. Antidepressants for chronic cases: Amitriptyline (TCA), mirtazapine and venlafaxine

4. Non-pharmacologic:

   • Stress reduction

   • Acupuncture/trigger point injection

   • Exercise

   • Physical therapy

   • Psychological treatment

   • Biofeedback / Cognitive-behavioral therapy

   • Diet

   • Massage

   • Manipulation

Differential diagnoses

Brain tumor, COVID-19, Medication-overuse headache, Migraine, Obstructive sleep apnea, Temporal arteritis