eMedicine Specialties > Neurology > Headache and Pain

Muscle Contraction Tension Headache

Author: Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University Hospital
Contributor Information and Disclosures

Updated: Sep 18, 2008

Introduction

Background

Tension-type headache (TTH) represents one of the most costly diseases because of its very high prevalence. TTH is the most common type of headache, and it is classified as episodic (ETTH) or chronic (CTTH). It had various ill-defined names in the past including tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, and psychogenic headache. See Medscape's Headache Resource Center for more information.

The International Headache Society (IHS) defines TTH more precisely and differentiates between the episodic and the chronic types. The following is a modified outline of the IHS diagnostic criteria:

Episodic tension-type headache

  • At least 10 previous headaches fulfilling the following criteria; number of days with such headache fewer than 15 per month
  • Headaches lasting from 30 minutes to 7 days
  • At least 2 of the following pain characteristics:
    • Pressing/tightening (nonpulsating) quality
    • Mild or moderate intensity (may inhibit but does not prohibit activities)
    • Bilateral location
    • No aggravation from climbing stairs or similar routine physical activity
  • Both of the following:
    • No nausea or vomiting
    • Photophobia and phonophobia absent or only one present
  • Secondary headache types not suggested or confirmed

Chronic tension-type headache

  • Average headache frequency of more than 15 days per month for more than 6 months fulfilling the following criteria
  • At least 2 of the following pain characteristics:
    • Pressing/tightening (nonpulsating) quality
    • Mild or moderate intensity (may inhibit but does not prohibit activities)
    • Bilateral location
    • No aggravation from climbing stairs or similar routine physical activity
  • Both of the following:
    • No vomiting
    • No more than one of the following: nausea, photophobia, or phonophobia
  • Secondary headache types not suggested or confirmed

Pathophysiology

Pathogenesis of TTH is complex and multifactorial, with contributions from both central and peripheral factors. In the past, various mechanisms including vascular, muscular (ie, constant overcontraction of scalp muscles), and psychogenic factors were suggested. The more likely cause of these headaches is believed now to be abnormal neuronal sensitivity and pain facilitation, not abnormal muscle contraction.

Various evidence suggests that, like migraine, TTH is associated with exteroceptive suppression (ES2), abnormal platelet serotonin, and decreased cerebrospinal fluid beta-endorphin. In one study, plasma levels of substance P, neuropeptide Y, and vasoactive intestinal peptide were found to be normal in patients with CTTH and unrelated to the headache state.

Several concurrent pathophysiologic mechanisms may be responsible for TTH; according to Jensen, extracranial myofascial nociception is one of them. Headache is not related directly to muscle contraction, and possible hypersensitivity of neurons in the trigeminal nucleus caudalis has been suggested.

Bendtsen described central sensitization at the level of the spinal dorsal horn/trigeminal nucleus due to prolonged nociceptive inputs from pericranial myofascial tissues.12 The central neuroplastic changes may affect regulation of peripheral mechanisms and can lead to increased pericranial muscle activity or release of neurotransmitters in myofascial tissues. This central sensitization may be maintained even after the initial eliciting factors have been normalized, resulting in conversion of ETTH into CTTH.

Further research is necessary to understand and clarify the mechanisms of TTH. Research may lead to the development of more specific and effective management in the future.

Frequency

United States

TTH is the most common primary headache syndrome.

International

Rasmussen et al reported a lifetime prevalence of TTH of 69% in men and 88% in women in the Danish population.1 The patient may experience more than one primary headache syndrome. In one study by Ulrich et al, the 1-year prevalence of TTH was the same among individuals with and without migraine.2

Sex

Women are slightly more likely to be affected than men.

  • The female-to-male ratio for TTH is approximately 1.4:1.
  • In CTTH, female preponderance is 1.9:1.

Age

TTH can occur at any age, but onset during adolescence or young adulthood is common. It can begin in childhood.

Clinical

History

Tension-type headaches (TTHs) are characterized by pain that is usually mild or moderate in severity and bilateral in distribution. Unilateral pain may be experienced by 10-20% of patients. Headache is a constant, tight, pressing, or bandlike sensation in the frontal, temporal, occipital, or parietal area (with frontal and temporal regions most common).

  • Ulrich et al reported that 82% of TTHs last less than 24 hours.2
  • The deep steady ache differs from the typical throbbing quality of migraine headache.
    • Prodrome and aura are absent.
    • Occasionally, the headache may be throbbing or unilateral, but most patients do not report photophobia, sonophobia, or nausea, which commonly are associated with migraine.
  • Some patients may have neck, jaw, or temporomandibular joint discomfort.

Physical

  • Patients with TTH have normal findings on general and neurologic examinations.
  • Some patients may have tender spots or taut bands in the pericranial or cervical muscles (trigger points).

Causes

Various precipitating factors may cause TTH in susceptible individuals. One half of patients with TTH identify stress or hunger as a precipitating factor.

  • Stress - Usually occurs in the afternoon after long stressful work hours
  • Sleep deprivation
  • Uncomfortable stressful position and/or bad posture
  • Irregular meal time (hunger)
  • Eyestrain

More on Muscle Contraction Tension Headache

Overview: Muscle Contraction Tension Headache
Differential Diagnoses & Workup: Muscle Contraction Tension Headache
Treatment & Medication: Muscle Contraction Tension Headache
Follow-up: Muscle Contraction Tension Headache
References
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Further Reading

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Keywords

episodic tension-type headache, ETTH (ICD code-339.11), chronic tension-type headache, CTTH (ICD code-339.12), tension-type headache, TTH (ICD code-339.10), tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, psychogenic headache, muscle contraction tension headache, headache

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Contributor Information and Disclosures

Author

Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University Hospital
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph Carcione Jr, DO, MBA, Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans
Joseph Carcione Jr, DO, MBA is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center
James H Halsey, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neuroimaging, Medical Association of the State of Alabama, New York Academy of Sciences, Pan American Medical Association, Sigma Xi, Society for Neuroscience, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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