Tension Headache Clinical Presentation

  • Author: Michelle Blanda, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: May 17, 2012
 

History

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.

IHS diagnostic criteria for tension-type headaches states that 2 of the following characteristics must be present[4] :

  • Pressing or tightening (nonpulsatile quality)
  • Frontal-occipital location
  • Bilateral - Mild/moderate intensity
  • Not aggravated by physical activity

Tension-type headache history is as follows:

  • Duration of 30 minutes to 7 days
  • No nausea or vomiting (anorexia may occur)[5]
  • Photophobia and/or phonophobia[5]
  • Minimum of 10 previous headache episodes;[5] fewer than 180 days per year with headache to be considered "infrequent"
  • Bilateral and occipitonuchal or bifrontal pain
  • Pain described as "fullness, tightness/squeezing, pressure," or "bandlike/viselike"
  • May occur acutely under emotional distress or intense worry
  • Insomnia
  • Often present upon rising or shortly thereafter
  • Muscular tightness or stiffness in neck, occipital, and frontal regions
  • Duration of more than 5 years in 75% of patients with chronic headaches
  • Difficulty concentrating
  • No prodrome

New headache onset in elderly patients should suggest etiologies other than tension headache.

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Physical

The physical examination serves mainly to exclude the possibility of other headache causes.

  • Vital signs should be normal.
  • Normal neurologic examination
  • Tenderness may be elicited in the scalp or neck, but no other positive physical exam findings should be noted.
  • Pain should not be elicited over temporal arteries or positive trigger zones.
  • Some patients with occipital tension headaches may be very tender when upper cervical muscles are palpated.
  • Pain associated with neck flexion and stretching of paracervical muscles must be distinguished from nuchal rigidity associated with meningeal irritation.
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Causes

Stress may cause contraction of neck and scalp muscles, although no evidence confirms that the origin of pain is sustained muscle contraction.

  • Stress and/or anxiety
  • Poor posture
  • Depression
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Contributor Information and Disclosures
Author

Michelle Blanda, MD  Chair, Department of Emergency Medicine, Summa Health System Akron City/St Thomas Hospital; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

Michelle Blanda, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Lori K Sargeant, MD  Consulting Staff, Summa Emergency Associates, Inc

Lori K Sargeant, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. Jan 2008;7(1):70-83. [Medline].

  2. Kiran U, Behari M, et al. The effect of autogenic relaxation on chronic tension headache and in modulating cortisol. Indian J Anaesth. 2005;49(6):474-8.

  3. Merikangas KR, Cui L, Richardson AK, Isler H, Khoromi S, Nakamura E, et al. Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study. BMJ. Aug 25 2011;343:d5076. [Medline]. [Full Text].

  4. Silver N. Headache (chronic tension-type). Am Fam Physician. Jul 1 2007;76(1):114-6. [Medline]. [Full Text].

  5. [Guideline] Martin V, Elkind A. Diagnosis and classification of primary headache disorders. In: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation; 2004. [Full Text].

  6. Ozkurt B, Cinar O, Cevik E, Acar AY, Arslan D, Eyi EY, et al. Efficacy of high-flow oxygen therapy in all types of headache: a prospective, randomized, placebo-controlled trial. Am J Emerg Med. May 2 2012;[Medline].

  7. [Guideline] Ruoff G, Urban G. Treatment of primary headache: episodic tension-type headache. In: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation; 2004. [Full Text].

  8. Arena JG, Bruno GM, Hannah SL, et al. A comparison of frontal electromyographic biofeedback training, trapezius electromyographic biofeedback training, and progressive muscle relaxation therapy in the treatment of tension headache. Headache. Jul-Aug 1995;35(7):411-9. [Medline].

  9. Bogaards MC, ter Kuile MM. Treatment of recurrent tension headache: a meta-analytic review. ALYSIS. Sep 1994;10(3):174-90. [Medline].

  10. Carlsson J, Augustinsson LE, Blomstrand C, et al. Health status in patients with tension headache treated with acupuncture or physiotherapy. Headache. Sep 1990;30(9):593-9. [Medline].

  11. De Benedittis G, Lorenzetti A, Sina C, Bernasconi V. Magnetic resonance imaging in migraine and tension-type headache. Headache. May 1995;35(5):264-8. [Medline].

  12. [Best Evidence] Detsky ME, McDonald DR, Baerlocher MO, et al. Does this patient with headache have a migraine or need neuroimaging?. JAMA. Sep 13 2006;296(10):1274-83. [Medline].

  13. Ficek SK, Wittrock DA. Subjective stress and coping in recurrent tension-type headache. Headache. Sep 1995;35(8):455-60. [Medline].

  14. Goldstein JN, Camargo CA Jr, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. Jun 2006;26(6):684-90. [Medline].

  15. Iversen HK, Langemark M, Andersson PG, et al. Clinical characteristics of migraine and episodic tension-type headache in relation to old and new diagnostic criteria. Headache. Jul 1990;30(8):514-9. [Medline].

  16. Landy S. Migraine throughout the life cycle: treatment through the ages. Neurology. Mar 9 2004;62(5 Suppl 2):S2-8. [Medline].

  17. Silberstein SD. Tension-type headaches. Headache. Sep 1994;34(8):S2-7. [Medline].

  18. Silberstein SD, Olesen J, Bousser MG, et al. The International Classification of Headache Disorders, 2nd Edition (ICHD-II)--revision of criteria for 8.2 Medication-overuse headache. Cephalalgia. Jun 2005;25(6):460-5. [Medline].

  19. Tfelt-Hansen P. Acute pharmacotherapy of migraine, tension-type headache, and cluster headache. J Headache Pain. Apr 2007;8(2):127-34. [Medline].

 
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