Introduction
Background
The International Headache Society (IHS) began developing a classification system for headaches in 1985. Finalized in 1988, this system includes a tension-type headache category, further defined as either episodic or chronic. Headache categories also are defined by whether they are associated with pericranial muscle disorders.
Episodic tension headache usually is associated with a stressful event. This headache type is of moderate intensity, self-limited, and usually responsive to nonprescription drugs.
Chronic tension headache often recurs daily and is associated with contracted muscles of the neck and scalp. This type of headache is bilateral and usually occipitofrontal.
Tension-type headache 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.
Pathophysiology
Both muscular and psychogenic factors are believed to be associated with tension-type headache.
Frequency
United States
Headaches account for 1-4% of all emergency department (ED) visits and is the ninth most common reason for a patient to consult a physician. Physicians classify 90% of headaches reported to them as muscle contraction or migraine headaches.
International
No literature suggests that headache frequency is different in other regions of the world.
Sex
A female preponderance of migraine exists, 14-17%, compared with 5-6% in males.
Age
All ages are susceptible, but most patients are young adults.
- Approximately 60% of headache onset occurs in those older than 20 years.
- Headache onset is unusual in those older than 50 years.
- In elderly patients, the practicing physician should never assume that headache onset is due to benign causes, such as tension-type headaches, until pathologic etiologies are explored.
Clinical
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:
- 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)
- Photophobia and/or phonophobia
- Minimum of 10 previous headache episodes; 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.
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.
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
More on Headache, Tension |
 Overview: Headache, Tension |
| Differential Diagnoses & Workup: Headache, Tension |
| Treatment & Medication: Headache, Tension |
| Follow-up: Headache, Tension |
| References |
| Next Page » |
References
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].
Bogaards MC, ter Kuile MM. Treatment of recurrent tension headache: a meta-analytic review. ALYSIS. Sep 1994;10(3):174-90. [Medline].
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].
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].
Ficek SK, Wittrock DA. Subjective stress and coping in recurrent tension-type headache. Headache. Sep 1995;35(8):455-60. [Medline].
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].
Landy S. Migraine throughout the life cycle: treatment through the ages. Neurology. Mar 9 2004;62(5 Suppl 2):S2-8. [Medline].
Silberstein SD. Tension-type headaches. Headache. Sep 1994;34(8):S2-7. [Medline].
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].
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].
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].
Further Reading
Keywords
tension headache, tension-type headache, chronic tension headache, episodic tension headache, chronic recurring head pain, cluster headache, migraine headache, muscle contraction headache
