Tension headache

Tension headache
A woman experiencing a tension headache
Specialty Neurology

Tension headache, also known as tension-type headache, is the most common type of primary headache. The pain can radiate from the lower back of the head, the neck, eyes or other muscle groups in the body typically affecting both sides of the head. Tension-type headaches account for nearly 90% of all headaches.

Pain medication, such as aspirin and ibuprofen, are effective for the treatment of tension headache.[1][2] Tricyclic antidepressants appear to be useful for prevention.[3] Evidence is poor for SSRIs, propranolol and muscle relaxants.[4][5]

As of 2013, tension headaches affect about 1.6 billion people (20.8% of the population)[6] and are more common in women than men (23% to 18% respectively).[7]

Signs and symptoms

Tension-type headache pain is often described as a constant pressure, as if the head were being squeezed in a vice. The pain is frequently present on both sides of the head at the same time. Tension-type headache pain is typically mild to moderate but may be severe.

According to the third edition of the International Classification of Headache Disorders,[8] the attacks must meet the following criteria:

  • A duration of between 30 minutes and 7 days.
  • 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
  • Both of the following:
    • no nausea or vomiting
    • no more than one of photophobia (sensitivity to bright light) or phonophobia (sensitivity to loud sounds)

Tension-type headaches may be accompanied by tenderness of the scalp on manual pressure during an attack.

Based on frequency, tension-type headaches can be sub-classified as

  • Infrequent episodic: occurring less than once per month on average, or less than 12 episodes a year;
  • Frequent episodic: occurring between 1-14 times per month on average for at least 3 months;
  • Chronic: occurring 15 times a month for at least 3 months (CTTH - chronic tension-type headache).

Cause

Various precipitating factors may cause tension-type headaches in susceptible individuals:[9]

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

Tension-type headaches may be caused by muscle tension around the head and neck.

Another theory is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information—for example from the temporal muscle or other muscles—and interprets this signal as pain. One of the main neurotransmitters that is probably involved is serotonin. Evidence for this theory comes from the fact that chronic tension-type headaches may be successfully treated with certain antidepressants such as nortriptyline. However, the analgesic effect of nortriptyline in chronic tension-type headache is not solely due to serotonin reuptake inhibition, and likely other mechanisms are involved. Recent studies of nitric oxide (NO) mechanisms suggest that NO may play a key role in the pathophysiology of CTTH.[10] The sensitization of pain pathways may be caused by or associated with activation of nitric oxide synthase (NOS) and the generation of NO. Patients with chronic tension-type headache have increased muscle and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain thresholds. Hyperexcitability of central nociceptive neurons (in trigeminal spinal nucleus, thalamus, and cerebral cortex) is believed to be involved in the pathophysiology of chronic tension-type headache.[11] Recent evidence for generalized increased pain sensitivity or hyperalgesia in CTTH strongly suggests that pain processing in the central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type headache.[12]

If other treatment is not working, a health care provider may use an MRI to confirm a more complicated diagnosis (e.g., new daily persistent headache).[13]

Prevention

Lifestyle

Drinking water and avoiding dehydration helps in preventing tension headache.[13] Using stress management and relaxing often makes headaches less likely.[13] Drinking alcohol can make headaches more likely or severe.[13] Good posture might prevent headaches if there is neck pain.[13] People who have jaw clenching might develop headaches, and getting treatment from a dentist might prevent those headaches.[13] Biofeedback techniques may also help.[14][15]

Medications

People who have 15 or more headaches in a month may be treated with certain types of daily antidepressants which act to prevent continued tension headaches from occurring.[13] In those who are predisposed to tension type headaches the first-line preventative treatment is amitriptyline, whereas mirtazapine and venlafaxine are second-line treatment options.[16] Tricyclic antidepressants appear to be useful for prevention.[3] Tricyclic antidepressants have been found to be more effective than SSRIs but have greater side effects.[3] Evidence is poor for the use of SSRIs, propranolol, and muscle relaxants for prevention of tension headaches.[4][5]

Treatment

Treatment for a current tension headache is to drink water and confirm that there is no dehydration.[13] If symptoms do not resolve within an hour for a person who has had water, then stress reduction might resolve the issue.[13]

Medications

Over-the-counter drugs, like acetaminophen, aspirin, or ibuprofen, can be effective but tend to only be helpful as a treatment for a few times in a week at most.[1][13][17] Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache.[2][16]

Botulinum toxin does not appear to be helpful.[18]

Manual therapy

Current evidence for acupuncture is slight. A 2016 systematic review suggests better evidence among those with frequent tension headaches, but concludes that further trials comparing acupuncture with other treatment options are needed.[19]

People with tension-type headache often use spinal manipulation, soft tissue therapy, and myofascial trigger point treatment. Studies of effectiveness are mixed. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache.[20] A 2005 structured review found only weak evidence for the effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[21] A 2004 Cochrane review found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache.[22] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.[23] A 2012 systematic review of manual therapy found that hands-on work may reduce both the frequency and the intensity of chronic tension-type headaches.[24]

Epidemiology

As of 2013 tension headaches affect about 1.6 billion people (20.8% of the population)[6] and are more common in women than men (23% to 18% respectively).[7] Despite its benign character, tension-type headache, especially in its chronic form, can impart significant disability on patients as well as burden on society at large.[25]

Prognosis

Tension headaches that do not occur as a symptom of another condition may be painful, but are not harmful. It is usually possible to receive relief through treatment. Tension headaches that occur as a symptom of another condition are usually relieved when the underlying condition is treated. Frequent use of pain medications in patients with tension-type headache may lead to the development of medication overuse headache or rebound headache.

References

  1. 1 2 Derry, S; Wiffen, PJ; Moore, RA; Bendtsen, L (31 July 2015). "Ibuprofen for acute treatment of episodic tension-type headache in adults". The Cochrane Database of Systematic Reviews. 7: CD011474. doi:10.1002/14651858.CD011474.pub2. PMID 26230487.
  2. 1 2 Loder, E; Rizzoli, P (12 January 2008). "Tension-type headache". BMJ (Clinical research ed.). 336 (7635): 88–92. doi:10.1136/bmj.39412.705868.AD. PMC 2190284. PMID 18187725.
  3. 1 2 3 Jackson JL, Shimeall W, Sessums L, et al. (2010). "Tricyclic antidepressants and headaches: systematic review and meta-analysis". BMJ. 341: c5222. doi:10.1136/bmj.c5222. PMC 2958257. PMID 20961988.
  4. 1 2 Verhagen AP, Damen L, Berger MY, Passchier J, Koes BW (April 2010). "Lack of benefit for prophylactic drugs of tension-type headache in adults: a systematic review". Fam Pract. 27 (2): 151–65. doi:10.1093/fampra/cmp089. PMID 20028727.
  5. 1 2 Banzi, R; Cusi, C; Randazzo, C; Sterzi, R; Tedesco, D; Moja, L (1 May 2015). "Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults". The Cochrane Database of Systematic Reviews. 5: CD011681. doi:10.1002/14651858.CD011681. PMID 25931277.
  6. 1 2 Global Burden of Disease Study 2013, Collaborators (22 August 2015). "Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet. 386 (9995): 743–800. doi:10.1016/s0140-6736(15)60692-4. PMC 4561509. PMID 26063472.
  7. 1 2 Vos, T; Flaxman, A. D.; Naghavi, M; Lozano, R; Michaud, C; Ezzati, M; Shibuya, K; Salomon, J. A.; Abdalla, S; Aboyans, V; Abraham, J; Ackerman, I; Aggarwal, R; Ahn, S. Y.; Ali, M. K.; Alvarado, M; Anderson, H. R.; Anderson, L. M.; Andrews, K. G.; Atkinson, C; Baddour, L. M.; Bahalim, A. N.; Barker-Collo, S; Barrero, L. H.; Bartels, D. H.; Basáñez, M. G.; Baxter, A; Bell, M. L.; Benjamin, E. J.; et al. (Dec 15, 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet. 380 (9859): 2163–96. doi:10.1016/S0140-6736(12)61729-2. PMID 23245607.
  8. ↑ Headache Classification Committee of the International Headache Society (IHS): The International Classification of Headache Disorders,3rd edition. Cephalalgia 33(9) 629–808
  9. ↑ Muscle Contraction Tension Headache at eMedicine
  10. ↑ Ashina M, Lassen LH, Bendtsen L, Jensen R, Olesen J; Lassen; Bendtsen; Jensen; Olesen (January 1999). "Effect of inhibition of nitric oxide synthase on chronic tension-type headache: a randomised crossover trial". Lancet. 353 (9149): 287–9. doi:10.1016/S0140-6736(98)01079-4. PMID 9929022.
  11. ↑ Ashina S, Bendtsen L, Ashina M; Bendtsen; Ashina (December 2005). "Pathophysiology of tension-type headache". Curr Pain Headache Rep. 9 (6): 415–22. doi:10.1007/s11916-005-0021-8. PMID 16282042.
  12. ↑ Pielsticker A, Haag G, Zaudig M, Lautenbacher S; Haag; Zaudig; Lautenbacher (November 2005). "Impairment of pain inhibition in chronic tension-type headache". Pain. 118 (1–2): 215–23. doi:10.1016/j.pain.2005.08.019. PMID 16202520.
  13. 1 2 3 4 5 6 7 8 9 10 Consumer Reports (28 April 2016). "Tension Headache Treatment and Prevention". Consumer Reports. Retrieved 25 May 2016.
  14. ↑ Nestoriuc Y, Rief W, Martin A; Rief; Martin (June 2008). "Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators". J Consult Clin Psychol. 76 (3): 379–96. doi:10.1037/0022-006X.76.3.379. PMID 18540732.
  15. ↑ Rains JC (May 2008). "Change mechanisms in EMG biofeedback training: cognitive changes underlying improvements in tension headache". Headache. 48 (5): 735–6, discussion 736–7. doi:10.1111/j.1526-4610.2008.01119_1.x. PMID 18471128.
  16. 1 2 Bendtsen L, Jensen R; Jensen (May 2011). "Treating tension-type headache — an expert opinion". Expert Opin Pharmacother. 12 (7): 1099–109. doi:10.1517/14656566.2011.548806. PMID 21247362.
  17. ↑ Derry, S; Wiffen, PJ; Moore, RA (13 January 2017). "Aspirin for acute treatment of episodic tension-type headache in adults". The Cochrane Database of Systematic Reviews. 1: CD011888. doi:10.1002/14651858.CD011888.pub2. PMID 28084009.
  18. ↑ Simpson, D. M.; Hallett, M.; Ashman, E. J.; Comella, C. L.; Green, M. W.; Gronseth, G. S.; Armstrong, M. J.; Gloss, D.; Potrebic, S.; Jankovic, J.; Karp, B. P.; Naumann, M.; So, Y. T.; Yablon, S. A. (18 April 2016). "Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology". Neurology. 86: 1818–1826. doi:10.1212/WNL.0000000000002560. PMC 4862245. PMID 27164716.
  19. ↑ Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, Vickers A, White AR; Linde; Allais; Brinkhaus; Fei; Mehring; Shin; Vickers; White (2016). "Acupuncture for the prevention of tension-type headache". Cochrane Database Syst Rev. 1 (4): CD007587. doi:10.1002/14651858.CD007587.pub2. PMC 4955729. PMID 27092807.
  20. ↑ Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA; Alonso-Blanco; Cuadrado; Miangolarra; Barriga; Pareja (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain. 22 (3): 278–85. doi:10.1097/01.ajp.0000173017.64741.86. PMID 16514329.
  21. ↑ Biondi DM (2005). "Physical treatments for headache: a structured review". Headache. 45 (6): 738–46. doi:10.1111/j.1526-4610.2005.05141.x. PMID 15953306.
  22. ↑ Bronfort G, Nilsson N, Haas M; et al. (2004). Brønfort, Gert, ed. "Non-invasive physical treatments for chronic/recurrent headache". Cochrane Database Syst Rev (3): CD001878. doi:10.1002/14651858.CD001878.pub2. PMID 15266458.
  23. ↑ Ernst E, Canter PH; Canter (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMC 1420782. PMID 16574972.
  24. ↑ Chaibi, A; Russell, MB (July 2012). "Manual therapies for cervicogenic headache: a systematic review". The journal of headache and pain. 13 (5): 351–9. doi:10.1007/s10194-012-0436-7. PMC 3381059. PMID 22460941.
  25. ↑ Lenaerts, M. E. (2006). "Burden of tension-type headache". Current Pain and Headache Reports. 10 (6): 459–62. doi:10.1007/s11916-006-0078-z. PMID 17087872.
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