Tension Type Headache

  • Amitriptyline for patients with frequent episodic TTH or chronic TTH. Exceptions include patients with obesity, bipolar disease, or cardiac conduction defects.  we start amitriptyline at 10 to 12.5 mg nightly and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated and as needed for sleep, until there is improvement in headache or until a maximum dose of 100 to 125 mg nightly is reached.
  • Protriptyline is nonsedating and may be somewhat stimulating. Use cautiously for patients who have anxiety and panic disorders. May cause weight loss. Start 5 mg q a.m. Increase in 5 mg increments every week with a target dose of 20 mg q a.m.
Essential Evidence PlusAuthors:
Aaron Saguil, MD, MPH, Assistant Residency Director, Dwight D. Eisenhower Army Medical Center
Gary Means, MD, Family Practitioner, Womack Army Medical Center
Editors:
Mark H. Ebell, MD, MS, Professor, College of Public Health, University of Georgia
Kenny Lin, MD, MPH, Professor of Family Medicine, Georgetown University
Mindy A. Smith, MD, MS, Clinical Professor, Department of Family Medicine, Michigan State University
Allen F. Shaughnessy, PharmD, Professor of Family Medicine, Tufts University
Last updated: 2017-11-18 © 2017 John Wiley & Sons, Inc.
Overall Bottom LineBackgroundTension-type headache (TTH) is an episodic or chronic headache lasting from minutes to days that is typically bilateral, pressing, of mild-to-moderate intensity, and without prominent nausea. Although either photophobia or phonophobia may be present, they do not occur simultaneously.Prevalence
  • The 1-year prevalence of episodic TTH is estimated to be 38.3%.17
  • The 1-year prevalence for chronic TTH is estimated to be 2.2%.17
  • The lifetime prevalence of tension headaches is estimated to be from 30% to 78%.8
  • Thirty-seven percent to 51% of 7-year-olds and 57% to 82% of 15-year-olds report having had a headache. 1
Economic Impact
  • In a Baltimore County, MD cohort of 13,343 people, over 4,200 workdays were lost to TTH. 16
  • In the Baltimore County cohort, TTH represented 22% of the annual 23,287 headache-related reduced effectiveness workday equivalents (a measure of productive days lost due to illness).16
  • A European study found that TTH was associated with a per-person cost of 303 euros yearly (approximately $400). 26
Other Impact
  • TTH is the most common type of primary headache.
  • Pain limits regular activities 38% of the time when present.15
  • Pain limits work or social activities for 60% of those afflicted.14
  • In a cross-sectional study of children ages 10 to 15 years, virtually all reported headache with 33% (61/184) having TTH. 41 Only migraine and more severe headaches (relative risk: 7.93; 95% confidence interval: 2.65-23.7) were associated with lower quality of life, and more severe headaches were also associated with lower grades in school.
Causes of the Condition
  • Both psychological and neurobiologic mechanisms are thought to underlie TTHs.8
Pathophysiology
  • Peripheral pain mechanisms are thought to cause episodic TTHs, whereas central pain mechanisms are thought to be responsible for chronic TTH.8
  • Pain sensitivity appears to be a mediator between stress and headache intensity. 29
  • Nitric oxide is thought to play a role in the central sensitization involved with chronic TTH.13
Risk FactorsRisk Factor
Female gender
Ages 30-39 years
White race
Increasing educational level
Head and neck injuries
Depression and anxiety disorders
Stress (increased days/month by 6%)
Sleep dysregulationReferences:
DiagnosisBottom Line
  • Patients should be asked about warning signs for concerning intracranial causes of headache, such as headache worsening over time, headache changing in character, "thunderclap" headaches, headache worsened by Valsalva maneuver or exertion, or associated neurologic signs. B 2
  • The physical examination should include vital signs, especially blood pressure, as well as a complete neurologic examination, including the optic fundi. B8 1
  • Neuroimaging is indicated in the presence of abnormal neurologic findings, or a "thunder clap" headache. A3
Differential DiagnosisDiagnosisFeatures
Migraine headacheUnilateral, pulsating, severe, worse with activity, nausea, and photophobia/phonophobia
Cluster headacheUnilateral, orbital, with conjunctival injection, miosis, and nasal congestion
Sinus headacheAssociated sinus pathology, responds to treatment of sinus condition
Cerebrovascular infarctFocal neurologic signs and abnormal neuroimaging
Subarachnoid hemorrhageThunderclap onset, disordered consciousness, and nuchal rigidity
MeningitisFever, nuchal rigidity, and altered sensorium
Giant cell arteritisTender scalp, older age, amaurosis fugax
Sleep apnea headachePresent on awakening, resolves with treatment of sleep apnea
Temporomandibular joint (TMJ) disorderWorse with chewing, tenderness over TMJUsing the History and Physical
  • History should focus on the nature of the headache to include quality, severity, duration, location, frequency, provocative, and palliative factors; the presence or absence of aura, photophobia, phonophobia, nausea, or vomiting; and whether there are systemic symptoms or comorbidities that could be causing the headache.8 1
  • A history of fear of smells, or osmophobia, may be helpful in distinguishing between TTH and migraine. In one study, osmophobia occurred in only 6.0% if 200 patients with acute TTH vs. 86.0% of 200 patients with acute migraine; no patients with TTH had osmophobia between headache attacks compared to 24% of those with migraines. 44
  • Patients should also be asked about warning signs for concerning intracranial causes such as headache worsening over time, headache changing in character, "thunderclap" headaches, headache worsened by Valsalva maneuver or exertion, or associated neurologic signs. 2
  • Additional signs and symptoms suggesting a secondary cause for headache noted in the National Institute for Health and Care Excellence (NICE) guideline on headache include new-onset cognitive dysfunction or personality change, head trauma within the past 3 months, orthostatic headache, or additional symptoms of giant cell arteritis or glaucoma. They also recommend a work-up for secondary causes in patients with compromised immunity, a past malignancy known to metastasize to the brain or for those under age 20 with a history of malignancy.
  • The physical examination should include vital signs, especially the blood pressure, as well as a complete neurologic examination, including the optic fundi.8 1 Additionally, extracranial structures such as the carotid arteries, sinuses, scalp arteries, and cervical paraspinal muscles should be assessed. C 2
Selecting Diagnostic Tests
  • Neuroimaging is indicated in the presence of abnormal neurologic findings or a "thunderclap" headache.3 See chapter on headache diagnosis for more information on the evaluation of headache.
  • There is no role for routine screening with neuroimaging, lumbar puncture, or EEG in the evaluation of headaches. 2
Approach to the Patient
  • See algorithm in .
History and Physical TestsTreatmentBottom Line
  • Acetaminophen, aspirin, and NSAIDs are first-line medications for treatment of TTH. A 2 27
  • If monotherapy fails, aspirin and/or acetaminophen with caffeine or combination caffeine-NSAIDs have been shown to reduce the severity and duration of TTH. B12
  • If nonprescription medications are unsuccessful, consider prescription NSAIDs, isometheptene-containing compounds, or prophylactic medications. 18 28C
  • Prophylactic therapy with tricyclic antidepressants or SSRIs is recommended for patients suffering over 15 headaches per month. B
Drug Therapy
  • Analgesics, Antidepressants and Anticonvulsants
    • Acetaminophen, aspirin, and NSAIDs are first-line medications for treatment of TTH. 2 27
    • Authors of a meta-analysis of 6 trials found no difference in pain relief for TTH between low-dose NSAIDs and acetaminophen; high-dose NSAIDs may be more effective but have more adverse effects. 30
    • Authors of a more recent systematic review of 55 RCTs also found no differences between paracetamol 1000 mg, ibuprofen 400 mg, or ketoprofen 25 mg with NNT for being pain-free at 2 hours of 8.7, 8.9, and 9.8, respectively. 45
    • If monotherapy fails, aspirin and/or acetaminophen with caffeine often provide good relief. 187 In a meta-analysis of 4 medication trials for episodic TTH, combination acetylsalicylic acid, acetaminophen, and caffeine resulted in more patients being pain-free at 2 hours than acetaminophen alone or placebo (28.5% vs. 21.0% and 18.0%, respectively). 37 Combination caffeine-NSAIDs have also been shown to reduce the severity and duration of TTH.12
    • If nonprescription medications are unsuccessful, prescription medications, to include NSAIDs, isometheptene-containing compounds, and prophylactic agents, should be considered. 18 28
    • Authors of a systematic review found that metamizole (NNT = 4), chlorpromazine (NNT = 4), and metoclopramide (NNT = 2) were superior to placebo for acute TTH pain. Neither meperidine with promethazine nor sumatriptan were more effective than placebo. 40
    • Use of medications for the acute treatment of headache for more than 9 days in 1 month increases the risk for medication overuse headache. Prophylactic therapy is recommended for patients suffering over 15 headaches per month. 2
    • Tricyclic antidepressant medications are first line prophylactic agents and may reduce headache activity, analgesic use, and headache-related disability in chronic TTH. 19 27However, a recent systematic review found poor quality or conflicting evidence for the effectiveness of antidepressants, muscle relaxants, benzodiazepines, or vasodilators as prophylaxis for frequent TTH.20
    • When compared with SSRIs, prophylactic use of tricyclic antidepressants led to less analgesic use and decreased headache frequency, intensity, and duration. More minor side effects, especially dry mouth and sedation, were noted with tricyclic antidepressants.15
    • In a RCT of 96 patients with chronic headache, 42 with TTH, the anticonvulsant levetiracetam was only minimally effective in reducing headache frequency (one extra headache-free day/month), disability and pain intensity, and was associated with mental health impairment on the Short-Form Quality of Life assessment instrument (SF-36). 31
    • Limited evidence from a single small RCT found memantine to be ineffective for TTH prophylaxis.21
Complementary/Alternative Therapy
  • There is moderate evidence that therapeutic touch is superior to placebo for headache pain relief.
  • Patients receiving acupuncture are more likely to have reduced headache severity, headache frequency, and medication use 3 months and 1 year after treatment.11 Authors of a Cochrane review found more participants experiencing at least 50% reduction of headache frequency in groups receiving acupuncture vs, control groups (2 studies: 48% and 45% vs. 19% and 4%) or sham acupuncture (51% vs. 43%) groups. 52 Four trials comparing acupuncture with physiotherapy, massage or exercise were of low to moderate quality and reported no significant superiority of acupuncture.
  • In a RCT comparing acupuncture to relaxation or physical training (N = 90; 30 per group), all patients improved in central nervous system symptoms. Those in physical training had significantly improved minor symptom evaluation profiles compared with the acupuncture group, and vitality and sleep significantly improved in the relaxation training group compared with the acupuncture group. 33
  • Authors of a systematic review of 5 small trials found spinal manipulation as part of combined therapy (osteopathic manipulation, manual therapy, or with amitriptyline) effective for the treatment of TTH with respect to headache frequency and severity. One trial found no differences between spinal manipulation alone compared with soft tissue therapy plus placebo laser treatment. Another sytematic review of fourteen RCTs over 14 years found that, in general, manual therapies were associated with positive results, such as decreased headache intensity or frequency or decreased medication consumption; however the authors cautioned that further high quality studies were needed. 25 38
  • In a small RCT of 30 patients with TTH, trigger point Positional Release Therapy was similar to medical therapy with respect to headache frequency, intensity, duration and tablet count. Neither appeared effective, however, in reducing pain intensity. 34
  • There is evidence suggesting that topical application of peppermint oil may be effective in relieving TTH.5
  • Dry needling may be helpful, when added to conventional therapies. 39
  • Guided imagery was more effective than usual care in one RCT of 60 patients with chronic TTH in reducing headache intensity, frequency and duration. 35
Rehabilitation and Physical Therapy
  • There is limited evidence that cranial electrotherapy and the combination of auto-massage, transcutaneous electrical nerve stimulation (TENS), and stretching is effective in providing headache pain relief.
  • Massage and physiotherapy also appear to be effective in the management of chronic TTH. 46
Behavioral Medicine and Psychotherapy
  • Both cognitive therapy and EMG biofeedback alone or in combination with relaxation therapy have been found to be superior to placebo and pseudo treatment control.423
  • Brief mindfulness therapy reduced headache frequency in one RCT. 47
  • Patients with chronic TTH randomized to 8 lessons and practical demonstration of a relaxation therapy called Brahmakumaris spiritual-based meditation (Rajyoga meditation) in addition to routine medical treatment with analgesics and muscle relaxants had greater relief in headache severity, duration and frequency than medication alone. 48
Other Treatment
  • Patients should avoid known triggers for their headaches and should ensure adequate sleep and hydration.
  • Data are conflicting regarding the role of botulinum toxin type A in patients with chronic TTH with respect to headache severity and frequency. Authors of one meta-analysis of clinical trials with 675 patients with chronic TTH, found no significant association between use of botulinum toxin A and reduction in headache number. 24 In the 4 RCTs comparing botulinum toxin A with medication (topiramate, amitripyline, or valproate), there were no significant differences in headache prevention. Side effects can include blepharoptosis, skin tightness, paresthesias, neck stiffness, muscle weakness, and neck pain.
  • Fifteen minutes of high-flow oxygen reduces pain and slightly decreased initial pain and need for additional analgesics in one RCT of 204 patients, half had TTH, who were seen in the emergency department (NNT = 8). 32
  • Conservative or invasive dental occlusal adjustments may be useful patients with TTH. 49
Duration of Treatment
  • Prophylactic medications should be increased in dose until headaches are relieved, the maximum dose is attained, or the patient experiences side effects. Most prophylactic medications should be maintained at the target dose for 8 to 12 weeks in order to exert maximal effect.8
  • NSAIDs should be used with caution in patients with comorbidities, especially cardiovascular and renal disease.
Management of Complications
  • Abnormal neurologic signs or symptoms; a new, worsening, or changing headache; or an acute "thunderclap" headache should prompt neuroimaging.
PrognosisBottom Line
  • Patients with episodic TTH have 30 headaches per year; those with chronic TTH have over 280 headaches per year. B17
  • More than 12 years: 47% of patients with chronic TTH improved to less than 180 headache days per year; 12% with episodic frequent TTH progressed to chronic TTH, 41% continued to have frequent episodic TTH, and 47% improved. B10
Natural History
  • Patients with episodic TTH can expect to have, on average, 30 headaches per year.
  • Patients with chronic TTH can expect to have 285.4 headaches per year.17
Prognosis
  • In a 12-year follow-up study, 47% of patients with chronic TTH improved to less than 180 headache days per year. Of those with frequent, episodic TTH, 12% progressed to chronic TTH, 41% continued to have frequent episodic TTH, and 47% improved.10
  • Coexisting migraine, not being married, and sleeping problems are predictive of poor prognosis. Frequent use of pain relievers may also be related to a poorer prognosis.10
  • In a population-based study, TTH was significantly associated with an increased risk of restless leg syndrome (hazard ratio [HR]  =  1.57; 95% CI  1.22-2.02), especially among patients aged 20 to 39 years. 53
Advice for patients
  • Patients should report whether they develop abnormal neurologic signs in association with their headache or whether the nature or severity of their headache changes.
  • If using the Headache Impact Test-6 (HIT-6) to monitor patients with chronic TTH, the optimal cut-off score discriminating between improved and not improved is 8 points out of a total of 42 points. 36
Management of Special PopulationsPregnancy
  • Do not use NSAIDs in the third trimester due to the risk of prematurely closing the ductus arteriosus in the newborn.
Infants and Children
  • TTH is associated with antenatal maternal smoking, self-reported problem behavior, and being bullied. 50
  • There is inadequate evidence to support routine laboratory or lumbar puncture examination in children with headaches. 1
  • EEG is not recommended in the routine evaluation of the child with recurrent headaches. 1
  • Neuroimaging is not recommended for the routine evaluation of the child with recurrent headache. It should be considered in the child with an abnormal neurologic examination, seizures, onset of severe headache, or change in the type of headache. 1
  • In one RCT, children with migraine or TTH who were randomized to 8 sessions of psychodynamic psychotherapy vs. usual care consisting of clinical interview, neurological examination, counseling, and symptomatic therapy had a significant improvement in headache frequency, intensity and duration at 6 months. 51
References and Additional ResourcesReferences
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  20. Verhagen AP, Damen L, Berger MY, Passchier J, Koes BW. Lack of benefit for prophylactic drugs of tension-type headache in adults: a systematic review. Fam Pract 2010;27:151-165.
  21. Lindelof K, Bendtsen L. Memantine for prophylaxis of chronic tension-type headache—a double-blind, randomized, crossover clinical trial. Cephalalgia 2009;29:314-321.
  22. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tension-type headache. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD007587. DOI: 10.1002/14651858.CD007587.
  23. Nestoriuc Y, Rief W, Martin A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J Consult Clin Psychol 2008;76:379-396.
  24. Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA 2012;307:1736-1745.
  25. Posadzki P, Ernst E. Spinal manipulations for tension-type headaches: a systematic review of randomized controlled trials. Complement Ther Med 2012;20:232–239.
  26. Linde M, Gustavsson A, Stovner LJ, Steiner TJ, Barré J, Katsarava Z, Lainez JM, Lampl C, Lantéri-Minet M, Rastenyte D, Ruiz de la Torre E, Tassorelli C, Andrée C. The cost of headache disorders in Europe: the Eurolight project. Eur J Neurol 2012;19:703–711.
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  30. Yoon YJ, Kim JH, Kim SY, Hwang IH, Kim MR. A comparison of efficacy and safety of non-steroidal anti-inflammatory drugs versus acetaminophen in the treatment of episodic tension-type headache: a meta-analysis of randomized placebo-controlled trial studies. Korean J Fam Med 2012;33:262–271.
  31. Beran RG, Spira PJ. Levetiracetam in chronic daily headache: a double-blind, randomised placebo-controlled study. (The Australian KEPPRA Headache Trial [AUS-KHT]). Cephalalgia 2011;31:530–536.
  32. Ozkurt B, Cinar O, Cevik E, Acar AY, Arslan D, Eyi EY, Jay L, Yamanel L, Madsen T. Efficacy of high-flow oxygen therapy in all types of headache: a prospective, randomized, placebo-controlled trial. Am J Emerg Med 2012;30:1760-1764.
  33. Söderberg EI, Carlsson JY, Stener-Victorin E, Dahlöf C. Subjective well-being in patients with chronic tension-type headache: effect of acupuncture, physical training, and relaxation training. Clin J Pain 2011;27:448–456.
  34. Ghanbari A, Rahimijaberi A, Mohamadi M, Abbasi L, Sarvestani FK. The effect of trigger point management by positional release therapy on tension type headache. NeuroRehabilitation 2012;30:333–339.
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Additional Resources
TablesTable 1: Diagnostic Criteria for Tension-Type Headache (TTH) Syndromes.Episodic TTH
  1. At least 10 episodes occurring <1 d per month on average (infrequent episodic TTH) OR At least 2 episodes occurring =1 but <15 d per month for at least 3 mo (frequent episodic TTH) AND Meets criteria 2 through 5 below.
  2. Lasts from 30 min to 7 d.
  3. At least 2 of the following:
    • Bilateral, pressing/tightening (nonpulsating) quality
    • Mild or moderate intensity
    • Not aggravated by routine physical activity
  4. Both of the following:
    • No nausea or vomiting
    • No more than one of photophobia or phonophobia
  5. Not attributed to another disorder.
Chronic TTH
  1. Headache occurring = 15 d per month on average for >3 mo (=180 d per year) AND Meets criteria 2 through 5 below.
  2. Lasts hours or may be contisdnuous.
  3. At least 2 of the following:
    • Bilateral, pressing/tightening (nonpulsating) quality
    • Mild or moderate intensity
    • Not aggravated by routine physical activity
  4. Both of the following:
    • Neither moderate nor severe nausea or vomiting
    • No more than one of photophobia, phonophobia, or mild nausea
  5. Not attributed to another disorder.
From Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24(Suppl 1):9-160.Article ID: eee0440