Tension-type Headache

Background

• Tension-type headache is the most common primary headache disorder, with a prevalence ranging from about 31-79%.
• Tension-type headache may be characterized based on the presence of pericranial tenderness on palpation and the frequency of headaches.
  • Episodic:
    • infrequent - ≥ 10 episodes occurring on < 1 day per month (< 12 days per year)
    • frequent - ≥ 10 episodes on 1-14 days per month for ≥ 3 months (≥ 12 days and < 180 days per year)
  • Chronic - episodes on ≥ 15 days per month on average for ≥ 3 months (≥ 180 days per year)

Evaluation

• Tension-type headache can be diagnosed by the presence of typical clinical features and a normal neurologic exam, after the exclusion of other causes.
  • Clinical features include:
    • headache lasting 30 minutes to 7 days for episodic tension-type headaches
    • headache lasting hours or that is continuous for chronic tension-type headaches
    • bilateral location
    • pressing or tightening quality (nonpulsating, may be described as "band around the head")
    • mild-to-moderate intensity
    • typically not incapacitating and not aggravated by routine physical activity (may help to differentiate from migraine headache)
    • absence of nausea and vomiting (mild nausea may occur with chronic tension-type headache)
    • possible photophobia or phonophobia, but not both
  • Diagnosis may be aided by a patient headache diary that is recorded over > 4 weeks.
  • Pericranial muscle tenderness on palpation is the most common abnormal finding on an exam.
• Neuroimaging is indicated for patients who present with signs or symptoms suggesting an increased risk of intracranial pathology (Strong recommendation).
  • The SNNOOP10 criteria may be helpful in identifying red flags that are suggesting a secondary cause of the headache.
  • See Headache for additional details on indications for imaging and other diagnostic testing for headaches.

Management

• Identify and address possible triggers and comorbid conditions.
• Acute treatment of a headache episode may include:
  • simple analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line options (Strong recommendation):
    • Ibuprofen 200-800 mg is the treatment of choice due to a favorable side-effect profile.
    • Other options include naproxen (375-550 mg), aspirin (500-1,000 mg), acetaminophen (1,000 mg), ketoprofen (25 mg), or diclofenac (12.5-100 mg).
  • combination analgesics containing caffeine 64-200 mg as a second-line option (Weak recommendation)
  • parenteral therapies, such as metoclopramide, metoclopramide plus diphenhydramine, and chlorpromazine, which have evidence of efficacy
  • limiting use of drugs to treat acute headache to 2-3 days/week and avoiding opioids and sedative hypnotics to minimize risk of medication overuse headache
  • not using triptans, opioids, and muscle relaxants to treat tension-type headache
• Consider prophylactic therapy if acute treatment is ineffective or overused, or if the patient has chronic or very frequent episodic tension-type headache.
  • Nonpharmacologic therapy, such as biofeedback, acupuncture, and physical therapy, should be considered for all patients.
  • For medication management, start with a low dose and gradually titrate (commonly at weekly intervals) until the target dose is reached or there are adverse side effects.
    • First-line medication for prophylaxis is amitriptyline 30-75 mg/day (Strong recommendation).
    • Second-line options include mirtazapine 30 mg/day and venlafaxine 150 mg/day (Weak recommendation).
    • Third-line options include maprotiline 75 mg/day, clomipramine 75-150 mg/day, and mianserin 30-60 mg/day (Weak recommendation).
  • Consider avoiding botulinum toxin injection for prophylaxis of chronic tension-type headache, as evidence for efficacy is limited (Weak recommendation).