2008

Diagnostic criteria

At least 10 episodes fulfilling following criteria Headache lasting 30 mins to 7 days Has 2 at least 2 of the following

Bilateral location Pressing/tightening (non-pulsating) quality Mild or moderate intensity Not aggravated by physical activity such as

walking or climbing stairs No nausea or vomiting < 2 episodes of photophobia or phonophobia Not attributable to another disorder

Categories

Infrequent episodic tension type headache Occurs < 1 day per month ( < 12 days/year)

Frequent episodic tension type headache Occurs > 1 and < 15 days/month ( > 12 and

<180 days/year) Chronic tension type headache

Occurs > 15 days/month ( 180 or more days/year)

Causes

Uncertain ? Activation of hyper excitable

peripheral afferent neurons from head and neck muscles

Associated with and aggravated by muscle tenderness and psychological tension but do not cause it

Abnormalities in central pain processing and generalised increased pain sensitivity are found in some individuals

Genetic factors

People at risk

Prevalence peaks at age 40-49 in both sexes

Mean life time prevalence is 46% Chronic tension type headache

affects 3% of general population Female to male ratio is 4:5 Prevalence increases with

educational level Can occur in children

Presentation

Mild to moderate bilateral pain Sensation of muscle tightness or

pressure Lasts hours to days Not associated with constitutional or

neurological symptoms People with chronic tension headache

more likely to seek help often have a history of episodic headache but delayed until frequency and disability are high

Differential diagnosis

Migraine – in chronic form characteristic features disappear and pain is less severe

Neck problems – muscle tenderness of tension type headache may involve the neck

Medication overuse headache – consider in patients taking opioid or combination analgesics for an average of 10 days/month

Examination and investigation Examination

Neurological examination Manual palpation of pericranial muscles (

frontal, temporal, masseter, pterygoid, sternomastoid, splenius and trapezius.

Fundoscopy for papilloedema Investigations

If neuro examination normal none needed

Investigation

Neuroimaging should be arranged if Atypical pattern of headache History of seizures Neurological signs or symptoms Symptomatic illness – acquired

immunodeficiency syndrome, tumours or neurofibromatosis

Treatment

Infrequent headache Good results from non prescription

medication May need reassurance

If require drugs on more than 2-3 days/week then medical treatment is indicated to prevent medication misuse headache

Treatment

Acute therapy for individual attacks Simple analgesia

Aspirin 500 – 1000mg NSAIDS Paracetamol more effective than placebo

less effective than NSAIDS Combination drugs containing simple

analgesics and caffeine are helpful Opioids or sedatives should not be used

as impair alertness and can cause overuse and dependence

Treatment

Preventive treatment Consider when headaches are frequent or

acute attacks don’t respond to abortive treatment Best evidence is for Amitriptyline 75-

150mg/day. It helps both pain and muscle tenderness. Works best when started at low dose and increased weekly

Mirtazipine 15-30mg/day Unhelpful

SSRI’s Botulinium toxin

Treatment

Preventive treatment Should be considered when at least 2

headaches/month as risk of chronic headache goes up exponentially when frequency reaches 1/week as does severity of pain

Benefit or preventive treatment is diminished when patients are simultaneously overusing abortive treatments. Withdrawal of medication is advised before starting preventative therapy

Treatment

Education, lifestyle and non-pharmacological treatment Little evidence exists to support or

refute most dietary or lifestyle recommendations for tension type headache.

Treatment

Referral Diagnosis is unclear Does not respond to treatment Complicated by medication

overuse Require neuroimaging

Prognosis

45% of adults with frequent or chronic tension type headache will go into remission

39% will carry on with frequent headaches

16% will carry on with chronic headache

Poor prognosis

Associated with Presence of chronic headache at

baseline Co-existing migraine Not being married Sleep problems

Good prognosis

Associated with Older age Absence of chronic tension type

headache at baseline

Important message intervene early before headaches become chronic