CHAPTER 9 TENSION-TYPE HEADACHE
1. Is there a medical term for the headaches of everyday life?
Yes. The most common form of primary headache is tension-type headache (TTH). Almost everyone experiences a TTH at one time or another, and about 40% of the population has had one within the past year. Although occurrence is slightly higher in females, the gender ratio is very close to 1:1. Tension-type headache affects individuals of all ages but is most common in middle life. It is seven times more common than migraine but is much less disabling. Nonetheless, because it is so common, TTH causes a societal impact equivalent to or greater than that of migraine.
2. What is meant by “primary” and “secondary” headache?
In primary headaches, the headache is the problem. In secondary headaches, the headache is symptomatic of an underlying condition such as a brain tumor.
3. What is the approach to diagnosing tension-type headache?
The steps in the diagnosis of TTH resemble the steps in the diagnosis of migraine. Secondary headache disorders are excluded based on a directed history and a careful general medical and neurologic examination. If red flags are present, a workup is required to diagnose or exclude secondary causes of headache. If no alarms are sounded by history or exam, the next step is to diagnose a specific primary headache disorder. If the patient fits neatly into a standard diagnostic category, a diagnosis is assigned and treatment is initiated. If the headache is atypical and does not meet criteria for a primary headache disorder, revisit the possibility of a secondary headache.
4. How is tension-type headache defined?
Tension-type headaches are characterized by recurrent attacks of head pain without specific associated features. To diagnose TTH, the International Headache Society requires a history of at least 10 lifetime attacks. Early in the course of TTH, however, patients will not yet have experienced that number of attacks. To make the diagnosis, two of the following four pain features should be present:
Pain on both sides of the head (bilateral pain)
Pain that is a steady ache or a pressure pain
Pain that is mild or moderate in severity
The pain of TTH is often bifrontal, bioccipital, or nuchal. It may be described as a squeezing sensation akin to wearing a hat that is too tight, as a headband of pain, or as a pressure sensation at the vertex of the head. On occasion, the pain is associated with palpation tenderness of the pericranial muscles. Headaches typically last from 30 minutes to several days, but a duration of several hours is most common.
5. What is the frequency of TTH?
TTH is the most common type of headache experienced, with a lifetime prevalence of 88% in women and 69% in men.
6. Are there different types of tension-type headache?
It is traditional to divide TTH into two broad groups: episodic and chronic. By definition, episodic attacks occur less than 15 days per month (or 180 days per year), and chronic headache occurs 15 or more days per month for at least 6 months (or 180 days per year). Otherwise, the clinical features of the attacks are quite similar. Chronic TTH affects about 3% of the population.
7. Discuss chronic tension-type headache in relation to chronic migraine
The differential diagnosis of chronic TTH includes chronic (or transformed) migraine. Although both chronic TTH and transformed migraine are characterized by frequent attacks of mild to moderate headache, these disorders are different. As the name implies, chronic migraine evolves out of episodic migraine, as headaches increase in frequency and decrease in severity, and the specific migraine features remit. Chronic TTH may arise de novo or in individuals with episodic TTH. Those with chronic migraine may have occasional episodes of full-blown migraine.
8. What is the differential diagnosis of tension-type headache?
Tension-type headache must be distinguished from other primary and secondary headache disorders. Its bilateral location, mild to moderate pain intensity, and absence of autonomic features make differentiating it from cluster headache relatively easy (see Chapter 11, Cluster Headache). Its distinction from migraine is discussed in Question 9. Underlying structural or metabolic causes must be considered in patients who have headaches resembling TTH.
Unfortunately, early in their course, brain tumors and other intracranial mass lesions tend to produce bilateral, dull headaches, which may be difficult to distinguish from TTH. Headaches resulting from brain tumors tend to progress in frequency and severity, and they are often associated with focal neurologic symptoms and signs or evidence of increased intracranial pressure (see Chapter 14, Brain Tumor Headaches). When headaches of similar profile have been present for months or years and the neurologic exam is normal, secondary headaches are unlikely.
