Tension-Type Headache -- American Family Physician

Pathophysiology Although tension-type headaches are common, the pathophysiology and likely mechanism remain unclear. Current knowledge of the nociceptive (pain receptor) system suggests that the derivative pain of tension-type headaches has a muscular origin. Muscular or myofascial pain tends to be dull and achy, poorly localized, and radiating, whereas pain originating from cutaneous structures is sharp, localized, and nonradiating. The supposition that the pain is muscular in origin and related to increased resting muscle tension corresponds with the current clinical understanding of tensiontype headache and derived treatment approaches. Controversy arises because an electromyogram (EMG) often cannot detect increased resting muscle tension in T ension-type headache, formerly called tension headache or muscle contraction headache, is a common condition usually self-treated with over-the-counter (OTC) analgesics. Prevalence rates of tension-type headaches vary among studies from 29 to 71 percent of patients examined, because of differences in research study design. Headaches are classified into two categories: primary and secondary. Primary headaches (including migraine, tensiontype, and cluster headaches) have no apparent underlying organic disease process. Secondary headaches are caused by an underlying organic disease and are a symptom of a recognized disease process. The International Headache Society’s criteria for diagnosing tension-type headache and chronic tension-type headache, and some commonly used criteria for chronic daily headache, are listed in Table 1. Tension-type headache typically causes pain that radiates in a band-like fashion bilaterally from the forehead to the occiput. Pain often radiates to the neck muscles and is described as tightness, pressure, or dull ache. Migraine-type features (unilateral, throbbing pain, nausea, photophobia) are not present. All patients with frequent or severe headaches need careful evaluation to exclude any occult serious condition that may be causing the headache. Neuroimaging is not needed in patients who have no worrisome findings on examination. Treatment of tension-type headache typically involves the use of over-the-counter analgesics. Use of pain relievers more than twice weekly places patients at risk for progression to chronic daily headache. Sedating antihistamines or antiemetics can potentiate the pain-relieving effects of standard analgesics. Analgesics combined with butalbital or opiates are often useful for tension-type pain but have an increased risk of causing chronic daily headache. Amitriptyline is the most widely researched prophylactic agent for frequent headaches. No large trials with rigorous methodologies have been conducted for most non-medication therapies. Among the commonly employed modalities are biofeedback, relaxation training, self-hypnosis, and cognitive therapy. (Am Fam Physician 2002;66:797-804,805. Copyright© 2002 American Academy of Family Physicians.) Tension-Type Headache