Tension-Type Headache: The Essentials

Most people will have a Headache of some kind at some point. The most common of all Headache disorders is Tension-Type Headache (TTH). A World Health Organization (WHO) report estimates that more than 70 percent of the population experiences TTH at some point.¹ Given its enormous prevalence, TTH has a very strong socio-economic impact. The International Headache Society’s International Classification of Headache Disorders, 3rd Edition (ICHD-3), describes TTH as:

“Infrequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, but photophobia or phonophobia may be present.”²

Tension-Type Headache has been called by other names in the past, including:

• tension headache,
• muscle contraction headache,
• psychogenic headache,
• stress headache,
• ordinary headache, essential headache,
• idiopathic headache,
• and psychogenic headache.

TTH was previously considered to be primarily psychogenic, meaning that it was thought to be caused by mental or emotional conflict. Since that time, studies have established that it has a neurobiological basis. This has improved available treatment and decreased social stigma.

As with Migraine, the exact mechanisms of TTH are not yet fully understood. It’s considered likely that peripheral pain mechanisms play a role. The most significant symptom in patients with TTH is increased pericranial (around the head and neck) tenderness discovered by manual palpation. The tenderness is typically present interictally, is further increased during actual Headache, and increases with the intensity and frequency of Headaches. Pericranial tenderness is easily identified by manual palpation by small rotating movements and a firm pressure.

Characteristics of Tension-Type Headache:

• Lasts from 30 minutes to seven days.
• Is usually bilateral.
• Pain has a pressing or tightening quality, non pulsing. Often described as a vice or band around the head.
• Mild or moderate in intensity.
• Not worsened by routine activity such as walking, bending, or climbing stairs.
• Not accompanied by nausea or vomiting.
• May be accompanied by phonophobia or photophobia, but not both.

ICHD-3 Information on TTH:

For those of us who like all the details, here are the descriptions and diagnostic criteria for TTH from the ICHD-3.

2. Tension-type headache (TTH)

2.1 Infrequent episodic tension-type headache

Description:

Infrequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, but photophobia or phonophobia may be present.

Diagnostic criteria:

1. At least 10 episodes of headache occurring on <1 day per month on average (<12 days per year) and fulfilling criteria B-D
2. Lasting from 30 minutes to 7 days
3. At least two of the following four characteristics:
   1. bilateral location
   2. pressing or tightening (non-pulsating) quality
   3. mild or moderate intensity
   4. not aggravated by routine physical activity such as walking or climbing stairs
4. Both of the following:
   1. no nausea or vomiting
   2. no more than one of photophobia or phonophobia
5. Not better accounted for by another ICHD-3 diagnosis.

2.1.1 Infrequent episodic tension-type headache associated with pericranial tenderness

Diagnostic criteria:

1. Episodes fulfilling criteria for 2.1 Infrequent episodic tension-type headache
2. Increased pericranial tenderness on manual palpation.

2.1.2 Infrequent episodic tension-type headache not associated with pericranial tenderness

Diagnostic criteria:

1. Episodes fulfilling criteria for 2.1 Infrequent episodic tension-type headache
2. No increase in pericranial tenderness.

2.2 Frequent episodic tension-type headache

Description:

Frequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, but photophobia or phonophobia may be present.

Diagnostic criteria:

1. At least 10 episodes of headache occurring on 1-14 days per month on average for >3 months (>12 and <180 days per year) and fulfilling criteria B-D
2. Lasting from 30 minutes to 7 days
3. At least two of the following four characteristics:
   1. bilateral location
   2. pressing or tightening (non-pulsating) quality

2.3 Chronic tension-type headache

Description:

A disorder evolving from frequent episodic tension-type headache, with daily or very frequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting hours to days, or unremitting. The pain does not worsen with routine physical activity, but may be associated with mild nausea, photophobia or phonophobia.

Diagnostic criteria:

1. Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year), fulfilling criteria B-D
2. Lasting hours to days, or unremitting
3. At least two of the following four characteristics:
   1. bilateral location
   2. pressing or tightening (non-pulsating) quality
   3. mild or moderate intensity
   4. not aggravated by routine physical activity such as walking or climbing stairs
4. Both of the following:
   1. no more than one of photophobia, phonophobia or mild nausea
   2. neither moderate or severe nausea nor vomiting
5. Not better accounted for by another ICHD-3 diagnosis

2.3.1 Chronic tension-type headache associated with pericranial tenderness

Diagnostic criteria:

1. Headache fulfilling criteria for 2.3 Chronic tension-type headache
2. Increased pericranial tenderness on manual palpation.

2.3.2 Chronic tension-type headache not associated with pericranial tenderness

Diagnostic criteria:

1. Headache fulfilling criteria for 2.3 Chronic tension-type headache
2. No increase in pericranial tenderness.

Summary, Comments, and Implications for Patients:

Affecting more than 70% of the population at some point in our lives, Tension-Type Headache is the most common of all Headache disorders. Unlike Migraine:

• It’s usually bilateral.
• It’s not accompanied by nausea or vomiting.
• It may be accompanied by phonophobia or photophobia, but not both.
• It’s not worsened by routine physical activity.

That said, a Tension-Type Headache can trigger a migraine attack. By breaking TTH into subtypes, the International Headache Society’s criteria help doctors and patients alike more completely define our diagnosis, which makes appropriate and effective treatment more likely.

Sources:

• World Health Organization. Lifting the Burden. “Atlas of headache disorders and resources in the world 2011.” WHO Press. 2011.
• Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd Edition (ICHD-3). Cephalalgia, Volume: 38 issue: 1, page(s): 1-211.