Tension-Type Headache: Episodic and Chronic Forms

What defines tension-type headache

The International Classification of Headache Disorders, 3rd edition (ICHD-3), sets out the criteria. Headaches last 30 minutes to 7 days (or are continuous in chronic TTH) and have at least two of these features:

1. both sides of the head
2. pressing or tightening, not pulsating
3. mild or moderate intensity
4. not aggravated by routine activity such as walking or climbing stairs

And both of these:

• no nausea or vomiting (chronic TTH allows mild nausea)
• no more than one of light sensitivity or sound sensitivity

The headache must not be better explained by another diagnosis.

For everyday advice on what it feels like and fast relief, see tension headache symptoms. For an overview of causes and triggers, see tension headache.

Episodic vs chronic tension-type headache

Each subtype is further described as "with" or "without pericranial tenderness", meaning tenderness of the scalp and neck muscles when a doctor presses on them. Tenderness is more common in frequent and chronic forms.

Probable tension-type headache

When a headache meets all but one criterion and does not fit another type, it is labeled "probable" TTH. Many people with mild migraine features fall into this group.

Why some people develop chronic TTH

Frequent pain signals from tight, tender muscles can sensitize the central nervous system. Over time, the brain's pain-dampening systems work less well, so headaches become more frequent and are felt with less provocation. Factors linked to the transition from episodic to chronic include:

• medication overuse
• poor sleep and sleep disorders
• anxiety and depression
• ongoing stress
• obesity and physical inactivity
• other pain conditions such as fibromyalgia

Diagnosis

Diagnosis is clinical. A doctor will take a detailed headache history and do a general and neurological examination, including the back of the eyes. A 4 to 8 week headache diary records headache days, intensity, triggers and medicines.

Important distinctions:

• Chronic migraine: many people with chronic daily headache have chronic migraine, where at least 8 headache days a month have migraine features. It responds to different preventive treatments.
• Medication-overuse headache: suspected when simple pain relievers are taken on 15 or more days a month, or triptans, combination analgesics or opioids on 10 or more days.
• New daily persistent headache: daily from a clearly remembered start.
• Secondary causes: sleep apnea, raised intracranial pressure, cervical spine disorders, medication side effects.

Imaging is reserved for atypical features or red flags.

Treatment of chronic and frequent TTH

Withdraw overused medicines

If medication overuse is present, stopping or limiting the overused drug is the first step. Headaches may worsen for 1 to 2 weeks before improving. Doctors sometimes start preventive treatment at the same time.

Preventive medicines

• Amitriptyline is first-line, started at a low dose at night and increased gradually. Side effects include drowsiness, dry mouth and weight gain.
• Mirtazapine and venlafaxine are second-line options.
• A trial of at least 2 to 3 months at an adequate dose is needed to judge effect.
• Muscle relaxants have little evidence. Botulinum toxin is not effective for TTH (unlike chronic migraine).

Non-drug treatments

• Cognitive behavioral therapy and relaxation training
• EMG biofeedback, which teaches control of muscle tension
• Physical therapy: posture correction, neck and shoulder strengthening, and stretching
• Regular aerobic exercise
• Acupuncture for some people
• Sleep improvement, including treating insomnia and sleep apnea

Acute treatment rules

Use simple analgesics such as ibuprofen, naproxen, aspirin or acetaminophen for individual headaches, but keep them to fewer than 10 to 15 days a month. Avoid opioids and butalbital.

Outlook

Episodic TTH has a good outlook. Chronic TTH tends to persist longer, but many people improve over a few years, especially with prevention, avoidance of medication overuse, and treatment of sleep and mood problems. Long-term follow-up studies show a substantial proportion of people with chronic TTH move back to episodic patterns.

Frequently asked questions

What is the difference between episodic and chronic tension-type headache?

Episodic tension-type headache occurs on fewer than 15 days a month, while chronic tension-type headache occurs on 15 or more days a month for more than 3 months. Chronic forms are linked to central pain sensitization, medication overuse, sleep and mood problems, and need preventive treatment.

What is the best treatment for chronic tension-type headache?

Low-dose amitriptyline is the best-studied preventive medicine. Combining it with cognitive behavioral therapy, relaxation or biofeedback, physical therapy, regular exercise and limiting acute pain relievers gives the best results. Treating sleep and mood problems also helps.

How many pain relievers per month is too many for headaches?

Simple pain relievers on 15 or more days a month, or combination analgesics and triptans on 10 or more days, can cause medication-overuse headache. A safer target is no more than 2 to 3 days a week. A headache diary helps track this.

Can tension-type headache turn into migraine?

They are separate conditions, but they often coexist, and people with migraine frequently also have tension-type headaches. Headaches can also be misclassified. If headaches throb, worsen with activity or bring nausea, ask your doctor whether migraine is part of the picture.