Tension headache

According to the third edition of the International Classification of Headache Disorders, the attacks must meet the following criteria: • A duration of between 30 minutes and 7 days. • At least two of the following four characteristics: • bilateral location • pressing or tightening (non-pulsating) quality • mild or moderate intensity • not aggravated by routine physical activity such as walking or climbing stairs • Both of the following: • no nausea or vomiting • no more than one of photophobia (sensitivity to bright light) or phonophobia (sensitivity to loud sounds) Tension-type headaches may be accompanied by tenderness of the scalp on manual pressure during an attack. == Risk factors ==

Various precipitating factors may cause tension-type headaches in susceptible individuals: • Anxiety • Stress • Sleep problems • Young age • Poor health == Mechanism ==

Although the musculature of the head and neck and psychological factors such as stress may play a role in the overall pathophysiology of TTH, neither is currently believed to be the sole cause of the development of TTH. Peripheral pain pathways receive pain signals from pericranial (around the head) myofascial tissue (protective tissue of muscles) and alteration of this pathway likely underlies episodic tension-type headache (ETTH). Additionally, CTTH patients exhibit decreased thermal and pain thresholds which further bolsters support for central sensitization occurring in CTTH. Synapses Regarding synaptic level changes, homosynaptic facilitation and heterosynaptic facilitation are both likely to be involved in central sensitization. Homosynaptic facilitation occurs when synapses normally involved in pain pathways undergo changes involving receptors on the post-synaptic membrane as well as the molecular pathways activated upon synaptic transmission. Lower pain thresholds of CTTH result from this homosynaptic facilitation. In contrast, heterosynaptic facilitation occurs when synapses not normally involved in pain pathways become involved. Once this occurs innocuous signals are interpreted as painful signals. Allodynia and hyperalgesia of CTTH represent this heterosynaptic facilitation clinically. Stress In the literature, stress is mentioned as a factor and may be implicated via the adrenal axis. This ultimately results in downstream activation of NMDA receptor activation, NFκB activation, and upregulation of iNOS with subsequent production of NO leading to pain as described above. == Diagnosis ==

With TTH, the physical exam is expected to be normal with perhaps the exception of either pericranial tenderness upon palpation of the cranial muscles, or presence of either photophobia or phonophobia. Classification The International Headache Society's most current classification system for headache disorders is the International Classification of Headache Disorders 3rd edition (ICHD-3) as of 2018. This classification system separates tension-type headache (TTH) into two main groups: episodic (ETTH) and chronic (CTTH). CTTH is defined as fifteen days or more per month with headache for greater than three months, or one-hundred eighty days or more, with headache per year. ETTH is less than fifteen days per month with headache or less than one-hundred eighty days with headache per year. However, ETTH is further sub-divided into frequent and infrequent TTH. Frequent TTH is defined as ten or more episodes of headache over the course of one to fourteen days per month for greater than three months, or at least twelve days per year, but less than one-hundred eighty days per year. Differential diagnosis Extensive testing is not needed as TTH is diagnosed by history and physical examination. However, if symptoms indicative of a more serious diagnosis are present, a contrast enhanced MRI may be utilized. Furthermore, giant cell arteritis should be considered in those 50 years of age and beyond. Screening for giant cell arteritis involves the blood tests of erythrocyte sedimentation rate (ESR) and c-reactive protein. • Migraine • Oromandibular dysfunction • Sinus disease • Eye disease • Cervical spine disease • Infection in immunocompromised • Intracranial mass • Idiopathic intracranial hypertension • Medication overuse headache • Secondary headache (headache due to other disorder) • Giant cell arteritis (≥50 years of age) • Dermatochalasis ==Prevention==

Lifestyle Good posture might prevent headaches if there is neck pain. People who have jaw clenching might develop headaches, and getting treatment from a dentist might prevent those headaches. Medications People who have 15 or more headaches in a month may be treated with certain types of daily antidepressants which act to prevent continued tension headaches from occurring. Tricyclic antidepressants appear to be useful for prevention. Tricyclic antidepressants have been found to be more effective than SSRIs but have greater side effects. Evidence is poor for the use of SSRIs, propranolol, and muscle relaxants for prevention of tension headaches. == Treatment ==

Treatment for a current tension headache is to drink water and confirm that there is no dehydration. Medications Episodic Over-the-counter drugs, like paracetamol, or NSAIDs (ibuprofen, aspirin, naproxen, ketoprofen), can be effective but tend to only be helpful as a treatment for a few times in a week at most. Chronic Classes of medications involved in treatment of CTTH include tricyclic antidepressants (TCAs), SSRIs, benzodiazepine (Clonazepam in small evening dose), and muscle relaxants. The most commonly utilized TCA is amitriptyline due to the postulated role in decreasing central sensitization and analgesic relief. Another popular TCA used is Doxepine. SSRIs may also be utilized for management of CTTH. For patients with concurrent muscle spasm and CTTH, the muscle relaxant Tizanidine can be a helpful option. People with tension-type headache often use spinal manipulation, soft tissue therapy, and myofascial trigger point treatment. Studies of effectiveness are mixed. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache. A 2005 structured review found only weak evidence for the effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine. Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation. A 2012 systematic review of manual therapy found that hands-on work may reduce both the frequency and the intensity of chronic tension-type headaches. More current literature also appears to be mixed however, CTTH patients may benefit from massage and physiotherapy as suggested by a systemic review examining these modalities via RCTs specifically for this patient population Despite being helpful, the review also makes a point to note that there is no difference in effectiveness long term (6 months) between those CTTH patients utilizing TCAs and physiotherapy. ==Epidemiology==

As of 2016 tension headaches affect about 1.89 billion people Despite its benign character, tension-type headache, especially in its chronic form, can impart significant disability on patients as well as burden on society at large. == References ==