What are tension headaches?

From the Guidelines

Tension headaches are a type of primary headache disorder characterized by recurrent episodes of headache, typically with a pressing or tightening quality, and are often associated with muscle tension and stress.

Key Characteristics of Tension Headaches

• They are the most common primary headache disorder, with a global prevalence of 26% [ 1 ]
• The goals of abortive and preventive treatment of tension-type headaches (TTH) are similar to those of migraine, including rapid and sustained alleviation of pain and restoration of function [ 1 ]
• Critical TTH outcomes include time to pain freedom and headache intensity 2 hours after treatment for studies related to abortive management, and reduction in headache days from baseline and change in the number of moderate or severe headache days for studies focusing on prevention [ 1 ]

Treatment Options for Tension Headaches

• Ibuprofen (400 mg) or acetaminophen (1000 mg) are suggested for the treatment of acute TTH, as they demonstrate statistically significant improvement in pain-free response at 2 hours [ 1 ]
• Amitriptyline at 50 mg and 100 mg is recommended for preventive treatment of chronic TTH, as it significantly reduces monthly headache days [ 1 ]
• Physical therapy or aerobic exercise can be used in the management of TTH, as they have been shown to reduce headache frequency and intensity [ 1 ]

Non-Pharmacologic Therapies for Tension Headaches

• Rehabilitation interventions, such as physical therapy, have been shown to be beneficial in the management of TTH [ 1 ]
• Aerobic exercise or progressive strength training has been recommended for the prevention of TTH, as it can help reduce headache frequency and intensity [ 1 ]
• Neuromodulation, such as non-invasive brain stimulation, may be considered for the treatment of TTH, although the evidence is limited [ 1 ]

From the Research

Definition and Prevalence of Tension Headaches

• Tension-type headache (TTH) is the most common form of primary headache in the general population 2
• It is estimated to have a prevalence of up to 78% in the general population 3
• TTH is characterized as a bilateral headache of mild-to-moderate intensity, with associated symptoms that are less intense than those observed in migraine 4

Pathophysiology of Tension Headaches

• The pathogenesis of TTH is multifactorial and varies between forms and individuals 5
• Both peripheral and central sensitization mechanisms seem to be involved in the process 6
• Peripheral mechanisms (myofascial nociception) and central mechanisms (sensitisation and inadequate endogenous pain control) are intermingled 5
• The role of associated muscle hyperalgesia seems to be an important factor in TTH 6

Clinical Features and Diagnosis of Tension Headaches

• Clinical features of TTH resemble common manifestations of muscle referred pain 6
• Episodic TTH may evolve into the chronic form by different aspects and several triggers may be involved at the same time 6
• The typical features and differential diagnosis of TTH are highlighted, and situations more likely to raise doubts are discussed 2
• A structured approach to the patient and a better comprehension of the very frequent coexistence of migraine and medication overuse headache in the clinical population are emphasized 2

Treatment and Management of Tension Headaches

• Therapeutic management of individuals with TTH should be multimodal, including appropriate use of pharmacological and non-pharmacological interventions to reduce the nociceptive peripheral drive to the central nervous system 6
• Simple analgesics are used for the acute treatment of the condition, and tricyclic antidepressants are the most effective class of drugs for its prevention 4
• The combination of drug therapies and non-drug therapies (such as relaxation and stress management techniques or physical therapies) is recommended for most patients with chronic TTH 5
• Strategies based solely on symptomatic drugs should be avoided, and treatment should aim at taking charge of the patient considering the processes behind this complex pathology 3