Tension headache
Encyclopedia
A tension headache is the most common type of primary headache
. The pain
can radiate from the neck, back, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches.
. The pain is frequently bilateral which means it is present on both sides of the head at once. Tension-type headache pain is typically mild to moderate, but may be severe.
or chronic
. Episodic tension-type headaches are defined as tension-type headaches occurring fewer than 15 days a month, whereas chronic tension headaches occur 15 days or more a month for at least 6 months. Tension-type headaches can last from minutes to days, months or even years, though a typical tension headache lasts 4–6 hours.
One half of patients with TTH identify stress or hunger as a precipitating factor.
Tension headaches may be caused by muscle tension around the head and neck. One of the theories says that the main cause for tension type headaches and migraine
is teeth clenching which causes a chronic contraction of the temporalis muscle
.
Another theory is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information, for example from the temporal muscle or other muscles, and interprets this signal as pain. One of the main neurotransmitters which is probably involved is serotonin
. Evidence for this theory comes from the fact that chronic tension-type headaches may be successfully treated with certain antidepressants such as amitriptyline
. However, the analgesic effect of amitriptyline in chronic tension-type headache is not solely due to serotonin reuptake inhibition, and likely other mechanisms are involved. Recent studies of nitric oxide
(NO) mechanisms suggest that NO may play a key role in the pathophysiology of CTTH. The sensitization of pain pathways may be caused by or associated with activation of nitric oxide synthase (NOS) and the generation of NO. Patients with chronic tension-type headache have increased muscle and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain thresholds. Hyperexcitability of central nociceptive
neurons (in trigeminal spinal nucleus, thalamus
, and cerebral cortex
) is believed to be involved in the pathophysiology of chronic tension-type headache. Recent evidence for generalized increased pain sensitivity or hyperalgesia
in CTTH strongly suggests that pain processing in the central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type headache.
s such as ibuprofen, paracetamol/acetaminophen, and aspirin. Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache. Other medications for chronic tension-type headaches include amitriptyline
mirtazapine
, topiramate
, and sodium valproate
(as prophylaxis). Biofeedback
techniques may also help.
Botulinum toxin is a treatment trialled by some people with tension-type headache, though results are varied.
, such as spinal manipulation
, soft tissue therapy
, and myofascial trigger point treatment
. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache. A 2005 structured review found that the evidence was weak for effectiveness of chiropractic
manipulation for tension headache, and that it was probably more effective for tension headache than for migraine. A 2004 Cochrane review found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache. Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.
, a South African Maxillo-Facial and Oral Surgeon, called a Posture Modifying Appliance (PMA).
.
Headache
A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...
. The pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
can radiate from the neck, back, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches.
Signs and symptoms
Tension-type headache pain is often described as a constant pressure, as if the head were being squeezed in a viseVise (tool)
A vise or vice is a mechanical screw apparatus used for holding or clamping a work piece to allow work to be performed on it with tools such as saws, planes, drills, mills, screwdrivers, sandpaper, etc. Vises usually have one fixed jaw and another, parallel, jaw which is moved towards or away from...
. The pain is frequently bilateral which means it is present on both sides of the head at once. Tension-type headache pain is typically mild to moderate, but may be severe.
Frequency and duration
Tension-type headaches can be episodicEpisodic
Episodic can refer to* The nature of television series that are divided into short programs. See Episode* Episodic memory relates to the types of memory that result from specific incidents in a lifetime...
or chronic
Chronic (medicine)
A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
. Episodic tension-type headaches are defined as tension-type headaches occurring fewer than 15 days a month, whereas chronic tension headaches occur 15 days or more a month for at least 6 months. Tension-type headaches can last from minutes to days, months or even years, though a typical tension headache lasts 4–6 hours.
Cause
Various precipitating factors may cause TTH in susceptible individuals:- Stress: usually occurs in the afternoon after long stressful work hours or after an exam
- Sleep deprivationSleep deprivationSleep deprivation is the condition of not having enough sleep; it can be either chronic or acute. A chronic sleep-restricted state can cause fatigue, daytime sleepiness, clumsiness and weight loss or weight gain. It adversely affects the brain and cognitive function. Few studies have compared the...
- Uncomfortable stressful position and/or bad posture
- Irregular meal time (hungerHungerHunger is the most commonly used term to describe the social condition of people who frequently experience the physical sensation of desiring food.-Malnutrition, famine, starvation:...
) - Eyestrain
- CaffeineCaffeineCaffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...
withdrawal - DehydrationDehydrationIn physiology and medicine, dehydration is defined as the excessive loss of body fluid. It is literally the removal of water from an object; however, in physiological terms, it entails a deficiency of fluid within an organism...
One half of patients with TTH identify stress or hunger as a precipitating factor.
Tension headaches may be caused by muscle tension around the head and neck. One of the theories says that the main cause for tension type headaches and migraine
Migraine
Migraine is a chronic neurological disorder characterized by moderate to severe headaches, and nausea...
is teeth clenching which causes a chronic contraction of the temporalis muscle
Temporalis muscle
The temporal muscle is one of the muscles of mastication.-Structure:It arises from the temporal fossa and the deep part of temporal fascia...
.
Another theory is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information, for example from the temporal muscle or other muscles, and interprets this signal as pain. One of the main neurotransmitters which is probably involved is serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
. Evidence for this theory comes from the fact that chronic tension-type headaches may be successfully treated with certain antidepressants such as amitriptyline
Amitriptyline
Amitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...
. However, the analgesic effect of amitriptyline in chronic tension-type headache is not solely due to serotonin reuptake inhibition, and likely other mechanisms are involved. Recent studies of nitric oxide
Nitric oxide
Nitric oxide, also known as nitrogen monoxide, is a diatomic molecule with chemical formula NO. It is a free radical and is an important intermediate in the chemical industry...
(NO) mechanisms suggest that NO may play a key role in the pathophysiology of CTTH. The sensitization of pain pathways may be caused by or associated with activation of nitric oxide synthase (NOS) and the generation of NO. Patients with chronic tension-type headache have increased muscle and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain thresholds. Hyperexcitability of central nociceptive
Nociception
Nociception is defined as "the neural processes of encoding and processing noxious stimuli." It is the afferent activity produced in the peripheral and central nervous system by stimuli that have the potential to damage tissue...
neurons (in trigeminal spinal nucleus, thalamus
Thalamus
The thalamus is a midline paired symmetrical structure within the brains of vertebrates, including humans. It is situated between the cerebral cortex and midbrain, both in terms of location and neurological connections...
, and cerebral cortex
Cerebral cortex
The cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different...
) is believed to be involved in the pathophysiology of chronic tension-type headache. Recent evidence for generalized increased pain sensitivity or hyperalgesia
Hyperalgesia
Hyperalgesia is an increased sensitivity to pain, which may be caused by damage to nociceptors or peripheral nerves. Temporary increased sensitivity to pain also occurs as part of sickness behavior, the evolved response to infection.-Types:...
in CTTH strongly suggests that pain processing in the central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type headache.
Prevention
Tricyclics have been found to be more effective than SSRIs but have greater side effects. Evidence is insufficient for the use of propranolol and muscle relaxants for prevention of tension headaches.Treatment
Episodic tension-type headaches generally respond well to over-the-counter analgesicAnalgesic
An analgesic is any member of the group of drugs used to relieve pain . The word analgesic derives from Greek an- and algos ....
s such as ibuprofen, paracetamol/acetaminophen, and aspirin. Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache. Other medications for chronic tension-type headaches include amitriptyline
Amitriptyline
Amitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...
mirtazapine
Mirtazapine
Mirtazapine is a tetracyclic antidepressant used primarily in the treatment of depression. It is also sometimes used as a hypnotic, antiemetic, and appetite stimulant, and for the treatment of anxiety, among other indications...
, topiramate
Topiramate
Topiramate is an anticonvulsant drug. It was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil...
, and sodium valproate
Sodium valproate
Sodium valproate or valproate sodium is the sodium salt of valproic acid and is an anticonvulsant used in the treatment of epilepsy, anorexia nervosa, panic attack, anxiety disorder, posttraumatic stress disorder, migraine and bipolar disorder, as well as other psychiatric conditions requiring...
(as prophylaxis). Biofeedback
Biofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
techniques may also help.
Botulinum toxin is a treatment trialled by some people with tension-type headache, though results are varied.
Manual therapy
People with tension-type headache often use manual therapyManual therapy
Manual therapy, manipulative therapy, or manual & manipulative therapy is a physical treatment primarily used by physiotherapists, chiropractors, osteopaths to treat musculoskeletal pain and disability; it most commonly includes massage therapy, joint mobilization and joint...
, such as spinal manipulation
Spinal manipulation
Spinal manipulation is a therapeutic intervention performed on spinal articulations which are synovial joints . These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse...
, soft tissue therapy
Soft tissue therapy
Soft tissue therapy is the assessment, treatment and management of soft tissue injury, pain and dysfunction primarily of the neuromusculoskeletal system....
, and myofascial trigger point treatment
Myofascial Release
The myofascial release approach is a form of soft tissue therapy used to treat somatic dysfunction and resulting pain and restriction of motion. It is a treatment described by Andrew Taylor Still, founder of osteopathy/osteopathic medicine, and his early students, which uses continual palpatory...
. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache. A 2005 structured review found that the evidence was weak for effectiveness of chiropractic
Chiropractic
Chiropractic is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. It is generally categorized as complementary and alternative medicine...
manipulation for tension headache, and that it was probably more effective for tension headache than for migraine. A 2004 Cochrane review found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache. Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.
Orthosis
Tension-type headaches respond very well to treatment with intra-oral appliances such as bite splints to prevent grinding. Good results have also been reported with a device designed by Elliot ShevelElliot Shevel
Elliot Shevel BDS, DipMFOS, MBBCh is a South African Maxillo-Facial and Oral Surgeon, best known for his contribution to understanding of the underlying processes involved in the pain of migraine. He is, inter alia, a tireless campaigner to have the work of Harold Wolff, which many migraine...
, a South African Maxillo-Facial and Oral Surgeon, called a Posture Modifying Appliance (PMA).
Prognosis
Tension headaches that do not occur as a symptom of another condition may be painful, but are not harmful. It is usually possible to receive relief through treatment. Tension headaches that occur as a symptom of another condition are usually relieved when the underlying condition is treated. Frequent use of pain medications in patients with tension-type headache may lead to the development of medication overuse headache or rebound headacheRebound headache
Medication overuse headaches , also known as rebound headaches usually occur when analgesics are taken frequently to relieve headaches. Rebound headaches frequently occur daily and can be very painful and are a common cause of chronic daily headache...
.