Approach
Tension-type headache (TTH) can present in any sex or age group, but is more common in females and in middle age.[3] It is diagnosed on the basis of headache history and the exclusion of other disorders that may mimic TTH.[3]
History
Patient history may include stress, missed meals, lack of sleep, fatigue, depression, and previous TTH. Overuse of analgesic medication often underlies the transformation from the episodic to the chronic form.
Clinical features
The pain is usually bilateral, nonthrobbing, and described as pressing or pressure-like. A typical description of TTH is the sensation of a tightening band around the head.[3] It is not typically associated with any significant autonomic symptoms.[1] Symptoms are often described as dull and nonpulsatile, of variable intensity, but not severe and are rarely disabling. They classically worsen as the day progresses. The frontal and occipital regions are more commonly affected. Symptoms such as photophobia, phonophobia, or mild nausea may be experienced, but no more than one of these during each episode. Moderate or severe nausea or vomiting excludes the diagnosis of TTH. Unlike migraine, symptoms of TTH are not aggravated by physical activity.
Headache diaries are a useful assessment tool for TTH and can be used to aid diagnosis and guide clinical decision-making. They allow patients to report clinical headache features (such as frequency, onset, duration, and characteristics) and accompanying symptoms.[3]
Differential consideration
A wide range of primary and secondary headache disorders can mimic TTH and need to be excluded. These include migraine, temporomandibular joint dysfunction, significant cervical pathology, giant cell arteritis in older patients, sinusitis (rarely), medication overuse in chronic headaches, pituitary tumors and other brain tumors, chronic subdural hematoma, idiopathic intracranial hypertension, spontaneous intracranial hypotension, and sleep apnea.[3] Careful exclusion of these disorders relies on a thorough review of medical history and adequate physical exam. Further diagnostic tests might be required if a patient has red flags that are suggestive of secondary headache causes. These may include neuroimaging, lumbar puncture, or polysomnography. Systematic testing of all patients with TTH (e.g., neuroimaging) should be avoided and does not appear to improve quality of life or mitigate health concerns in the long term.[3][17]
Because TTH is often misdiagnosed as migraine, and mild migraines are often misdiagnosed as TTH, special consideration should be given to this differential diagnosis. The International Classification of Headache Disorders-3 (ICHD-3) diagnostic criteria for TTH include the absence of several associated symptoms that are present in migraine and distinguish the two conditions.[1] In particular, osmophobia (defined as a fear, aversion, or psychological hypersensitivity to odors) is seen in migraine but rarely in TTH.[18] It should be noted that migraine sufferers can also experience TTH; in fact, patients with migraine have coexisting TTH with a similar prevalence to that seen in the general nonmigraine population. Differentiating migraine from chronic TTH can be difficult, as chronic TTH often manifests with more severe headaches (of at least moderate pain intensity) than episodic TTH, comparable to those seen in patients with migraine.[3]
Physical examination
Physical examination should be carried out in all patients with suspected TTH. Pericranial tenderness may be noted on examination. Specific muscles that are commonly tender include sternocleidomastoid, trapezius, temporalis, lateral pterygoid, and masseter; however, the presence of tenderness is not essential for diagnosis.
Neurologic examination
Neurologic examination, including assessment of mental status, cranial nerves (including fundoscopy), motor and sensory function, balance and coordination, reflexes, and gait, should be normal.[3] An abnormal neurologic examination should prompt an investigation for possible causes of secondary headaches. These include causes of elevated intracranial pressure (idiopathic intracranial hypertension, brain tumor, hypertensive encephalopathy, acute hydrocephalus), a bleed (cerebrovascular incident, pituitary apoplexy, venous sinus thrombosis, epidural hematoma, subarachnoid hemorrhage, subdural hematoma, giant cell arteritis), infections (meningitis, brain abscess), or trauma. If the exam reveals papilledema (suggestive of an intracranial mass lesion), reflex asymmetry, sensory asymmetry, or motor weakness, brain imaging is required.
Laboratory/imaging
Imaging and laboratory studies do not aid in the diagnosis of TTH.[19] For patients with no red flags and a normal neurologic examination, do not request imaging for patients with a primary headache.[17][20]
CT of sinuses, MRI of brain, and lumbar puncture, or polysomnography can be useful to exclude other headache disorders and should be considered in refractory or progressive cases.[3]
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