History and exam
Key diagnostic factors
common
generalized head pain
Attacks are generalized throughout the head; often the pain is bilateral, pressure-like, and nonthrobbing.
frontal or occipital head pain
Pain is often in these regions.
nonpulsatile head pain
Often described as dull pain.
constricting pain
Pain described as tight band around head.
normal neurologic examination
Abnormal neurologic examination should prompt investigation for possible causes of secondary headaches.
Other diagnostic factors
common
pericranial tenderness
Presence of tenderness not essential for diagnosis.
sternocleidomastoid muscle tenderness
Presence of tenderness not essential for diagnosis.
trapezius muscle tenderness
Presence of tenderness not essential for diagnosis.
temporalis muscle tenderness
Presence of tenderness not essential for diagnosis.
lateral pterygoid muscle tenderness
Presence of tenderness not essential for diagnosis.
masseter muscle tenderness
Presence of tenderness not essential for diagnosis.
uncommon
photophobia or phonophobia
Only one of the following may be seen: photophobia or phonophobia. Vomiting or moderate/severe nausea excludes the diagnosis.
nausea
Mild nausea may be experienced.
regular analgesic use
Medication overuse often underlies the transformation from the episodic to the chronic form. This is often due to the "medication-overuse syndrome" (also termed "analgesic rebound") in which the analgesics cease to provide pain relief and actually perpetuate and intensify the headaches. Withdrawal of the analgesic also causes the headache to worsen in the short term. The mechanism of this effect is poorly understood.
anxiety and depression
Often comorbid with episodic tension-type headache attacks.
somatization
Often comorbid with episodic tension-type headache attacks.
Risk factors
strong
mental tension
Stress and mental tension are reported to be the most common precipitants for tension-type headache.[15]
stress
Stress and mental tension are reported to be the most common precipitants for tension-type headache.[15]
missing meals
Aggravating factor.
fatigue
Aggravating factor.
lack of sleep
Aggravating factor.
weak
somatization
Often comorbid with episodic tension-type headache attacks.
female sex
Female preponderance (around 1.2:1).[3]
age 20-39 years
The onset of tension-type headaches is generally between 20 to 30 years of age, with prevalence peaking between the ages of 20 to 39 years and then declining.[3]
lower socioeconomic status
There is a higher prevalence of chronic tension-type headache in less educated and poorer populations.[16] This does not necessarily represent causation, but it might indicate that poor work performance due to chronic tension-type headache contributes to a downward socioeconomic drift, or increased stress linked to economic hardship and working conditions.[16]
analgesic overuse
Overuse of analgesic medications often underlies the transformation from the episodic to the chronic form.
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