Definition and Overview
Tension-type headache (TTH) is the most common type of primary headache as defined by the International Classification of Headache Disorders (ICHD-3). The nature of the headache is a feeling of pressure or tightness, without a throbbing sensation, and is usually bilateral. Even if there is hypersensitivity to light or sound, it is limited to one type and is not accompanied by nausea or vomiting.
Worldwide, the one-year prevalence of tension-type headache is reported to be approximately 38.3%, and the lifetime prevalence is reported to be over 78%. Women (approximately 86%) have a higher lifetime prevalence rate than men (approximately 63%).
Diagnostic criteria (ICHD-3)
Episodic tension headache (episodic TTH):
1. Duration: 30 minutes to 7 days 2. At least 2 of the following 4: - bilateral - Compressive or constricting (non-pulsatile) appearance - Mild to moderate intensity - Does not worsen with daily activities (walking, climbing stairs) 3. Both meet: - No nausea or vomiting - Either light sensitivity or sound sensitivity is allowed (but not both)
Subclassification according to frequency of occurrence: - Low-frequency episodes: less than once a month (less than 12 times a year) - High frequency episodes: 1 to 14 days per month - Chronic: more than 15 days per month, more than 3 months
Causes and Mechanisms
The mechanism of tension headache involves a combination of peripheral and central mechanisms.
Peripheral mechanisms (episodic TTH)
Continuous tension in the scalp, neck, and shoulder muscles and fascia creates trigger points within the fascia. From this trigger point, pain signals through A-delta and C fibers are transmitted to the trigeminal nervous system. Poor posture, prolonged fixed posture (computer work), and muscle tension around the neck are direct causes.
Central mechanism (chronic TTH)
In chronic tension headache, central sensitization of central pain processing acts as a major mechanism. Due to a decrease in the function of the pain suppression system, stimuli that would not normally be felt as pain are perceived as pain. Even increased pericranial muscle contraction is processed as more intense pain in a state of central sensitization.
trigger factor
- Psychological: mental stress, anxiety, depression, tension
- Physical: sleep deprivation or oversleeping, poor posture, prolonged fixed posture, physical fatigue.
- Environment: Consumption or withdrawal of caffeine, dehydration, bright light, noise, strong odors, changes in weather.
symptoms
nature of pain
The pain of tension headaches is described as follows:
- Bilateral: Feels like it covers the entire forehead, temples, and back of the head.
- Pressure, tightness: It feels like something is being tightened by a belt or helmet, or something heavy is being placed on it.
- No pulsation: There is no throbbing in sync with the heartbeat.
- Mild to moderate: Not severe enough to completely interfere with daily activities.
accompanying symptoms
- Stiffness and tenderness of the scalp, neck, and shoulder muscles
- poor concentration
- Sensitivity to light or sound (may be only one)
- decreased appetite
treatment
acute care
In the acute phase of episodic tension-type headache, nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen, aspirin) or paracetamol (acetaminophen) are the first-line drugs. Caffeine enhances the analgesic effect, but be careful not to overuse it because there is a risk of caffeine overdose and withdrawal headaches.
Non-pharmacological acute care
- Relaxation training and deep breathing
- Cervical and scalp massage
- neck and shoulder stretches
- Warm compress (relieves muscle tension)
- drink enough water
preventive care
Preventive treatment is recommended for chronic tension headaches (more than 15 days per month).
Drug prevention: - Amitriptyline (tricyclic antidepressant) 10 to 75 mg/day is the primary preventive drug with the strongest evidence. - Mirtazapine and venlafaxine have also been reported to be effective.
Non-pharmacological prevention: - Relaxation training and biofeedback: Electromyography biofeedback is effective in reducing headache frequency and intensity. - Cognitive behavioral therapy: Trains stress management and pain coping strategies. - Physical therapy: Treatment of cervical spine dysfunction and myofascial pain trigger points. - Transcranial magnetic stimulation (TMS): It is being studied as an adjunctive treatment to stimulate central pain inhibition circuits in chronic tension headaches.
Medication Overuse Headache Management
If you take painkillers more than 10 to 15 days a month, medication overuse headaches may occur. In this case, despite short-term withdrawal symptoms, cessation of the overused drug is essential and should be done under the guidance of a specialist.
Progress and prognosis
According to a follow-up study, in about 45% of patients with tension headaches, headaches disappeared or decreased to a low frequency after 10 years, but persisted in about 39%. Excessive use of headache medication, sleep disorders, and anxiety/depression are known as risk factors for transition to chronic disease.
life management
- Headache diary: Record the date of headache occurrence, duration, intensity, triggers, and medications taken to identify triggers.
- Sleep regularly: Go to bed and wake up at the same time every day. Changes in sleep patterns on weekends can also cause headaches.
- Regular meals: Do not skip meals. Low blood sugar is a common trigger for headaches.
- Water intake: Drink 1.5 to 2 liters of water per day. Dehydration makes headaches worse.
- Correct your posture: When working on a computer, adjust the height of your monitor and chair, and stretch every hour.
- Exercise: Aerobic exercise 3-5 times a week helps reduce headache frequency.