Clinical Review

Tension-type headache

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39412.705868.AD (Published 10 January 2008) Cite this as: BMJ 2008;336:88
  1. Elizabeth Loder, chief1,
  2. Paul Rizzoli, director 2
  1. 1Division of Headache and Pain, Department of Neurology, Brigham and Women’s/Faulkner Hospitals, Harvard Medical School, Boston, MA, USA
  2. 2Graham Headache Center, Faulkner Hospital, Boston, MA, USA
  1. Correspondence to: Dr E Loder, 1153 Centre Street, #4970, Boston, MA 02130, USA eloder{at}partners.org

    Summary points

    • Episodic tension-type headache is the most common cause of headache in the general population and is usually self managed

    • Chronic tension-type headache may be highly disabling and often prompts medical consultation

    • Diagnosis is clinical, based on widely accepted and validated criteria

    • Peripheral factors are implicated in episodic tension-type headache, whereas central factors probably underlie chronic tension-type headache

    • Simple analgesics, especially aspirin, are used for acute treatment

    • Amitriptyline and biofeedback assisted relaxation training have the best evidence of effectiveness for headache prevention

    Tension-type headache is a neurological disorder characterised by a predisposition to attacks of mild to moderate headache with few associated symptoms. The diagnosis is based on the history and examination. Over the past few decades research on headache has centred on migraine, and much of the best quality evidence for the treatment of tension-type headache is decades old. Some consensus based treatment guidelines are available (see Additional Educational Resources box towards the end of this article). Treatment has changed little over the past two decades. Many patients self treat acute attacks and seek advice when attacks become frequent or chronic. This review focuses on how to identify and manage patients who require medical advice about acute attacks and preventive treatment to minimise further attacks.

    What is tension-type headache?

    Box 1 summarises the criteria for tension-type headache outlined in the second revision of the international classification of headache disorders, in which such headache is classified according to whether it is episodic or chronic and whether muscle tenderness is present.1

    Box 1 Diagnostic criteria for tension-type headache*

    • (A) At least 10 episodes fulfilling the criteria B-D:

    • (B) Headache lasting from 30 minutes to 7 days

    • (C) Headache has at least two of the following characteristics:

      • Bilateral location

      • Pressing/tightening (non-pulsating) quality

      • Mild or moderate intensity

      • Not aggravated by routine physical activity such as walking or climbing stairs

    • (D) Both of the following: …

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