Tension headache - Symptoms

Factors of headache chronicity

An important role in the formation of a chronic pain pattern (i.e. in the transformation of episodic cephalgias into chronic ones) in both tension headaches and migraines is played by so-called chronicity factors.

Among the mental factors that predispose to chronic pain, depression ranks first. A frequent mechanism for the formation of chronic stress and depression can be the accumulation of traumatic life events, when the patient is faced with problems that are insoluble for him.

It has also been shown that specific personality characteristics and the patient's choice of imperfect behavioral strategies for coping with pain also play an important role in the transformation of episodic cephalgia into chronic and its persistence.

The second most important factor of chronicity is drug abuse, i.e. excessive use of symptomatic painkillers. In Europe, more than 70% of patients with chronic daily headaches abuse analgesics, ergotamine derivatives, and combination drugs that include analgesics, sedatives, caffeine- and codeine-containing components. It has been shown that in patients who consume large amounts of analgesics, the chronic type of pain develops twice as fast and that drug abuse significantly complicates the treatment of patients with chronic daily headaches. Therefore, the most important condition that guarantees the effectiveness of preventive therapy is the withdrawal of the drug that caused the abuse.

The muscular factor, which has already been mentioned, also contributes to the chronic course of cephalgic syndromes. Emotional stress and mental disorders (depression and anxiety), which are obligatory for patients with chronic forms of headache, in turn, maintain muscular tension, leading to the persistence of pain.

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Symptoms and diagnostic criteria of tension headache

Patients with tension headaches typically describe it as diffuse, mild to moderate, often bilateral, non-pulsating, and squeezing like a "hoop" or "helmet". The pain does not increase with normal physical activity, and is rarely accompanied by nausea, although photo- or phonophobia is possible. The pain usually appears soon after waking up, is present throughout the day, sometimes increasing, sometimes decreasing.

As already noted, the main difference between episodic tension headache and chronic headache is the number of days with headache during the month. The other clinical manifestations of both forms are similar.

Diagnostic criteria for tension headache (ICHD-2, 2004)

• Headache lasting from 30 minutes to 7 days.
• At least two of the following:
  • bilateral localization;
  • pressing/squeezing/non-pulsating character;
  • light to moderate intensity;
  • the pain does not increase with normal physical activity (walking, climbing stairs).
• Both of the following:
  • there is no nausea or vomiting (anorexia may occur);
  • only one of the symptoms: photo- or phonophobia.
• The headache is not associated with other disorders.

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Additional diagnostic features of tension headache

• A "hoop" or "helmet" type of pain pattern.
• Mild to moderate intensity (up to 6 points on the visual analogue pain scale).
• Pain relief with positive emotions and in a state of psychological relaxation.
• Increased pain due to emotional experiences.

Along with cephalgia, most patients with tension headaches complain of transient or constant pain or a feeling of tension and discomfort in the back of the head, the back of the neck and the shoulders (the "coat hanger" syndrome). Therefore, an important element of examining a patient with tension headaches is the examination of the pericranial muscles, especially since other neurological manifestations are usually not detected in these patients.

It has been shown that of the three diagnostic techniques: conventional palpation, EMG with surface electrodes, and algometry, only the palpation method is the most sensitive for detecting pericranial muscle dysfunction in patients with tension headache and migraine. Therefore, in ICHD-2, only the palpation method is proposed for differential diagnostics of tension headache subtypes with and without muscle tension. Complaints of pain and tension in the neck and back of the head muscles (a clinical reflection of pericranial muscle dysfunction) increase with the increase in the intensity and frequency of headache episodes, as well as with the increase in the strength of pain during the episode itself. It has been shown that the pathogenesis of chronic muscular-tonic pain syndrome is based on a vicious circle mechanism, when the resulting muscle tension causes overexcitation of spinal neurons, postural disturbances, and an even greater increase in pain. A special role is given to the trigeminocervical system.

Dysfunction of the pericranial muscles is easily detected by palpation with small rotational movements of the II and III fingers, as well as by pressing in the area of the frontal, temporal, masseter, sternocleidomastoid and trapezius muscles. To obtain a total pain score for each patient, it is necessary to sum up the local pain scores obtained by palpation of each individual muscle and calculated using a verbal scale from 0 to 3 points. The presence of dysfunction of the pericranial muscles must be taken into account when choosing a treatment strategy. In addition, when talking to the patient, it is necessary to explain to him the mechanism of muscle tension and its significance for the course of the disease. If there is increased sensitivity (pain) of the pericranial muscles during palpation, a diagnosis of "episodic tension headache (chronic tension headache) with tension of the pericranial muscles" should be made.

In addition, patients with tension headaches almost always complain of increased anxiety, low mood, melancholy, apathy or, conversely, aggressiveness and irritability, poor quality of night sleep. This is a manifestation of anxiety and depressive disorders, their degree in patients with tension headaches varies from mild to severe. Significant depression is most often found in patients with chronic tension headaches, it maintains muscle tension and pain syndrome, leading to serious maladaptation of these patients.

For most patients with tension headaches, additional examinations are not considered necessary. Instrumental methods and specialist consultations are indicated only if there is a suspicion of a symptomatic (secondary) nature of cephalgia.

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Combination of migraine and tension headache

Some patients experience a combination of episodic migraine and episodic tension-type headache. These are usually patients with a typical history of migraine who eventually develop attacks of episodic tension-type headache. Because of the obvious differences between the two forms of headache, patients usually differentiate migraine attacks from attacks of episodic tension-type headache.

The situation is more complicated if there is a need to differentiate chronic tension headache and chronic migraine, when migraine attacks lose their typicality. If it is not possible to establish from questioning how many episodes of cephalgia correspond to the criteria of chronic migraine, and how many correspond to the criteria of chronic tension headache, the patient should be asked to keep a diagnostic diary of cephalgia for a certain period of time (1-2 months), noting in it the clinical manifestations, provoking and relieving factors of each pain episode. In this case, along with the diagnostic criteria, it is necessary to rely on anamnestic information: a previous history of episodic tension headaches for chronic tension cephalgia and typical episodic migraine attacks for chronic migraine.

Combination of chronic tension headache and medication overuse headache

If a patient with chronic tension-type headache abuses medications, which corresponds to the diagnostic criteria for cephalgia with excessive use of drugs (drug overuse headache), two diagnoses should be established: "possible chronic tension-type headache" and "possible drug overuse headache". If 2-month withdrawal of the drug that caused the overuse does not relieve the cephalgia, the diagnosis of "chronic tension-type headache" is established. However, if improvement occurs during these 2 months against the background of drug withdrawal and the criteria for chronic tension-type headache do not correspond to the clinical picture, it is more correct to establish the diagnosis of "drug overuse headache".

In very rare cases, tension headaches occur in people who have not had complaints of cephalalgia before, i.e. from the very beginning it occurs without remissions as a chronic tension headache (cephalalgia becomes chronic during the first 3 days after its occurrence, as if bypassing the stage of episodic tension headache). In this case, the diagnosis should be "New daily (initially) persistent headache". The most important factor in diagnosing a new daily persistent headache is the patient's ability to accurately recall the onset of the pain, its initially chronic nature.

Clinical types of tension headaches

Patients with infrequent episodic tension headaches rarely seek medical attention. As a rule, a specialist has to deal with frequent episodic and chronic tension headaches. Chronic tension headache is a disorder that originates from episodic tension headaches and manifests itself in very frequent or daily episodes of cephalgia lasting from several minutes to several days. Like chronic migraine, chronic tension headache is a form of chronic daily headache that is characterized by the most severe course and is always associated with pronounced maladaptation of patients, and therefore, with significant individual and socio-economic losses.

In chronic tension headache, cephalalgia occurs for 15 days a month or more over an average period of more than 3 months (at least 180 days a year). In severe cases, there may be no pain-free intervals at all, and patients experience cephalalgia constantly, day after day. An important diagnostic feature of chronic tension headache is a previous history of episodic tension headache (just as for the diagnosis of "chronic migraine", a history of typical episodic migraine attacks is required).

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