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Tension-type headache

Nature Reviews Disease Primers volume 7, Article number: 24 (2021) Cite this article

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Abstract

Tension-type headache (TTH) is the most prevalent neurological disorder worldwide and is characterized by recurrent headaches of mild to moderate intensity, bilateral location, pressing or tightening quality, and no aggravation by routine physical activity. Diagnosis is based on headache history and the exclusion of alternative diagnoses, with clinical criteria provided by the International Classification of Headache Disorders, third edition. Although the biological underpinnings remain unresolved, it seems likely that peripheral mechanisms are responsible for the genesis of pain in TTH, whereas central sensitization may be involved in transformation from episodic to chronic TTH. Pharmacological therapy is the mainstay of clinical management and can be divided into acute and preventive treatments. Simple analgesics have evidence-based effectiveness and are widely regarded as first-line medications for the acute treatment of TTH. Preventive treatment should be considered in individuals with frequent episodic and chronic TTH, and if simple analgesics are ineffective, poorly tolerated or contraindicated. Recommended preventive treatments include amitriptyline, venlafaxine and mirtazapine, as well as some selected non-pharmacological therapies. Despite the widespread prevalence and associated disability of TTH, little progress has been made since the early 2000s owing to a lack of attention and resource allocation by scientists, funding bodies and the pharmaceutical industry.

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Fig. 1: Pathophysiology of tension-type headache.
Fig. 2: Proposed mechanisms of chronification of tension-type headache.
Fig. 3: Management of tension-type headache.

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Acknowledgements

The authors thank T. P. Do, for skilful assistance and providing the initial sketches for Figs. 1 and 2. They also thank R. Burstein for helping with editing and advising on structural and functional neuroanatomy in Fig. 2. They also thank K. MacDonald from Alliance for Headache Disorders Advocacy for providing her perspective on tension-type headache.

Author information

Authors and Affiliations

  1. BIDMC Comprehensive Headache Center, Department of Neurology and Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Sait Ashina

  2. Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark

    Sait Ashina

  3. First Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece

    Dimos D. Mitsikostas

  4. Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

    Mi Ji Lee

  5. Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

    Nooshin Yamani

  6. Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Brain Research Center, National Yang-Ming University, Taipei, Taiwan

    Shuu-Jiun Wang

  7. Neuroimaging Research Unit and Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy

    Roberta Messina

  8. Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark

    Håkan Ashina & Rigmor H. Jensen

  9. Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA

    Dawn C. Buse & Richard B. Lipton

  10. Headache Unit, Neurology Department, Vall d’Hebron University Hospital, Barcelona, Spain

    Patricia Pozo-Rosich

  11. Headache and Neurological Pain Research Group, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain

    Patricia Pozo-Rosich

  12. Faculty of Medicine, Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Essen, Germany

    Hans-Christoph Diener

  13. Montefiore Headache Center, Bronx, NY, USA

    Richard B. Lipton

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Contributions

Introduction (H.A., R.B.L. and S.A.); Epidemiology (S.J.W., S.A. and R.B.L.); Mechanisms/pathophysiology (R.M., M.J.L., S.A. and R.H.J.); Diagnosis, screening and prevention (H.A., H.C.D. and S.A.); Management (D.D.M, D.C.B. and R.B.L.); Quality of life (N.Y., P.P.R. and R.B.L.); Outlook (S.A., H.-C.D., R.H.J. and R.B.L.); Overview of Primer (S.A.)

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Correspondence to Sait Ashina.

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Competing interests

S.A. received honoraria for consulting from Allergan/AbbVie, Amgen, Biohaven, Eli Lilly, Impel NeuroPharma, Novartis, Satsuma, Supernus, Theranica and Percept. S.A. is an associate editor for Neurology Reviews and BMC Neurology, serves on an Advisory Board for the Journal of Headache and Pain, and is a member of the Education Committee of the International Headache Society. D.D.M. has received honoraria as a consultant and/or speaker from Allergan/AbbVie, Amgen, Biogen, Cefaly, Eli Lilly, Genesis Pharma, Medscape, Merz, Mylan, Novartis, Roche, Sanofi, Specifar and Teva Pharmaceuticals; has received funding for clinical trials from Alder, Cefaly, Electrocore, Biogen, Eli Lilly, Genesis Pharma, Merz, Novartis and Teva. D.D.M. is also past president of the European Headache Federation, current co-chair of the Headache Panel in the European Academy of Neurology and president of the Hellenic Headache Society, and is an associate editor for Journal of Headache and Pain. D.D.M. does not own stocks from any pharmaceutical company. M.J.L. has received honoraria as a consultant and/or speaker for Eli Lilly, Sanofi-Aventis and YuYu Pharma; has been the PI or co-investigator in trials sponsored by Eli Lilly, Novartis, Teva (Otsuka), Allergan/AbbVie, Yuhan Company, Samjin Pharm and DongA ST; received research support from the National Research Foundation of Korea; is a trustee member of the board of the International Headache Society and junior editor of Cephalalgia. S-J.W. has served on the advisory boards of Daiichi-Sankyo, Eli Lilly and Taiwan Novartis; has received honoraria as a moderator from Allergan/AbbVie, Pfizer, Eli Lilly and Eisai and has been the PI in trials sponsored by Eli Lilly, Novartis, and Allergan/AbbVie. S-J.W. has received research grants from the Taiwan Minister of Technology and Science (MOST), Brain Research Center, National Yang-Ming University from The Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan, Taipei Veterans General Hospital and Taiwan Headache Society. R.M. has received honoraria as speaker for Eli Lilly, Novartis and Teva Pharmaceuticals. D.B. received honoraria for consulting for Allergan, Amgen, Biohaven, Eli Lilly, Novartis and Teva, and has received grant support from Amgen, the National Headache Foundation and the FDA. D.B. is an editor for Current Pain and Headache Reports. P.P.-R. has received honoraria as a consultant and/or speaker for Allergan/AbbVie, Almirall, Biohaven, Chiesi, Eli Lilly, Lundbeck, Medscape, Neurodiem, Novartis and Teva Pharmaceuticals. Her research group has received research grants from AGAUR, ERANet Neuron, la Caixa foundation, International Headache Society, Migraine Research Foundation, FEDER RISC3CAT, Instituto Investigación Carlos III, PERIS, Novartis and Teva; and has received funding for clinical trials from AbbVie, Alder, Electrocore, Eli Lilly, Lundbeck, Novartis and Teva. P.P.-R. is a trustee member of the board of the International Headache Society and a member of the Council of the European Headache Federation, and is on the editorial board of Revista de Neurologia; is an associate editor for Cephalalgia, Headache, Frontiers in Neurology, Neurologia and is on the Scientific Advisory Board of the Journal of Headache and Pain. P.P.-R. does not own stocks from any pharmaceutical company. R.H.J. has received honoraria for lectures and patient leaflets from MSD, Berlin-Chemie Menarini, ATI, Novartis, Teva, Allergan and Pfizer and is conducting clinical trials for Eli-Lilly and Lundbeck. H.-C.D. received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from Allergan/AbbVie, Amgen, Electrocore, Lilly, Medtronic, Novartis, Pfizer, Teva and Weber & Weber. Electrocore provided financial support for research projects. The German Research Council (DFG), the German Ministry of Education and Research (BMBF) and the European Union support his headache research. H.-C.D. serves on the editorial boards of Cephalalgia and Lancet Neurology, chairs the Clinical Guidelines Committee of the German Society of Neurology and is a member of the Clinical Trials Committee of the IHS. R.B.L. is the Edwin S. Lowe Professor of Neurology at the Albert Einstein College of Medicine in New York. He receives research support from the NIH. R.B.L. also receives support from the Migraine Research Foundation and the National Headache Foundation. R.B.L. serves on the editorial board of Neurology, is senior adviser to Headache, associate editor for Cephalalgia and has reviewed for the NIA and NINDS, holds stock options in Biohaven Holdings and CntrlM; serves as consultant, advisory board member, or has received honoraria or conducted research funded by Allergan/Abbvie, American Academy of Neurology, American Headache Society, Amgen, Biohaven, Biovision, Dr. Reddy’s (Promius), Electrocore, Eli Lilly, eNeura Therapeutics, GlaxoSmithKline, Grifols, Lundbeck (Alder), Merck, Pernix, Pfizer, Teva, Trigemina, Vector, Vedanta. R.L. receives royalties from Wolff’s Headache seventh and eighth editions, Oxford University Press, 2009, Wiley and Informa. All other authors declare no competing interests.

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Nature Reviews Disease Primers thanks V. Gómez-Mayordomo, who co-reviewed with M. Cuadrado, H. Göbel, P. Martin and L. Stovner for their contribution to the peer review of this work.

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Glossary

Photophobia

Sensitivity to light.

Phonophobia

Sensitivity to sound.

Chronic daily headache

Primary or secondary headache, defined as the presence of a headache on ≥15 days/month for at least 3 months, which may include chronic tension-type headache, chronic migraine, new daily persistent headache, medication overuse headache or other disorders with headaches.

Probable TTH

Tension-type headache (TTH) that is missing one of the features required to fulfil all ICHD-3 criteria for a type or subtype of TTH.

Medication overuse headache

Secondary headache characterized as headache occurring on ≥15 days/month that is attributed to regular overuse of analgesics or migraine-specific acute medications (on ≥10 or ≥15 days/month, depending on the medication) in individuals with a pre-existing headache disorder such as tension-type headache or migraine.

New daily persistent headache

Primary headache disorder characterized by unremitting pain within 24 h of a clearly remembered onset and for >3 months.

Cognitive behavioural therapy

A time-limited psychotherapeutic approach that focuses on assessing and modifying dysfunctional moods and thoughts (cognitive) and actions and behaviours (behavioural) and replacing them with strategies to help patients reach their goals.

Biofeedback

A psychotherapeutic approach in which physiological data are fed back to the user in the form of visual and auditory stimuli, and in the case of tension-type headache there is a focus on recognizing activation of the nervous system and learning techniques to calm and relax the nervous system.

Relaxation therapy

A psychological intervention that teaches various approaches to relaxing the nervous system including paced diaphragmatic breathing, imagery, distraction and meditation.

Stress management therapy

A combination of relaxation with cognitive coping skills for preventing and managing stress and headaches.

Headache triggers

Factors associated with an increased probability of headache over a relatively short, clinically relevant time period.

Transformed migraine

Subtype of the chronic daily headache, not defined by ICHD, that initially begins as episodic migraine and then evolves over months or years to daily or near-daily headaches resembling a mixture of tension-type headache and migraine.

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Ashina, S., Mitsikostas, D.D., Lee, M.J. et al. Tension-type headache. Nat Rev Dis Primers 7, 24 (2021). https://doi.org/10.1038/s41572-021-00257-2

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