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Tension-type headache

Subjects

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.

References

  1. 1.

    GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 17, 954–976 (2018). An important study that used data from the GBD 2016 study to provide global, regional, and national estimates for prevalence and years of life lived with disability for migraine and TTH.

    Google Scholar 

  2. 2.

    Deuschl, G. et al. The burden of neurological diseases in Europe: an analysis for the Global Burden of Disease Study 2017. Lancet Public. Health 5, e551–e567 (2020). Updated data from the GBD 2017 providing global and European estimates for incidence, prevalence and years of life lived with disability for migraine and TTH.

    Google Scholar 

  3. 3.

    GBD 2017 US Neurological Disorders Collaborators. Burden of neurological disorders across the US from 1990-2017: a Global Burden Of Disease Study. JAMA Neurol. 78, 165–176 (2020). Updated data from the GBD 2017 providing estimates for incidence, prevalence and years of life lived with disability for migraine and TTH in the United States.

    Google Scholar 

  4. 4.

    Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia 38, 1–211 (2018). This is the third and the latest edition of the ICHD-3, which is used as a diagnostic tool for headache disorders including TTH.

    Google Scholar 

  5. 5.

    Jensen, R. H. Tension-type headache - the normal and most prevalent headache. Headache 58, 339–345 (2018).

    Google Scholar 

  6. 6.

    Lyngberg, A. C., Rasmussen, B. K., Jorgensen, T. & Jensen, R. Incidence of primary headache: a Danish epidemiologic follow-up study. Am. J. Epidemiol. 161, 1066–1073 (2005). One of the few population-based studies on the incidence of TTH in the general population.

    CAS  Google Scholar 

  7. 7.

    Lu, S. R. et al. Incidence and risk factors of chronic daily headache in young adolescents: a school cohort study. Pediatrics 132, e9–e16 (2013).

    Google Scholar 

  8. 8.

    United Nations, Department of Economic and Social Affairs Population Division. World population prospects 2017 – data booklet (ST/ESA/SER.A/401), https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2017_world_population_prospects-2017_revision_databooklet.pdf (2017).

  9. 9.

    U.S. Census Bureau, https://www.census.gov (2021).

  10. 10.

    Yu, S. et al. The prevalence and burden of primary headaches in China: a population-based door-to-door survey. Headache 52, 582–591 (2012).

    Google Scholar 

  11. 11.

    Alzoubi, K. H. et al. Prevalence of migraine and tension-type headache among adults in Jordan. J. Headache Pain 10, 265–270 (2009).

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Schwartz, B. S., Stewart, W. F., Simon, D. & Lipton, R. B. Epidemiology of tension-type headache. JAMA 279, 381–383 (1998).

    CAS  Google Scholar 

  13. 13.

    Rasmussen, B. K., Jensen, R., Schroll, M. & Olesen, J. Epidemiology of headache in a general population - a prevalence study. J. Clin. Epidemiol. 44, 1147–1157 (1991).

    CAS  Google Scholar 

  14. 14.

    Stovner, L. J. et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27, 193–210 (2007).

    Google Scholar 

  15. 15.

    Russell, M. B., Levi, N., Saltyte-Benth, J. & Fenger, K. Tension-type headache in adolescents and adults: a population based study of 33,764 twins. Eur. J. Epidemiol. 21, 153–160 (2006).

    Google Scholar 

  16. 16.

    Winkler, A. et al. The prevalence of headache with emphasis on tension-type headache in rural Tanzania: a community-based study. Cephalalgia 29, 1317–1325 (2009).

    Google Scholar 

  17. 17.

    Leonardi, M. et al. Global Burden of Headache Disorders in Children and Adolescents 2007-2017. Int. J. Environ Res. Public Health 18, 250 (2020).

    PubMed  PubMed Central  Google Scholar 

  18. 18.

    Pascual, J., Colas, R. & Castillo, J. Epidemiology of chronic daily headache. Curr. Pain Headache Rep. 5, 529–536 (2001).

    CAS  Google Scholar 

  19. 19.

    Gobel, H., Petersen-Braun, M. & Soyka, D. The epidemiology of headache in Germany: a nationwide survey of a representative sample on the basis of the headache classification of the International Headache Society. Cephalalgia 14, 97–106 (1994).

    CAS  Google Scholar 

  20. 20.

    Wang, S. J. et al. Chronic daily headache in Chinese elderly: prevalence, risk factors, and biannual follow-up. Neurology 54, 314–319 (2000).

    CAS  Google Scholar 

  21. 21.

    Lavados, P. M. & Tenhamm, E. Epidemiology of tension-type headache in Santiago, Chile: a prevalence study. Cephalalgia 18, 552–558 (1998).

    CAS  Google Scholar 

  22. 22.

    Pryse-Phillips, W. et al. A Canadian population survey on the clinical, epidemiologic and societal impact of migraine and tension-type headache. Can. J. Neurol. Sci. 19, 333–339 (1992).

    CAS  Google Scholar 

  23. 23.

    Ferrante, T. et al. The PACE study: past-year prevalence of tension-type headache and its subtypes in Parma’s adult general population. Neurol. Sci. 36, 35–42 (2015).

    CAS  Google Scholar 

  24. 24.

    Wang, S. J., Fuh, J. L., Lu, S. R. & Juang, K. D. Chronic daily headache in adolescents: prevalence, impact, and medication overuse. Neurology 66, 193–197 (2006).

    Google Scholar 

  25. 25.

    Silberstein, S. D., Lipton, R. B. & Sliwinski, M. Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology 47, 871–875 (1996).

    CAS  Google Scholar 

  26. 26.

    Rasmussen, B. K. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 53, 65–72 (1993).

    Google Scholar 

  27. 27.

    Wang, S. J., Fuh, J. L., Lu, S. R. & Juang, K. D. Outcomes and predictors of chronic daily headache in adolescents: a 2-year longitudinal study. Neurology 68, 591–596 (2007).

    Google Scholar 

  28. 28.

    Lyngberg, A. C., Rasmussen, B. K., Jorgensen, T. & Jensen, R. Prognosis of migraine and tension-type headache: a population-based follow-up study. Neurology 65, 580–585 (2005).

    Google Scholar 

  29. 29.

    Ashina, S., Lyngberg, A. & Jensen, R. Headache characteristics and chronification of migraine and tension-type headache: a population-based study. Cephalalgia 30, 943–952 (2010).

    Google Scholar 

  30. 30.

    GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388, 1545–1602 (2016).

    Google Scholar 

  31. 31.

    Cassidy, E. M., Tomkins, E., Hardiman, O. & O’Keane, V. Factors associated with burden of primary headache in a specialty clinic. Headache 43, 638–644 (2003).

    Google Scholar 

  32. 32.

    Rasmussen, B. K., Jensen, R. & Olesen, J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. J. Epidemiol. Community Health 46, 443–446 (1992).

    CAS  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Rasmussen, B. K. Migraine and tension-type headache in a general population: psychosocial factors. Int. J. Epidemiol. 21, 1138–1143 (1992).

    CAS  Google Scholar 

  34. 34.

    Bigal, M. E., Bigal, J. M., Betti, M., Bordini, C. A. & Speciali, J. G. Evaluation of the impact of migraine and episodic tension-type headache on the quality of life and performance of a university student population. Headache 41, 710–719 (2001).

    CAS  Google Scholar 

  35. 35.

    Lipton, R. B., Cady, R. K., Stewart, W. F., Wilks, K. & Hall, C. Diagnostic lessons from the Spectrum study. Neurology 58, S27–S31 (2002).

    CAS  Google Scholar 

  36. 36.

    Lipton, R. B. et al. 2000 Wolfe Award. Sumatriptan for the range of headaches in migraine sufferers: results of the Spectrum Study. Headache 40, 783–791 (2000).

    CAS  Google Scholar 

  37. 37.

    Jensen, R. & Stovner, L. J. Epidemiology and comorbidity of headache. Lancet Neurol. 7, 354–361 (2008).

    Google Scholar 

  38. 38.

    Ashina, S. et al. Neuroticism, depression and pain perception in migraine and tension-type headache. Acta Neurol. Scand. 136, 470–476 (2017).

    CAS  Google Scholar 

  39. 39.

    Ødegård, S. S., Sand, T., Engstrøm, M., Zwart, J. A. & Hagen, K. The impact of headache and chronic musculoskeletal complaints on the risk of insomnia: longitudinal data from the Nord-Trøndelag health study. J. Headache Pain 14, 24 (2013).

    PubMed  PubMed Central  Google Scholar 

  40. 40.

    Ødegård, S. S. et al. Associations between sleep disturbance and primary headaches: the third Nord-Trøndelag Health Study. J. Headache Pain 11, 197–206 (2010).

    PubMed  PubMed Central  Google Scholar 

  41. 41.

    Kim, J. et al. Insomnia in tension-type headache: a population-based study. J. Headache Pain 18, 95 (2017).

    PubMed  PubMed Central  Google Scholar 

  42. 42.

    Song, T. J. et al. Anxiety and depression in tension-type headache: a population-based study. PLoS ONE 11, e0165316 (2016).

    PubMed  PubMed Central  Google Scholar 

  43. 43.

    Mitsikostas, D. D. & Thomas, A. M. Comorbidity of headache and depressive disorders. Cephalalgia 19, 211–217 (1999).

    CAS  Google Scholar 

  44. 44.

    Fuensalida-Novo, S. et al. The burden of headache is associated to pain interference, depression and headache duration in chronic tension type headache: a 1-year longitudinal study. J. Headache Pain 18, 119 (2017).

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Minen, M. T. et al. Migraine and its psychiatric comorbidities. J. Neurol. Neurosurg. Psychiatry 87, 741–749 (2016).

    Google Scholar 

  46. 46.

    Buse, D. C., Silberstein, S. D., Manack, A. N., Papapetropoulos, S. & Lipton, R. B. Psychiatric comorbidities of episodic and chronic migraine. J. Neurol. 260, 1960–1969 (2013).

    Google Scholar 

  47. 47.

    Yoon, M. S. et al. Chronic migraine and chronic tension-type headache are associated with concomitant low back pain: results of the German Headache Consortium study. Pain 154, 484–492 (2013).

    Google Scholar 

  48. 48.

    Ashina, S. et al. Increased pain sensitivity in migraine and tension-type headache coexistent with low back pain: a cross-sectional population study. Eur. J. Pain 22, 904–-914 (2018).

    CAS  Google Scholar 

  49. 49.

    Ashina, S. et al. Prevalence of neck pain in migraine and tension-type headache: a population study. Cephalalgia 35, 211–219 (2015).

    Google Scholar 

  50. 50.

    Ulrich, V., Gervil, M. & Olesen, J. The relative influence of environment and genes in episodic tension-type headache. Neurology 62, 2065–2069 (2004).

    Google Scholar 

  51. 51.

    Russell, M. B., Levi, N. & Kaprio, J. Genetics of tension-type headache: a population based twin study. Am. J. Med. Genetics. B Neuropsychiatr. Genet. 144b, 982–986 (2007).

    Google Scholar 

  52. 52.

    Russell, M. B., Saltyte-Benth, J. & Levi, N. Are infrequent episodic, frequent episodic and chronic tension-type headache inherited? A population-based study of 11 199 twin pairs. J. Headache Pain 7, 119–126 (2006).

    PubMed  PubMed Central  Google Scholar 

  53. 53.

    Ostergaard, S., Russell, M. B., Bendtsen, L. & Olesen, J. Comparison of first degree relatives and spouses of people with chronic tension headache. Br. Med. J. 314, 1092–1093 (1997).

    CAS  Google Scholar 

  54. 54.

    Park, J. W., Kim, J. S., Lee, H. K., Kim, Y. I. & Lee, K. S. Serotonin transporter polymorphism and harm avoidance personality in chronic tension-type headache. Headache 44, 1005–1009 (2004).

    Google Scholar 

  55. 55.

    Fernández-de-las-Peñas, C. et al. Genetic contribution of catechol-O-methyltransferase polymorphism (Val158Met) in children with chronic tension-type headache. Pediatr. Res. 70, 395–399 (2011).

    Google Scholar 

  56. 56.

    Fernández-de-las-Peñas, C. et al. Catechol-O-methyltransferase (COMT) rs4680Val158Met polymorphism is associated with widespread pressure pain sensitivity and depression in women with chronic, but not episodic, tension-type headache. Clin. J. Pain 35, 345–352 (2019).

    Google Scholar 

  57. 57.

    Gupta, R., Kumar, V., Luthra, K., Banerjee, B. & Bhatia, M. S. Polymorphism in apolipoprotein E among migraineurs and tension-type headache subjects. J. Headache Pain 10, 115–120 (2009).

    CAS  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Jensen, R. Peripheral and central mechanisms in tension-type headache: an update. Cephalalgia 23 (Suppl. 1), 49–52 (2003).

    Google Scholar 

  59. 59.

    Jensen, R. Pathophysiological mechanisms of tension-type headache: a review of epidemiological and experimental studies. Cephalalgia 19, 602–621 (1999).

    CAS  Google Scholar 

  60. 60.

    Langemark, M. & Olesen, J. Pericranial tenderness in tension headache. A blind, controlled study. Cephalalgia 7, 249–255 (1987).

    CAS  Google Scholar 

  61. 61.

    Jensen, R., Rasmussen, B. K., Pedersen, B. & Olesen, J. Muscle tenderness and pressure pain thresholds in headache. A population study. Pain 52, 193–199 (1993).

    Google Scholar 

  62. 62.

    Ashina, S., Bendtsen, L. & Ashina, M. Pathophysiology of tension-type headache. Curr. Pain Headache Rep. 9, 415–422 (2005).

    Google Scholar 

  63. 63.

    Jensen, R. & Olesen, J. Initiating mechanisms of experimentally induced tension-type headache. Cephalalgia 16, 175–182 (1996).

    CAS  Google Scholar 

  64. 64.

    Buchgreitz, L., Lyngberg, A. C., Bendtsen, L. & Jensen, R. Increased pain sensitivity is not a risk factor but a consequence of frequent headache: a population-based follow-up study. Pain 137, 623–630 (2008).

    CAS  Google Scholar 

  65. 65.

    Fernandez-de-Las-Penas, C., Cuadrado, M. L., Arendt-Nielsen, L., Ge, H. Y. & Pareja, J. A. Increased pericranial tenderness, decreased pressure pain threshold, and headache clinical parameters in chronic tension-type headache patients. Clin. J. Pain 23, 346–352 (2007).

    Google Scholar 

  66. 66.

    Ashina, M., Bendtsen, L., Jensen, R., Sakai, F. & Olesen, J. Muscle hardness in patients with chronic tension-type headache: relation to actual headache state. Pain 79, 201–205 (1999).

    CAS  Google Scholar 

  67. 67.

    Bendtsen, L., Ashina, S., Moore, A. & Steiner, T. J. Muscles and their role in episodic tension-type headache: implications for treatment. Eur. J. Pain 20, 166–175 (2016). A review on peripheral and muscular factors involved in the pathophysiology of TTH and implications for the treatment of episodic TTH.

    CAS  Google Scholar 

  68. 68.

    Sakai, F., Ebihara, S., Akiyama, M. & Horikawa, M. Pericranial muscle hardness in tension-type headache. A non-invasive measurement method and its clinical application. Brain 118, 523–531 (1995).

    Google Scholar 

  69. 69.

    Ashina, M., Lassen, L. H., Bendtsen, L., Jensen, R. & Olesen, J. Effect of inhibition of nitric oxide synthase on chronic tension-type headache: a randomised crossover trial. Lancet 353, 287–289 (1999).

    CAS  Google Scholar 

  70. 70.

    Ashina, M., Bendtsen, L., Jensen, R., Sakai, F. & Olesen, J. Possible mechanisms of glyceryl-trinitrate-induced immediate headache in patients with chronic tension-type headache. Cephalalgia 20, 919–924 (2000).

    CAS  Google Scholar 

  71. 71.

    Fernandez-De-Las-Penas, C. & Arendt-Nielsen, L. Improving understanding of trigger points and widespread pressure pain sensitivity in tension-type headache patients: clinical implications. Expert Rev. Neurother. 17, 933–939 (2017).

    CAS  Google Scholar 

  72. 72.

    Schmidt-Hansen, P. T., Svensson, P., Jensen, T. S., Graven-Nielsen, T. & Bach, F. W. Patterns of experimentally induced pain in pericranial muscles. Cephalalgia 26, 568–577 (2006).

    CAS  Google Scholar 

  73. 73.

    Fernandez-de-Las-Penas, C. Myofascial head pain. Curr. Pain Headache Rep. 19, 28 (2015).

    Google Scholar 

  74. 74.

    Do, T. P., Heldarskard, G. F., Kolding, L. T., Hvedstrup, J. & Schytz, H. W. Myofascial trigger points in migraine and tension-type headache. J. Headache Pain 19, 84 (2018).

    PubMed  PubMed Central  Google Scholar 

  75. 75.

    Palacios-Cena, M. et al. Trigger points are associated with widespread pressure pain sensitivity in people with tension-type headache. Cephalalgia 38, 237–245 (2018).

    Google Scholar 

  76. 76.

    Arendt-Nielsen, L., Castaldo, M., Mechelli, F. & Fernandez-de-Las-Penas, C. Muscle triggers as a possible source of pain in a subgroup of tension-type headache patients? Clin. J. Pain 32, 711–718 (2016).

    Google Scholar 

  77. 77.

    Bezov, D., Ashina, S., Jensen, R. & Bendtsen, L. Pain perception studies in tension-type headache. Headache 51, 262–271 (2011).

    Google Scholar 

  78. 78.

    Bendtsen, L. & Fernandez-de-la-Penas, C. The role of muscles in tension-type headache. Curr. Pain Headache Rep. 15, 451–458 (2011).

    Google Scholar 

  79. 79.

    Hubbard, D. R. & Berkoff, G. M. Myofascial trigger points show spontaneous needle EMG activity. Spine 18, 1803–1807 (1993).

    CAS  Google Scholar 

  80. 80.

    Jensen, R., Fuglsang-Frederiksen, A. & Olesen, J. Quantitative surface EMG of pericranial muscles in headache. A population study. Electroencephalogr. Clin. Neurophysiol. 93, 335–344 (1994).

    CAS  Google Scholar 

  81. 81.

    Cathcart, S., Winefield, A. H., Lushington, K. & Rolan, P. Stress and tension-type headache mechanisms. Cephalalgia 30, 1250–1267 (2010).

    Google Scholar 

  82. 82.

    Melzack, R. From the gate to the neuromatrix. Pain Suppl. 6, S121–S126 (1999).

    Google Scholar 

  83. 83.

    Choi, J. C., Chung, M. I. & Lee, Y. D. Modulation of pain sensation by stress-related testosterone and cortisol. Anaesthesia 67, 1146–1151 (2012).

    CAS  Google Scholar 

  84. 84.

    Leistad, R. B., Sand, T., Westgaard, R. H., Nilsen, K. B. & Stovner, L. J. Stress-induced pain and muscle activity in patients with migraine and tension-type headache. Cephalalgia 26, 64–73 (2006).

    CAS  Google Scholar 

  85. 85.

    Hatch, J. P. et al. Electromyographic and affective responses of episodic tension-type headache patients and headache-free controls during stressful task performance. J. Behav. Med. 15, 89–112 (1992).

    CAS  Google Scholar 

  86. 86.

    Mense, S. The pathogenesis of muscle pain. Curr. Pain Headache Rep. 7, 419–425 (2003).

    Google Scholar 

  87. 87.

    Mork, H., Ashina, M., Bendtsen, L., Olesen, J. & Jensen, R. Possible mechanisms of pain perception in patients with episodic tension-type headache. A new experimental model of myofascial pain. Cephalalgia 24, 466–475 (2004).

    CAS  Google Scholar 

  88. 88.

    Bendtsen, L. Central and peripheral sensitization in tension-type headache. Curr. Pain Headache Rep. 7, 460–465 (2003).

    Google Scholar 

  89. 89.

    Henriksson, K. & Lindman, R. in Tension-Type Headache: Classification, Mechanisms and Treatment (eds Olesen, J. & Schoenen, J.) 97–107 (Raven Press, New York, 1993).

  90. 90.

    Kocer, A., Kocer, E., Memisogullari, R., Domac, F. M. & Yuksel, H. Interleukin-6 levels in tension headache patients. Clin. J. Pain 26, 690–693 (2010).

    Google Scholar 

  91. 91.

    Ashina, M. et al. Tender points are not sites of ongoing inflammation -in vivo evidence in patients with chronic tension-type headache. Cephalalgia 23, 109–116 (2003).

    CAS  Google Scholar 

  92. 92.

    Langemark, M., Jensen, K. & Olesen, J. Temporal muscle blood flow in chronic tension-type headache. Arch. Neurol. 47, 654–658 (1990).

    CAS  Google Scholar 

  93. 93.

    Ashina, M. et al. In vivo evidence of altered skeletal muscle blood flow in chronic tension-type headache. Brain 125, 320–326 (2002).

    CAS  Google Scholar 

  94. 94.

    Olesen, J. Clinical and pathophysiological observations in migraine and tension-type headache explained by integration of vascular, supraspinal and myofascial inputs. Pain 46, 125–132 (1991).

    Google Scholar 

  95. 95.

    Schytz, H. W., Amin, F. M., Selb, J. & Boas, D. A. Non-invasive methods for measuring vascular changes in neurovascular headaches. J. Cereb. Blood Flow. Metab. 39, 633–649 (2019).

    Google Scholar 

  96. 96.

    Wallasch, T. M. Transcranial Doppler ultrasonic features in episodic tension-type headache. Cephalalgia 12, 293–296 (1992).

    CAS  Google Scholar 

  97. 97.

    Sliwka, U. et al. Spontaneous oscillations in cerebral blood flow velocity give evidence of different autonomic dysfunctions in various types of headache. Headache 41, 157–163 (2001).

    CAS  Google Scholar 

  98. 98.

    Karacay Ozkalayci, S., Nazliel, B., Batur Caglayan, H. Z. & Irkec, C. Cerebral blood flow velocity in migraine and chronic tension-type headache patients. J. Pain Res. 11, 661–666 (2018).

    CAS  PubMed  PubMed Central  Google Scholar 

  99. 99.

    Sarchielli, P., Alberti, A., Floridi, A. & Gallai, V. L-Arginine/nitric oxide pathway in chronic tension-type headache: relation with serotonin content and secretion and glutamate content. J. Neurol. Sci. 198, 9–15 (2002).

    CAS  Google Scholar 

  100. 100.

    Hannerz, J. & Jogestrand, T. Is Chronic tension-type headache a vascular headache? The relation between chronic tension-type headache and cranial hemodynamics. Headache 38, 668–675 (1998).

    CAS  Google Scholar 

  101. 101.

    Drummond, P. D. & Lance, J. W. Extracranial vascular reactivity in migraine and tension headache. Cephalalgia 1, 149–155 (1981).

    CAS  Google Scholar 

  102. 102.

    Langemark, M., Jensen, K., Jensen, T. S. & Olesen, J. Pressure pain thresholds and thermal nociceptive thresholds in chronic tension-type headache. Pain 38, 203–210 (1989).

    CAS  Google Scholar 

  103. 103.

    Gobel, H., Weigle, L., Kropp, P. & Soyka, D. Pain sensitivity and pain reactivity of pericranial muscles in migraine and tension-type headache. Cephalalgia 12, 142–151 (1992).

    CAS  Google Scholar 

  104. 104.

    Metsahonkala, L. et al. Extracephalic tenderness and pressure pain threshold in children with headache. Eur. J. Pain 10, 581–585 (2006).

    Google Scholar 

  105. 105.

    Headache Classification Committee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia 24 (Suppl. 1), 9–160 (2004).

    Google Scholar 

  106. 106.

    Buchgreitz, L., Lyngberg, A. C., Bendtsen, L. & Jensen, R. Frequency of headache is related to sensitization: a population study. Pain 123, 19–27 (2006).

    CAS  Google Scholar 

  107. 107.

    Fernández-de-Las-Peñas, C. et al. Evidence of localized and widespread pressure pain hypersensitivity in patients with tension-type headache: A systematic review and meta-analysis. Cephalalgia 41, 265–273 (2021).

    Google Scholar 

  108. 108.

    Bendtsen, L. Central sensitization in tension-type headache–possible pathophysiological mechanisms. Cephalalgia 20, 486–508 (2000). A comprehensive review on the important role and mechansms of central sensitization in the pathophysiology of CTTH.

    CAS  Google Scholar 

  109. 109.

    Castien, R. F., van der Wouden, J. C. & De Hertogh, W. Pressure pain thresholds over the cranio-cervical region in headache: a systematic review and meta-analysis. J. Headache Pain 19, 9 (2018).

    PubMed  PubMed Central  Google Scholar 

  110. 110.

    Bendtsen, L., Jensen, R. & Olesen, J. Decreased pain detection and tolerance thresholds in chronic tension-type headache. Arch. Neurol. 53, 373–376 (1996).

    CAS  Google Scholar 

  111. 111.

    Ashina, S. et al. Increased muscular and cutaneous pain sensitivity in cephalic region in patients with chronic tension-type headache. Eur. J. Neurol. 12, 543–549 (2005).

    CAS  Google Scholar 

  112. 112.

    Ashina, S., Bendtsen, L., Ashina, M., Magerl, W. & Jensen, R. Generalized hyperalgesia in patients with chronic tension-type headache. Cephalalgia 26, 940–948 (2006).

    CAS  Google Scholar 

  113. 113.

    Bendtsen, L., Jensen, R. & Olesen, J. Qualitatively altered nociception in chronic myofascial pain. Pain 65, 259–264 (1996).

    CAS  Google Scholar 

  114. 114.

    Cathcart, S., Winefield, A. H., Lushington, K. & Rolan, P. Noxious inhibition of temporal summation is impaired in chronic tension-type headache. Headache 50, 403–412 (2010).

    Google Scholar 

  115. 115.

    Bendtsen, L. & Jensen, R. Tension-type headache. Neurol. Clin. 27, 525–535 (2009).

    Google Scholar 

  116. 116.

    Chen, W. T. et al. Comparison of somatosensory cortex excitability between migraine and “strict-criteria” tension-type headache: a magnetoencephalographic study. Pain 159, 793–803 (2018).

    Google Scholar 

  117. 117.

    Rossi, P., Vollono, C., Valeriani, M. & Sandrini, G. The contribution of clinical neurophysiology to the comprehension of the tension-type headache mechanisms. Clin. Neurophysiol. 122, 1075–1085 (2011).

    Google Scholar 

  118. 118.

    Ashina, M. Neurobiology of chronic tension-type headache. Cephalalgia 24, 161–172 (2004). This review contributes to our understanding of the mechanisms leading to CTTH, and explains the role NO and neuropeptides have in the pathophysiology of this primary headache.

    CAS  Google Scholar 

  119. 119.

    Ashina, M., Bendtsen, L., Jensen, R. & Olesen, J. Nitric oxide-induced headache in patients with chronic tension-type headache. Brain 123, 1830–1837 (2000).

    Google Scholar 

  120. 120.

    Alam, Z., Coombes, N., Waring, R. H., Williams, A. C. & Steventon, G. B. Plasma levels of neuroexcitatory amino acids in patients with migraine or tension headache. J. Neurol. Sci. 156, 102–106 (1998).

    CAS  Google Scholar 

  121. 121.

    de Tommaso, M. et al. Clinical features of headache patients with fibromyalgia comorbidity. J. Headache Pain 12, 629–638 (2011).

    PubMed  PubMed Central  Google Scholar 

  122. 122.

    Gonçalves, D. A., Bigal, M. E., Jales, L. C., Camparis, C. M. & Speciali, J. G. Headache and symptoms of temporomandibular disorder: an epidemiological study. Headache 50, 231–241 (2010).

    Google Scholar 

  123. 123.

    Cho, S. J., Song, T. J. & Chu, M. K. Sleep and tension-type headache. Curr. Neurol. Neurosci. Rep. 19, 44 (2019).

    Google Scholar 

  124. 124.

    Engstrøm, M. et al. Sleep quality, arousal and pain thresholds in tension-type headache: a blinded controlled polysomnographic study. Cephalalgia 34, 455–463 (2014).

    Google Scholar 

  125. 125.

    Fernández-de-Las-Peñas, C. et al. Sleep disturbances in tension-type headache and migraine. Ther. Adv. Neurol. Disord. 11, 1756285617745444 (2017).

    PubMed  PubMed Central  Google Scholar 

  126. 126.

    Wang, P. et al. Regional homogeneity abnormalities in patients with tension-type headache: a resting-state fMRI study. Neurosci. Bull. 30, 949–955 (2014).

    PubMed  PubMed Central  Google Scholar 

  127. 127.

    Schmidt-Wilcke, T. et al. Gray matter decrease in patients with chronic tension type headache. Neurology 65, 1483–1486 (2005).

    CAS  Google Scholar 

  128. 128.

    Chen, W. T. et al. Comparison of gray matter volume between migraine and “strict-criteria” tension-type headache. J. Headache Pain 19, 4 (2018).

    PubMed  PubMed Central  Google Scholar 

  129. 129.

    Chen, B., He, Y., Xia, L., Guo, L. L. & Zheng, J. L. Cortical plasticity between the pain and pain-free phases in patients with episodic tension-type headache. J. Headache Pain 17, 105 (2016).

    PubMed  PubMed Central  Google Scholar 

  130. 130.

    Fumal, A. & Schoenen, J. Tension-type headache: current research and clinical management. Lancet Neurol. 7, 70–83 (2008).

    CAS  Google Scholar 

  131. 131.

    Sandrini, G. et al. Abnormal modulatory influence of diffuse noxious inhibitory controls in migraine and chronic tension-type headache patients. Cephalalgia 26, 782–789 (2006).

    CAS  PubMed  PubMed Central  Google Scholar 

  132. 132.

    Buchgreitz, L., Egsgaard, L. L., Jensen, R., Arendt-Nielsen, L. & Bendtsen, L. Abnormal pain processing in chronic tension-type headache: a high-density EEG brain mapping study. Brain 131, 3232–3238 (2008).

    CAS  PubMed  PubMed Central  Google Scholar 

  133. 133.

    Law, L. F. & Sluka, K. A. How does physical activity modulate pain? Pain 158, 369–370 (2017).

    PubMed  PubMed Central  Google Scholar 

  134. 134.

    D’Andrea, G. et al. Metabolism and menstrual cycle rhythmicity of serotonin in primary headaches. Headache 35, 216–221 (1995).

    PubMed  PubMed Central  Google Scholar 

  135. 135.

    Marazziti, D. et al. Platelet 3H-imipramine binding and sulphotransferase activity in primary headache. Cephalalgia 14, 210–214 (1994).

    CAS  PubMed  PubMed Central  Google Scholar 

  136. 136.

    Bendtsen, L. & Mellerup, E. T. The platelet serotonin transporter in primary headaches. Eur. J. Neurol. 5, 277–282 (1998).

    CAS  PubMed  PubMed Central  Google Scholar 

  137. 137.

    Bendtsen, L., Jensen, R., Hindberg, I., Gammeltoft, S. & Olesen, J. Serotonin metabolism in chronic tension-type headache. Cephalalgia 17, 843–848 (1997).

    CAS  PubMed  PubMed Central  Google Scholar 

  138. 138.

    Sawynok, J. & Reid, A. Interactions of descending serotonergic systems with other neurotransmitters in the modulation of nociception. Behav. Brain Res. 73, 63–68 (1996).

    CAS  PubMed  PubMed Central  Google Scholar 

  139. 139.

    Bendtsen, L., Jensen, R. & Olesen, J. A non-selective (amitriptyline), but not a selective (citalopram), serotonin reuptake inhibitor is effective in the prophylactic treatment of chronic tension-type headache. J. Neurol. Neurosurg. Psychiatry 61, 285–290 (1996).

    CAS  PubMed  PubMed Central  Google Scholar 

  140. 140.

    Ashina, S., Bendtsen, L. & Jensen, R. Analgesic effect of amitriptyline in chronic tension-type headache is not directly related to serotonin reuptake inhibition. Pain 108, 108–114 (2004).

    CAS  PubMed  PubMed Central  Google Scholar 

  141. 141.

    Kumamoto, E., Mizuta, K. & Fujita, T. Opioid actions in primary-afferent fibers — involvement in analgesia and anesthesia. Pharmaceuticals 4, 343–365 (2011).

    CAS  Google Scholar 

  142. 142.

    Bach, F. W., Langemark, M., Secher, N. H. & Olesen, J. Plasma and cerebrospinal fluid beta-endorphin in chronic tension-type headache. Pain 51, 163–168 (1992).

    Google Scholar 

  143. 143.

    Leone, M., Sacerdote, P., D’Amico, D., Panerai, A. E. & Bussone, G. Beta-endorphin concentrations in the peripheral blood mononuclear cells of migraine and tension-type headache patients. Cephalalgia 12, 154–157 (1992).

    CAS  Google Scholar 

  144. 144.

    Mazzotta, G., Sarchielli, P., Gaggioli, A. & Gallai, V. Study of pressure pain and cellular concentration of neurotransmitters related to nociception in episodic tension-type headache patients. Headache 37, 565–571 (1997).

    CAS  Google Scholar 

  145. 145.

    Langemark, M., Bach, F. W., Ekman, R. & Olesen, J. Increased cerebrospinal fluid Met-enkephalin immunoreactivity in patients with chronic tension-type headache. Pain 63, 103–107 (1995).

    CAS  Google Scholar 

  146. 146.

    de Lourdes Figuerola, M., Leston, J. & Barontini, M. Plasma met-enkephalin levels: its relationship with age and type of headache. Arch. Gerontol. Geriatr. 22, 137–143 (1996).

    PubMed  PubMed Central  Google Scholar 

  147. 147.

    Bach, F. W. et al. Effect of sulpiride or paroxetine on cerebrospinal fluid neuropeptide concentrations in patients with chronic tension-type headache. Neuropeptides 27, 129–136 (1994).

    CAS  PubMed  PubMed Central  Google Scholar 

  148. 148.

    Tajti, J., Uddman, R., Moller, S., Sundler, F. & Edvinsson, L. Messenger molecules and receptor mRNA in the human trigeminal ganglion. J. Auton. Nerv. Syst. 76, 176–183 (1999).

    CAS  PubMed  PubMed Central  Google Scholar 

  149. 149.

    Goadsby, P. J., Edvinsson, L. & Ekman, R. Vasoactive peptide release in the extracerebral circulation of humans during migraine headache. Ann. Neurol. 28, 183–187 (1990).

    CAS  PubMed  PubMed Central  Google Scholar 

  150. 150.

    Ashina, M., Bendtsen, L., Jensen, R., Schifter, S. & Olesen, J. Evidence for increased plasma levels of calcitonin gene-related peptide in migraine outside of attacks. Pain 86, 133–138 (2000).

    CAS  PubMed  PubMed Central  Google Scholar 

  151. 151.

    Ashina, M. et al. Plasma levels of calcitonin gene-related peptide in chronic tension-type headache. Neurology 55, 1335–1340 (2000).

    CAS  PubMed  PubMed Central  Google Scholar 

  152. 152.

    Gupta, R., Ahmed, T., Banerjee, B. & Bhatia, M. Plasma calcitonin gene-related peptide concentration is comparable to control group among migraineurs and tension type headache subjects during inter-ictal period. J. Headache Pain 10, 161–166 (2009).

    CAS  PubMed  PubMed Central  Google Scholar 

  153. 153.

    Ashina, M., Bendtsen, L., Jensen, R., Schifter, S. & Olesen, J. Calcitonin gene-related peptide levels during nitric oxide-induced headache in patients with chronic tension-type headache. Eur. J. Neurol. 8, 173–178 (2001).

    CAS  PubMed  PubMed Central  Google Scholar 

  154. 154.

    Uddman, R. et al. Peptide-containing nerve fibres in human extracranial tissue: a morphological basis for neuropeptide involvement in extracranial pain? Pain 27, 391–399 (1986).

    PubMed  PubMed Central  Google Scholar 

  155. 155.

    Ashina, M., Bendtsen, L., Jensen, R., Ekman, R. & Olesen, J. Plasma levels of substance P, neuropeptide Y and vasoactive intestinal polypeptide in patients with chronic tension-type headache. Pain 83, 541–547 (1999).

    CAS  PubMed  PubMed Central  Google Scholar 

  156. 156.

    Gallai, V. et al. Neuropeptide Y in juvenile migraine and tension-type headache. Headache 34, 35–40 (1994).

    CAS  PubMed  PubMed Central  Google Scholar 

  157. 157.

    Jensen, R. & Becker, W. J. in The Headaches (eds Olesen, J. et al.) 685-692 (Lippincott, Williams & Wilkins, 2005).

  158. 158.

    Jensen, R. & Becker, W. J. in The Headaches (eds Olesen, J. et al.) 693-699 (Lippincott, Williams & Wilkins, 2005).

  159. 159.

    Aaseth, K., Grande, R. B., Lundqvist, C. & Russell, M. B. Pericranial tenderness in chronic tension-type headache: the Akershus population-based study of chronic headache. J. Headache Pain 15, 58 (2014).

    PubMed  PubMed Central  Google Scholar 

  160. 160.

    Schoenen, J. & Jensen, R. in The Headaches (eds Olesen, J. et al.) 701-709 (Lippincott, Williams & Wilkins, 2005).

  161. 161.

    Rasmussen, B. K., Jensen, R. & Olesen, J. Questionnaire versus clinical interview in the diagnosis of headache. Headache 31, 290–295 (1991).

    CAS  PubMed  PubMed Central  Google Scholar 

  162. 162.

    Steiner, T. J. et al. Aids to management of headache disorders in primary care (2nd edition): on behalf of the European Headache Federation and Lifting The Burden: the Global Campaign against Headache. J. Headache Pain 20, 57 (2019). This publication by experts convened by Lifting The Burden: the Global Campaign against Headache in collaboration with the European Headache Federation provides educational materials with practical aids for primary care physicians and non-specialist health-care providers for management of headache disorders.

    CAS  PubMed  PubMed Central  Google Scholar 

  163. 163.

    Do, T. P. et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology 92, 134–144 (2019).

    PubMed  PubMed Central  Google Scholar 

  164. 164.

    Evans, R. W. et al. Neuroimaging for migraine: the American Headache Society systematic review and evidence-based guideline. Headache 60, 318–336 (2020).

    PubMed  PubMed Central  Google Scholar 

  165. 165.

    Howard, L. et al. Are investigations anxiolytic or anxiogenic? A randomised controlled trial of neuroimaging to provide reassurance in chronic daily headache. J. Neurol. Neurosurg. Psychiatry 76, 1558 (2005).

    CAS  PubMed  PubMed Central  Google Scholar 

  166. 166.

    Ashina, M. Migraine. N. Engl. J. Med. 383, 1866–1876 (2020).

    CAS  PubMed  PubMed Central  Google Scholar 

  167. 167.

    Rasmussen, B. K., Jensen, R., Schroll, M. & Olesen, J. Interrelations between migraine and tension-type headache in the general population. Arch. Neurol. 49, 914–918 (1992).

    CAS  PubMed  PubMed Central  Google Scholar 

  168. 168.

    Lyngberg, A. C., Rasmussen, B. K., Jorgensen, T. & Jensen, R. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survey. Eur. J. Epidemiol. 20, 243–249 (2005).

    PubMed  PubMed Central  Google Scholar 

  169. 169.

    Diener, H. C. et al. Pathophysiology, prevention, and treatment of medication overuse headache. Lancet Neurol. 18, 891–902 (2019).

    PubMed  PubMed Central  Google Scholar 

  170. 170.

    Yamani, N. & Olesen, J. New daily persistent headache: a systematic review on an enigmatic disorder. J. Headache Pain 20, 80 (2019).

    PubMed  PubMed Central  Google Scholar 

  171. 171.

    Bigal, M. E., Sheftell, F. D., Rapoport, A. M., Tepper, S. J. & Lipton, R. B. Chronic daily headache: identification of factors associated with induction and transformation. Headache 42, 575–581 (2002).

    PubMed  PubMed Central  Google Scholar 

  172. 172.

    Bigal, M. E., Lipton, R. B., Tepper, S. J., Rapoport, A. M. & Sheftell, F. D. Primary chronic daily headache and its subtypes in adolescents and adults. Neurology 63, 843–847 (2004).

    CAS  PubMed  PubMed Central  Google Scholar 

  173. 173.

    Forsyth, P. A. & Posner, J. B. Headaches in patients with brain tumors. Neurology 43, 1678 (1993).

    CAS  PubMed  PubMed Central  Google Scholar 

  174. 174.

    Buse, D. C. & Lipton, R. B. Facilitating communication with patients for improved migraine outcomes. Curr. Pain Headache Rep. 12, 230–236 (2008).

    PubMed  PubMed Central  Google Scholar 

  175. 175.

    Gaul, C. et al. Clinical outcome of a headache-specific multidisciplinary treatment program and adherence to treatment recommendations in a tertiary headache center: an observational study. J. Headache Pain 12, 475–483 (2011).

    PubMed  PubMed Central  Google Scholar 

  176. 176.

    Joseph-Williams, N. et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. Br. Med. J. 357, j1744 (2017).

    Google Scholar 

  177. 177.

    Mitsikostas, D. D. Nocebo in headache. Curr. Opin. Neurol. 29, 331–336 (2016).

    Google Scholar 

  178. 178.

    Hagen, K., Jensen, R., Bøe, M. G. & Stovner, L. J. Medication overuse headache: a critical review of end points in recent follow-up studies. J. Headache Pain 11, 373–377 (2010).

    PubMed  PubMed Central  Google Scholar 

  179. 179.

    Stephens, G., Derry, S. & Moore, R. A. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst. Rev. 6, CD011889 (2016).

    Google Scholar 

  180. 180.

    Derry, S., Wiffen, P. J. & Moore, R. A. Aspirin for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst. Rev. 1, CD011888 (2017).

    Google Scholar 

  181. 181.

    Bendtsen, L. et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur. J. Neurol. 17, 1318–1325 (2010). Evidence-based or expert recommendations for the management of the TTH.

    CAS  Google Scholar 

  182. 182.

    Fernández-de-Las-Peñas, C. et al. Variables associated with use of symptomatic medication during a headache attack in individuals with tension-type headache: a European study. BMC Neurol. 20, 43–43 (2020).

    PubMed  PubMed Central  Google Scholar 

  183. 183.

    Derry, S., Wiffen, P. J., Moore, R. A. & Bendtsen, L. Ibuprofen for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst. Rev. 7, CD011474 (2015).

    Google Scholar 

  184. 184.

    Veys, L., Derry, S. & Moore, R. A. Ketoprofen for episodic tension-type headache in adults. Cochrane Database Syst. Rev. 9, CD012190 (2016).

    Google Scholar 

  185. 185.

    Prior, M. J., Cooper, K. M., May, L. G. & Bowen, D. L. Efficacy and safety of acetaminophen and naproxen in the treatment of tension-type headache. A randomized, double-blind, placebo-controlled trial. Cephalalgia 22, 740–748 (2002).

    CAS  Google Scholar 

  186. 186.

    Kubitzek, F., Ziegler, G., Gold, M. S., Liu, J. M. & Ionescu, E. Low-dose diclofenac potassium in the treatment of episodic tension-type headache. Eur. J. Pain 7, 155–162 (2003).

    CAS  Google Scholar 

  187. 187.

    Pini, L. A. et al. Tolerability and efficacy of a combination of paracetamol and caffeine in the treatment of tension-type headache: a randomised, double-blind, double-dummy, cross-over study versus placebo and naproxen sodium. J. Headache Pain 9, 367–373 (2008).

    CAS  PubMed  PubMed Central  Google Scholar 

  188. 188.

    Diener, H. C., Pfaffenrath, V., Pageler, L., Peil, H. & Aicher, B. The fixed combination of acetylsalicylic acid, paracetamol and caffeine is more effective than single substances and dual combination for the treatment of headache: a multicentre, randomized, double-blind, single-dose, placebo-controlled parallel group study. Cephalalgia 25, 776–787 (2005).

    CAS  Google Scholar 

  189. 189.

    Diener, H.-C., Gold, M. & Hagen, M. Use of a fixed combination of acetylsalicylic acid, acetaminophen and caffeine compared with acetaminophen alone in episodic tension-type headache: meta-analysis of four randomized, double-blind, placebo-controlled, crossover studies. J. Headache Pain 15, 76 (2014).

    PubMed  PubMed Central  Google Scholar 

  190. 190.

    Lipton, R. B., Diener, H. C., Robbins, M. S., Garas, S. Y. & Patel, K. Caffeine in the management of patients with headache. J. Headache Pain 18, 107 (2017).

    PubMed  PubMed Central  Google Scholar 

  191. 191.

    Migliardi, J. R., Armellino, J. J., Friedman, M., Gillings, D. B. & Beaver, W. T. Caffeine as an analgesic adjuvant in tension headache. Clin. Pharmacol. Ther. 56, 576–586 (1994).

    CAS  Google Scholar 

  192. 192.

    Silverman, K., Evans, S. M., Strain, E. C. & Griffiths, R. R. Withdrawal syndrome after the double-blind cessation of caffeine consumption. N. Engl. J. Med. 327, 1109–1114 (1992).

    CAS  Google Scholar 

  193. 193.

    Göbel, H., Fresenius, J., Heinze, A., Dworschak, M. & Soyka, D. Effectiveness of Oleum menthae piperitae and paracetamol in therapy of headache of the tension type. Nervenarzt 67, 672–681 (1996).

    Google Scholar 

  194. 194.

    Göbel, H., Heinze, A., Heinze-Kuhn, K., Göbel, A. & Göbel, C. Peppermint oil in the acute treatment of tension-type headache. Schmerz 30, 295–310 (2016).

    Google Scholar 

  195. 195.

    Diener, H. C. et al. European Academy of Neurology guideline on the management of medication-overuse headache. Eur. J. Neurol. 27, 1102–1116 (2020). An important guideline on the management of MOH, a complication of primary headaches including migraine and TTH.

    CAS  Google Scholar 

  196. 196.

    Brennum, J., Kjeldsen, M. & Olesen, J. The 5-HT1-like agonist sumatriptan has a significant effect in chronic tension-type headache. Cephalalgia 12, 375–379 (1992).

    CAS  Google Scholar 

  197. 197.

    Banzi, R. et al. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults. Cochrane Database Syst. Rev. 4, CD011681 (2015).

    Google Scholar 

  198. 198.

    Exposto, F. G., Bendixen, K. H., Ernberg, M., Bach, F. W. & Svensson, P. Characterization and predictive mechanisms of experimentally induced tension-type headache. Cephalalgia 39, 1207–1218 (2019).

    Google Scholar 

  199. 199.

    Starling, A. J. Diagnosis and management of headache in older adults. Mayo Clin. Proc. 93, 252–262 (2018).

    Google Scholar 

  200. 200.

    Palacios-Ceña, M. et al. Variables associated with the use of prophylactic amitriptyline treatment in patients with tension-type headache. Clin. J. Pain 35, 315–320 (2019).

    Google Scholar 

  201. 201.

    Bendtsen, L. & Jensen, R. Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Neurology 62, 1706–1711 (2004).

    CAS  Google Scholar 

  202. 202.

    Martin-Araguz, A., Bustamante-Martinez, C. & de Pedro-Pijoan, J. M. Treatment of chronic tension type headache with mirtazapine and amitriptyline [Spanish]. Rev. Neurol. 37, 101–105 (2003).

    CAS  Google Scholar 

  203. 203.

    Zissis, N. P. et al. A randomized, double-blind, placebo-controlled study of venlafaxine XR in out-patients with tension-type headache. Cephalalgia 27, 315–324 (2007).

    CAS  Google Scholar 

  204. 204.

    Jackson, J. L., Mancuso, J. M., Nickoloff, S., Bernstein, R. & Kay, C. Tricyclic and tetracyclic antidepressants for the prevention of frequent episodic or chronic tension-type headache in adults: a systematic review and meta-analysis. J. Gen. Intern. Med. 32, 1351–1358 (2017).

    PubMed  PubMed Central  Google Scholar 

  205. 205.

    Fogelholm, R. & Murros, K. Tizanidine in chronic tension-type headache: a placebo controlled double-blind cross-over study. Headache 32, 509–513 (1992).

    CAS  Google Scholar 

  206. 206.

    Murros, K. et al. Modified-release formulation of tizanidine in chronic tension-type headache. Headache 40, 633–637 (2000).

    CAS  Google Scholar 

  207. 207.

    Agius, A. M., Jones, N. S. & Muscat, R. A randomized controlled trial comparing the efficacy of low-dose amitriptyline, amitriptyline with pindolol and surrogate placebo in the treatment of chronic tension-type facial pain. Rhinology 51, 143–153 (2013).

    CAS  Google Scholar 

  208. 208.

    Mitsikostas, D. D., Gatzonis, S., Thomas, A. & Ilias, A. Buspirone vs amitriptyline in the treatment of chronic tension-type headache. Acta Neurol. Scand. 96, 247–251 (1997).

    CAS  Google Scholar 

  209. 209.

    Lenaerts, M., Bastings, E., Sianard, J. & Schoenen, J. Sodium valproate in severe migraine and tension-type headache: an open study of long-term efficacy and correlation with blood levels. Acta Neurol. Belg. 96, 126–129 (1996).

    CAS  Google Scholar 

  210. 210.

    Lampl, C., Marecek, S., May, A. & Bendtsen, L. A prospective, open-label, long-term study of the efficacy and tolerability of topiramate in the prophylaxis of chronic tension-type headache. Cephalalgia 26, 1203–1208 (2006).

    CAS  Google Scholar 

  211. 211.

    Bottiroli, S. et al. Psychological, clinical, and therapeutic predictors of the outcome of detoxification in a large clinical population of medication-overuse headache: a six-month follow-up of the COMOESTAS Project. Cephalalgia 39, 135–147 (2018).

    Google Scholar 

  212. 212.

    Monteith, T. S. & Oshinsky, M. L. Tension-type headache with medication overuse: pathophysiology and clinical implications. Curr. Pain Headache Rep. 13, 463–469 (2009).

    PubMed  PubMed Central  Google Scholar 

  213. 213.

    Grande, R. B., Aaseth, K., Benth, J., Lundqvist, C. & Russell, M. B. Reduction in medication-overuse headache after short information. The Akershus study of chronic headache. Eur. J. Neurol. 18, 129–137 (2011).

    CAS  Google Scholar 

  214. 214.

    Carlsen, L. N. et al. Comparison of 3 treatment strategies for medication overuse headache: a randomized clinical trial. JAMA Neurol. 77, 1069–1078 (2020).

    Google Scholar 

  215. 215.

    Chiang, C. C., Schwedt, T. J., Wang, S. J. & Dodick, D. W. Treatment of medication-overuse headache: a systematic review. Cephalalgia 36, 371–386 (2016).

    Google Scholar 

  216. 216.

    Andrasik, F. et al. Non-pharmacological approaches for headaches in young age: an updated review. Front. Neurol. 9, 1009 (2018).

    PubMed  PubMed Central  Google Scholar 

  217. 217.

    Nestoriuc, Y., Rief, W. & Martin, A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J. Consult. Clin. Psychol. 76, 379–396 (2008).

    Google Scholar 

  218. 218.

    Holroyd, K. A. et al. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. JAMA 285, 2208–2215 (2001).

    CAS  PubMed  PubMed Central  Google Scholar 

  219. 219.

    Ukestad, L. K. & Wittrock, D. A. Pain perception and coping in female tension headache sufferers and headache-free controls. Health Psychol. 15, 65–68 (1996).

    CAS  Google Scholar 

  220. 220.

    Rollnik, J. D., Karst, M., Fink, M. & Dengler, R. Coping strategies in episodic and chronic tension-type headache. Headache 41, 297–302 (2001).

    CAS  Google Scholar 

  221. 221.

    Martin, P. R. et al. Behavioral management of the triggers of recurrent headache: a randomized controlled trial. Behav. Res. Ther. 61, 1–11 (2014).

    Google Scholar 

  222. 222.

    Christiansen, S., Jürgens, T. P. & Klinger, R. Outpatient combined group and individual cognitive-behavioral treatment for patients with migraine and tension-type headache in a routine clinical setting. Headache 55, 1072–1091 (2015).

    Google Scholar 

  223. 223.

    Gu, Q., Hou, J. C. & Fang, X. M. Mindfulness meditation for primary headache pain: a meta-analysis. Chin. Med. J. 131, 829–838 (2018).

    PubMed  PubMed Central  Google Scholar 

  224. 224.

    Wang, J. et al. Triggers of migraine and tension-type headache in China: a clinic-based survey. Eur. J. Neurol. 20, 689–696 (2013).

    CAS  Google Scholar 

  225. 225.

    Pellegrino, A. B. W., Davis-Martin, R. E., Houle, T. T., Turner, D. P. & Smitherman, T. A. Perceived triggers of primary headache disorders: a meta-analysis. Cephalalgia 38, 1188–1198 (2018).

    Google Scholar 

  226. 226.

    Lipton, R. B., Pavlovic, J. M., Haut, S. R., Grosberg, B. M. & Buse, D. C. Methodological issues in studying trigger factors and premonitory features of migraine. Headache 54, 1661–1669 (2014).

    Google Scholar 

  227. 227.

    Kim, K. M. et al. Excessive daytime sleepiness in tension-type headache: a population study. Front. Neurol. 10, 1282 (2019).

    PubMed  PubMed Central  Google Scholar 

  228. 228.

    Benito-González, E. et al. Variables associated with sleep quality in chronic tension-type headache: A cross-sectional and longitudinal design. PLoS ONE 13, e0197381 (2018).

    PubMed  PubMed Central  Google Scholar 

  229. 229.

    Sullivan, D. P., Martin, P. R. & Boschen, M. J. Psychological sleep interventions for migraine and tension-type headache: a systematic review and meta-analysis. Sci. Rep. 9, 6411 (2019).

    PubMed  PubMed Central  Google Scholar 

  230. 230.

    Tornøe, B. et al. Specific strength training compared with interdisciplinary counseling for girls with tension-type headache: a randomized controlled trial. J. Pain Res. 9, 257–270 (2016).

    PubMed  PubMed Central  Google Scholar 

  231. 231.

    Andersen, C. H. et al. Effect of resistance training on headache symptoms in adults: secondary analysis of a RCT. Musculoskelet. Sci. Pract. 32, 38–43 (2017).

    CAS  Google Scholar 

  232. 232.

    Krøll, L. S., Hammarlund, C. S., Linde, M., Gard, G. & Jensen, R. H. The effects of aerobic exercise for persons with migraine and co-existing tension-type headache and neck pain. A randomized, controlled, clinical trial. Cephalalgia 38, 1805–1816 (2018).

    Google Scholar 

  233. 233.

    Espí-López, G. V., Zurriaga-Llorens, R., Monzani, L. & Falla, D. The effect of manipulation plus massage therapy versus massage therapy alone in people with tension-type headache. A randomized controlled clinical trial. Eur. J. Phys. Rehabil. Med. 52, 606–617 (2016).

    Google Scholar 

  234. 234.

    Falsiroli Maistrello, L., Geri, T., Gianola, S., Zaninetti, M. & Testa, M. Effectiveness of Trigger point manual treatment on the frequency, intensity, and duration of attacks in primary headaches: a systematic review and meta-analysis of randomized controlled trials. Front. Neurol. 9, 254 (2018).

    PubMed  PubMed Central  Google Scholar 

  235. 235.

    Falsiroli Maistrello, L., Rafanelli, M. & Turolla, A. Manual therapy and quality of life in people with headache: systematic review and meta-analysis of randomized controlled trials. Curr. Pain Headache Rep. 23, 78 (2019).

    Google Scholar 

  236. 236.

    Bot, M. N. et al. Physical treatments reduce pain in children with tension-type headache: a systematic review and meta-analysis. J. Oral. Facial Pain Headache 34, 240–254 (2020).

    Google Scholar 

  237. 237.

    Kamonseki, D. H., Lopes, E. P., van der Meer, H. A. & Calixtre, L. B. Effectiveness of manual therapy in patients with tension-type headache. A systematic review and meta-analysis. Disabil. Rehabil. https://doi.org/10.1080/09638288.2020.1813817 (2020).

    Article  Google Scholar 

  238. 238.

    Linde, K. et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst. Rev. 4, CD007587 (2016).

    PubMed  PubMed Central  Google Scholar 

  239. 239.

    Karadaş, Ö., Gül, H. L. & Inan, L. E. Lidocaine injection of pericranial myofascial trigger points in the treatment of frequent episodic tension-type headache. J. Headache Pain 14, 44 (2013).

    PubMed  PubMed Central  Google Scholar 

  240. 240.

    Gildir, S., Tüzün, E. H., Eroğlu, G. & Eker, L. A randomized trial of trigger point dry needling versus sham needling for chronic tension-type headache. Medicine 98, e14520 (2019).

    PubMed  PubMed Central  Google Scholar 

  241. 241.

    Vázquez-Justes, D., Yarzábal-Rodríguez, R., Doménech-García, V., Herrero, P. & Bellosta-López, P. Effectiveness of dry needling for headache: a systematic review. Neurologia https://doi.org/10.1016/j.nrl.2019.09.010 (2020).

    Article  Google Scholar 

  242. 242.

    Linde, M. et al. The cost of headache disorders in Europe: the Eurolight project. Eur. J. Neurol. 19, 703–711 (2012).

    CAS  Google Scholar 

  243. 243.

    Edmeads, J. et al. Impact of migraine and tension-type headache on life-style, consulting behaviour, and medication use: a canadian population survey. Can. J. Neurol. Sci. 20, 131–137 (1993).

    CAS  Google Scholar 

  244. 244.

    Lyngberg, A. C., Rasmussen, B. K., Jorgensen, T. & Jensen, R. Secular changes in health care utilization and work absence for migraine and tension-type headache: a population based study. Eur. J. Epidemiol. 20, 1007–1014 (2005).

    CAS  Google Scholar 

  245. 245.

    Lavados, P. M. & Tenhamm, E. Consulting behaviour in migraine and tension-type headache sufferers: a population survey in Santiago, Chile. Cephalalgia 21, 733–737 (2001).

    CAS  Google Scholar 

  246. 246.

    Wang, S. J., Fuh, J. L., Young, Y. H., Lu, S. R. & Shia, B. C. Frequency and predictors of physician consultations for headache. Cephalalgia 21, 25–30 (2001).

    CAS  Google Scholar 

  247. 247.

    Jensen, R. & Rasmussen, B. K. Burden of headache. Expert Rev. Pharmacoecon Outcomes Res. 4, 353–359 (2004).

    Google Scholar 

  248. 248.

    Lenaerts, M. E. Burden of tension-type headache. Curr. Pain Headache Rep. 10, 459–462 (2006). This review article discusses the burden caused by TTH on society including economic impact, loss of productivity, increase in health-care utilization and reduced quality of life.

    Google Scholar 

  249. 249.

    Saylor, D. & Steiner, T. J. The global burden of headache. Semin. Neurol. 38, 182–190 (2018).

    Google Scholar 

  250. 250.

    Penacoba-Puente, C., Fernandez-de-Las-Penas, C., Gonzalez-Gutierrez, J. L., Miangolarra-Page, J. C. & Pareja, J. A. Interaction between anxiety, depression, quality of life and clinical parameters in chronic tension-type headache. Eur. J. Pain 12, 886–894 (2008).

    Google Scholar 

  251. 251.

    Abu Bakar, N. et al. Quality of life in primary headache disorders: A review. Cephalalgia 36, 67–91 (2016).

    Google Scholar 

  252. 252.

    Lampl, C. et al. Will (or can) people pay for headache care in a poor country? J. Headache Pain 13, 67–74 (2012).

    PubMed  PubMed Central  Google Scholar 

  253. 253.

    Guitera, V., Munoz, P., Castillo, J. & Pascual, J. Quality of life in chronic daily headache: a study in a general population. Neurology 58, 1062–1065 (2002).

    PubMed  PubMed Central  Google Scholar 

  254. 254.

    Ashina, S. et al. Health-related quality of life in tension-type headache: a population-based study. Scand. J. Pain https://doi.org/10.1515/sjpain-2020-0166 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  255. 255.

    Wang, S. J., Fuh, J. L., Lu, S. R. & Juang, K. D. Quality of life differs among headache diagnoses: analysis of SF-36 survey in 901 headache patients. Pain 89, 285–292 (2001).

    CAS  PubMed  PubMed Central  Google Scholar 

  256. 256.

    Solomon, G. D., Skobieranda, F. G. & Gragg, L. A. Does quality of life differ among headache diagnoses? Analysis using the medical outcomes study instrument. Headache 34, 143–147 (1994).

    CAS  PubMed  PubMed Central  Google Scholar 

  257. 257.

    Stewart, A. L., Hays, R. D. & Ware, J. E. Jr. The MOS short-form general health survey. Reliability and validity in a patient population. Med. Care 26, 724–735 (1988).

    CAS  PubMed  PubMed Central  Google Scholar 

  258. 258.

    Palermo, T. M., Putnam, J., Armstrong, G. & Daily, S. Adolescent autonomy and family functioning are associated with headache-related disability. Clin. J. Pain 23, 458–465 (2007).

    PubMed  PubMed Central  Google Scholar 

  259. 259.

    Nachit-Ouinekh, F. et al. Use of the headache impact test (HIT-6) in general practice: relationship with quality of life and severity. Eur. J. Neurol. 12, 189–193 (2005).

    CAS  PubMed  PubMed Central  Google Scholar 

  260. 260.

    Bigal, M. E. & Lipton, R. B. Modifiable risk factors for migraine progression (or for chronic daily headaches)–clinical lessons. Headache 46 (Suppl. 3), S144–S146 (2006).

    PubMed  PubMed Central  Google Scholar 

  261. 261.

    Durham, P. & Papapetropoulos, S. Biomarkers associated with migraine and their potential role in migraine management. Headache 53, 1262–1277 (2013).

    PubMed  PubMed Central  Google Scholar 

  262. 262.

    Burstein, R., Collins, B. & Jakubowski, M. Defeating migraine pain with triptans: a race against the development of cutaneous allodynia. Ann. Neurol. 55, 19–26 (2004).

    CAS  PubMed  PubMed Central  Google Scholar 

  263. 263.

    Müller, K. I., Alstadhaug, K. B. & Bekkelund, S. I. A randomized trial of telemedicine efficacy and safety for nonacute headaches. Neurology 89, 153–162 (2017).

    PubMed  PubMed Central  Google Scholar 

  264. 264.

    Friedman, B. W. et al. A randomized trial of intravenous ketorolac versus intravenous metoclopramide plus diphenhydramine for tension-type and all nonmigraine, noncluster recurrent headaches. Ann. Emerg. Med. 62, 311–318.e314 (2013).

    PubMed  PubMed Central  Google Scholar 

  265. 265.

    Cicek, M. et al. Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes. Emerg. Med. J. 21, 323–326 (2004).

    CAS  PubMed  PubMed Central  Google Scholar 

  266. 266.

    Bendtsen, L., Buchgreitz, L., Ashina, S. & Jensen, R. Combination of low-dose mirtazapine and ibuprofen for prophylaxis of chronic tension-type headache. Eur. J. Neurol. 14, 187–193 (2007).

    CAS  Google Scholar 

  267. 267.

    Pothmann, R. & Lobisch, M. Acute treatment of episodic childhood tension-type headache with flupirtine and paracetamol - a double-blind crossover-study [German]. Schmerz 14, 1–4 (2000).

    CAS  PubMed  PubMed Central  Google Scholar 

  268. 268.

    Hershey, A. D., Powers, S. W., Bentti, A. L. & Degrauw, T. J. Effectiveness of amitriptyline in the prophylactic management of childhood headaches. Headache 40, 539–549 (2000).

    CAS  PubMed  PubMed Central  Google Scholar 

  269. 269.

    Andrasik, F., Grazzi, L., Usai, S. & Bussone, G. Pharmacological treatment compared to behavioural treatment for juvenile tension-type headache: results at two-year follow-up. Neurol. Sci. 28 (Suppl. 2), S235–S238 (2007).

    PubMed  PubMed Central  Google Scholar 

  270. 270.

    Balottin, U. et al. Psychotherapy versus usual care in pediatric migraine and tension-type headache: a single-blind controlled pilot study. Ital. J. Pediatr. 40, 6 (2014).

    PubMed  PubMed Central  Google Scholar 

  271. 271.

    Klausen, S. H., Rønde, G., Tornøe, B. & Bjerregaard, L. Nonpharmacological interventions addressing pain, sleep, and quality of life in children and adolescents with primary headache: a systematic review. J. Pain Res. 12, 3437–3459 (2019).

    PubMed  PubMed Central  Google Scholar 

  272. 272.

    Soee, A. B., Skov, L., Skovgaard, L. T. & Thomsen, L. L. Headache in children: effectiveness of multidisciplinary treatment in a tertiary paediatric headache clinic. Cephalalgia 33, 1218–1228 (2013).

    PubMed  PubMed Central  Google Scholar 

  273. 273.

    Berk, T., Ashina, S., Martin, V., Newman, L. & Vij, B. Diagnosis and treatment of primary headache disorders in older adults. J. Am. Geriatr. Soc. 66, 2408–2416 (2018).

    PubMed  PubMed Central  Google Scholar 

  274. 274.

    Yang, F. C. et al. Increased risk of dementia in patients with tension-type headache: a nationwide retrospective population-based cohort study. PLoS ONE 11, e0156097 (2016).

    PubMed  PubMed Central  Google Scholar 

  275. 275.

    Negro, A. et al. Headache and pregnancy: a systematic review. J. Headache Pain 18, 106 (2017).

    CAS  PubMed  PubMed Central  Google Scholar 

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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.

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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.)

Corresponding author

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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