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Chronic Tension Headache
Tension-type headache (TTH) is the most common form of headache. It is sometimes referred to as “stress headache” or “muscle tension headache.” There are two classifications of TTH: episodic tension-type headache (ETTH), which occurs randomly and infrequently, and chronic tension-type headache (CTTH), which occurs daily or continuously on at least 15 days per month, although the intensity of the pain may vary during a 24-hour cycle.1 It is estimated that 30 to 80% of the adult population in the United States suffers from occasional TTH, yet only 3% suffer from CTTH.2
Symptoms of TTH include a tight feeling in head or neck muscles or a tightening band-like sensation around the neck or head, which creates a “vise-like” ache. The pain is typically found in the forehead, temples, or the back of the head or neck. However, there is frequently significant crossover between the symptoms of TTH and migraine without aura. In fact, in the Spectrum study, 71% of the participants initially diagnosed with episodic TTH subsequently had their diagnosis changed to migraine or migrainous headache after their headache diary was reviewed by the investigators.3 The second edition of the International Classification of Headache Disorders (ICHD-II) subdivides TTH into three divisions: infrequent episodic, frequent episodic, and chronic4 (Tables 15.1 and 15.2). The etiology of TTH is thought to be related to cervical myofascial activity involving the neck, face, and scalp, which likely reflects a complex syndrome involving peripheral nociceptors in ETTH and central dysnociception in CTTH.1
Nonpharmacologic treatments such as relaxation and electromyography (EMG) biofeedback therapies, cognitive behavioral interventions, and various physical therapy techniques have shown various degrees of success at reducing the frequency and severity of TTH. Medications used to treat chronic daily headache include simple analgesics, such as aspirin and paracetamol, and nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen and naproxen sodium. The addition of caffeine increases the efficacy of these medications. Prophylactic medications such as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), the antispasmodic drug tizanidine, and topiramate may provide additional relief for some patients. Unfortunately, current pharmacotherapy for CTTH can be limited by either incomplete efficacy or intolerable side effects.
Table 15.1 Tension-Type Headache (Episodic Form)—General Diagnostic Criteria B–E
B. Headache lasting from 30 minute to 7 days C. At least two of the following pain characteristics: 1. Bilateral location 2. Pressing or tightening (nonpulsating) quality 3. Mild or moderate intensity 4. Not aggravated by routine physical activity, such as walking or climbing stairs D. Both of the following: 1. No nausea or vomiting (anorexia can occur) 2. No more than one of photophobia or phonophobia E. Not attributed to another disorder |
(From International Headache Society. The International Classification of Headache Dis orders, 2nd ed (ICHD-II). Cephalalgia 2004;24(suppl 1): 9–160. Reprinted by permission.)
Given its effects on nociception and muscle contraction, botulinum neurotoxin (BoNT) appears to be an attractive agent in the prophylaxis of TTH. In addition to its well-known effects in reducing muscle contractions, it may also block the release of pain mediators such as substance P, glutamate, and calcitonin gene-related peptide.5
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