Tension-type headache (TTH) is characterized by a bilateral, pressing tightening pain of mild to moderate intensity, occurring either in short episodes of variable duration, infrequent TTH ≤1 days/month or as frequent episodic TTH occurring between 1 and 14 days/month or continuously in the chronic form ≥15 days/month. The headache is pressing in quality, often bilateral and not aggravated by physical activity as in migraine. Furthermore, TTH is not associated with the typical migraine features as vomiting, severe nausea, photophobia and/or phonophobia. Only one of the migraine accompanying symptoms is allowed, so either photophobia, phonophobia or nausea is accepted. Due to lack of accompanying symptoms and the relatively mild pain intensity, patients are rarely severely incapacitated by their pain to the same degree as to migraine and cluster headache. In the clinic, TTH patients often call these headaches “normal” or their “background” headache. Likewise, migraine or medication-overuse headache (MOH) patients tend to underestimate these headaches in the direct interview, and a diagnostic diary where all headaches are registered is therefore a very useful instrument. As TTH also is the most featureless of the primary headaches and because many secondary headaches may mimic TTH, a diagnosis of TTH requires exclusion of other organic disorders.

A general and neurological examination and a prospective follow-up using diagnostic headache diaries with registration of all consumed drugs are therefore of utmost importance to reach the diagnosis. There are no reliable specific paraclinical tests that are useful in the differential diagnosis. Manual palpation of the pericranial muscles and their insertions should always be done to demonstrate a possible muscular factor for the patient and to plan the treatment strategy, where physical training and relaxation therapy are important components.

The differential diagnosis is most frequently migraine and MOH, as they most frequently coexist with TTH. A migraine attack may start as a TTH-like headache, high-frequency TTH may trigger a latent migraine and a long-lasting severe migraine attack may also be accompanied by a TTH in the postictal phase. Based on the medical history, the diagnostic diary and the phenotype, secondary headaches as MOH, posttraumatic headaches and idiopathic intracranial hypertension should also be ruled out. MOH can be identified by a detailed interview and a prospective diary if all pain medications are indicated. Posttraumatic headache is required to have occurred in close relation (within 8 days) to a head trauma and, despite the headaches, is most often accompanied by a variety of cognitive complaints, fatigue, isolation, alcohol intolerance and sleep problems. IIH can present in variable forms but most often manifest as a severe more migraine-like constant headache, along with pulsating tinnitus, and transitory visual obscurations in obese, young individuals. In all cases of chronic headache, a detailed funduscopy in the search for papilledema is required.

In case 1, there is a very typical coexisting migraine once or twice a month but this headache is fully responsive to triptans, whereas the “normal” featureless background headache, the chronic tension-type headache, is unresponsive to triptans or simple analgesics, which is the most significant problem for the patient.

In case 2, the patient is suffering from a “pure” chronic TTH without any other primary or secondary headaches, and the headaches are completely constant without day to variation.

A correct diagnosis should be assured by means of a headache diary recorded over at least 4 weeks (Figs. 21.1 and 21.2). The diagnostic problem most often encountered is to discriminate between TTH and mild migraines. The diary may also reveal triggers and medication overuse, and it will establish the baseline against which to measure the efficacy of treatments. Identification of a high intake of analgesics is essential as other treatments are largely ineffective in the presence of medication overuse. Significant co-morbidities, e.g. anxiety or depression, should be identified during the consultation and treated concomitantly.

Information about the nature of the disease is important. It can be explained that muscle pain can lead to a disturbance of the brain’s pain-modulating mechanisms, so that normally innocuous stimuli are perceived as painful, with secondary perpetuation of muscle pain and risk of anxiety and depression. The very fact that the physician takes the problem seriously may have a therapeutic effect, particularly if the patient is concerned about serious disease, e.g. brain tumour, and can be reassured by thorough muscle and neurological examination. The most frequently reported triggers for TTH are stress (mental or physical), irregular or inappropriate meals, high intake of coffee and other caffeine-containing drinks, dehydration, sleep disorders, too much or too little sleep, reduced or inappropriate physical exercise, psychological problems as well as variations during the female menstrual cycle and hormonal substitution. It should be explained to the patient that frequent TTH only seldom can be cured, but that a meaningful improvement can be obtained with the combination of non-pharmacological and pharmacological treatments. These treatments are described separately in the following but should go hand in hand.

Non-pharmacological management should be considered for all patients with TTH and is widely used. However, the scientific evidence for efficacy of most treatment modalities is sparse. Physical therapy is the most used non-pharmacological treatment of TTH and includes the improvement of posture, relaxation and exercise programmes. Active treatment strategies are generally recommended (here to case 1). It has been reported that adding craniocervical training to classical physiotherapy was better than physiotherapy alone and a recent study indicated the effect of manual therapy. There are conflicting results regarding the efficacy of acupuncture for the treatment of TTH.

Psychological treatment strategies have reasonable scientific support for effectiveness. Relaxation training is a self-regulation strategy that provides patients with the ability to consciously reduce muscle tension and autonomic arousal that can precipitate and result from headaches. Electromyographic (EMG) biofeedback has been demonstrated to be effective. During EMG biofeedback, patients are presented with an auditory or visual display of electrical activity of the muscles in the face, neck or shoulders. This feedback helps the patients to develop control over pericranial muscle tension. It is most likely that cognitive changes (i.e. self-efficacy) rather than reductions in muscle tension account for the improvement in TTH with EMG biofeedback. Cognitive-behavioural therapy (stress management) aims to teach the patient to identify thoughts and beliefs that generate stress and aggravate headaches (here to case 1). The exact degree of effect of psychological treatment strategies is difficult to estimate, but cognitive-behavioural therapy has been found to be comparable with treatment with tricyclic antidepressants, while a combination of the two treatments seemed to be more effective than either treatment alone.