The International Classification of Headache Disorders 2nd Edition



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2. TENSION-TYPE HEADACHE (TTH)


2.1 Infrequent episodic tension-type headache

2.1.1 Infrequent episodic tension-type headache associated with pericranial tenderness

2.1.2 Infrequent episodic tension-type headache not associated with pericranial tenderness

2.2 Frequent episodic tension-type headache

2.2.1 Frequent episodic tension-type headache associated with pericranial tenderness

2.2.2 Frequent episodic tension-type headache not associated with pericranial tenderness

2.3 Chronic tension-type headache

2.3.1 Chronic tension-type headache associated with pericranial tenderness

2.3.2 Chronic tension-type headache not associated with pericranial tenderness

2.4 Probable tension-type headache

2.4.1 Probable infrequent episodic tension-type headache

2.4.2 Probable frequent episodic tension-type headache

2.4.3 Probable chronic tension-type headache

Previously used terms:

Tension headache, muscle contraction headache, psychomyogenic headache, stress headache, ordinary headache, essential headache, idiopathic headache and psychogenic headache
Coded elsewhere:

Tension-type-like headache attributed to another disorder is coded to that disorder.

General comment

Primary or secondary headache or both?

When a headache with tension-type characteristics occurs for the first time in close temporal relation to another disorder that is a known cause of headache, it is coded according to the causative disorder as a secondary headache. When pre-existing tension-type headache is made worse in close temporal relation to another disorder that is a known cause of headache, there are two possibilities, and judgment is required. The patient can either be given only the tension-type headache diagnosis or be given both the tension-type headache diagnosis and a secondary headache diagnosis according to the other disorder. Factors that support adding the latter diagnosis are: a very close temporal relation to the disorder, a marked worsening of the tension-type headache, very good evidence that the disorder can cause or aggravate tension-type headache and, finally, improvement or resolution of tension-type headache after relief from the disorder.

Introduction


This is the most common type of primary headache: its lifetime prevalence in the general population ranges in different studies from 30 to 78%. At the same time, it is the least studied of the primary headache disorders, despite the fact that it has the highest socio-economic impact.

Whilst this type of headache was previously considered to be primarily psychogenic, a number of studies have appeared after the first edition of The International Classification of Headache Disorders that strongly suggest a neurobiological basis, at least for the more severe subtypes of tension-type headache.

The division into episodic and chronic subtypes that was introduced in the first edition of the classification has proved extremely useful. The chronic subtype is a serious disease causing greatly decreased quality of life and high disability. In the present edition we have decided to subdivide episodic tension-type headache further, into an infrequent subtype with headache episodes less than once per month and a frequent subtype. The infrequent subtype has very little impact on the individual and does not deserve much attention from the medical profession. However, frequent sufferers can encounter considerable disability that sometimes warrants expensive drugs and prophylactic medication. The chronic subtype is of course always associated with disability and high personal and socio-economic costs.

The first edition arbitrarily separated patients with and without disorder of the pericranial muscles. This has proved to be a valid subdivision but the only really useful distinguishing feature is tenderness on manual palpation and not, as suggested in the first edition, evidence from surface EMG or pressure algometry. Therefore, we now use only manual palpation, preferably as pressure-controlled palpation, to subdivide all three subtypes of tension-type headache.

The exact mechanisms of tension-type headache are not known. Peripheral pain mechanisms are most likely to play a role in 2.1 Infrequent episodic tension-type headache and 2.2 Frequent episodic tension-type headache whereas central pain mechanisms play a more important role in 2.3 Chronic tension-type headache. The classification subcommittee encourages further research into the pathophysiological mechanisms and treatment of tension-type headache.

There are some reasons to believe that, with the diagnostic criteria set out in the first edition, patients coded for episodic tension-type headache included some who had a mild form of migraine without aura and patients coded for chronic tension-type headache included some who had chronic migraine. Clinical experience favours this suspicion, especially in patients who also have migraine attacks, and some patients may display pathophysiological features typical of migraine (Schoenen et al, 1987). Within the classification subcommittee there was an attempt to tighten the diagnostic criteria for tension-type headache for the second edition, with the hope to exclude migraine patients whose headache phenotypically resembles tension-type headache. However, this would have compromised the sensitivity of the criteria and there was no evidence to show the beneficial effects of such a change. Therefore a consensus was not reached, but a proposal for new, stricter diagnostic criteria is published under A2 Tension-type headache in the appendix. The classification subcommittee recommends comparisons between patients diagnosed according to the explicit criteria and others diagnosed according to the appendix criteria. This pertains not only to the clinical features but also to pathophysiological mechanisms and response to treatments.


2.1 Infrequent episodic tension-type headache

Description:

Infrequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present.
Diagnostic criteria:

A. At least 10 episodes occurring on <1 day per month on average (<12 days per year) and fulfilling criteria B-D

B. Headache lasting from 30 minutes to 7 days

C. Headache has at least two of the following characteristics:

1. bilateral location

2. pressing/tightening (non-pulsating) 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 may occur)

2. no more than one of photophobia or phonophobia

E. Not attributed to another disorder1

Note:

1. History and physical and neurological examinations do not suggest any of the disorders listed in groups 5-12, or history and/or physical and/or neurological examinations do suggest such disorder but it is ruled out by appropriate investigations, or such disorder is present but headache does not occur for the first time in close temporal relation to the disorder.

2.1.1 Infrequent episodic tension-type headache associated with pericranial tenderness

Diagnostic criteria:

A. Episodes fulfilling criteria A-E for 2.1 Infrequent episodic tension-type headache

B. Increased pericranial tenderness on manual palpation



2.1.2 Infrequent episodic tension-type headache not associated with pericranial tenderness

Diagnostic criteria:

A. Episodes fulfilling criteria A-E for 2.1 Infrequent episodic tension-type headache

B. No increased pericranial tenderness



Comments:

Increased pericranial tenderness recorded by manual palpation is the most significant abnormal finding in patients with tension-type headache. The tenderness increases with the intensity and frequency of headache and is further increased during actual headache. The diagnostic value of EMG and pressure algometry is limited and these recordings are therefore omitted from the second edition. Pericranial tenderness is easily recorded by manual palpation by small rotating movements and a firm pressure (preferably aided by use of a palpometer) with the second and third finger on the frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius and trapezius muscles. A local tenderness score from 0-3 on each muscle can be summated to yield a total tenderness score for each individual. It has been demonstrated that, using a pressure sensitive device that allows palpation with a controlled pressure, this clinical examination becomes more valid and reproducible. However, such equipment is not generally available to clinicians and it is advised that clinicians simply perform the manual palpation as a traditional clinical examination.

Palpation is a useful guide for the treatment strategy. It also adds value and credibility to the explanations given to the patient.


2.2 Frequent episodic tension-type headache

Description:

Frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present.
Diagnostic criteria:

A. At least 10 episodes occurring on 1 but <15 days per month for at least 3 months (12 and <180 days per year) and fulfilling criteria B-D

B. Headache lasting from 30 minutes to 7 days

C. Headache has at least two of the following characteristics:

1. bilateral location

2. pressing/tightening (non-pulsating) 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 may occur)

2. no more than one of photophobia or phonophobia

E. Not attributed to another disorder1

Note:

1. History and physical and neurological examinations do not suggest any of the disorders listed in groups 5-12, or history and/or physical and/or neurological examinations do suggest such disorder but it is ruled out by appropriate investigations, or such disorder is present but headache does not occur for the first time in close temporal relation to the disorder.
Comment:

Frequent tension-type headache often coexists with migraine without aura. Coexisting tension-type headache in migraineurs should preferably be identified by a diagnostic headache diary. The treatment of migraine differs considerably from that of tension-type headache and it is important to educate patients to differentiate between these types of headaches in order to select the right treatment and to prevent medication-overuse headache.

2.2.1 Frequent episodic tension-type headache associated with pericranial tenderness

Diagnostic criteria:

A. Episodes fulfilling criteria A-E for 2.2 Frequent episodic tension-type headache

B. Increased pericranial tenderness on manual palpation



2.2.2 Frequent episodic tension-type headache not associated with pericranial tenderness

Diagnostic criteria:

A. Episodes fulfilling criteria A-E for 2.2 Frequent episodic tension-type headache

B. No increased pericranial tenderness



2.3 Chronic tension-type headache

Coded elsewhere:

4.8 New daily-persistent headache
Description:

A disorder evolving from episodic tension-type headache, with daily or very frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There may be mild nausea, photophobia or phonophobia.
Diagnostic criteria:

A. Headache occurring on 15 days per month on average for >3 months (180 days per year)1 and fulfilling criteria B-D

B. Headache lasts hours or may be continuous

C. Headache has at least two of the following characteristics:

1. bilateral location

2. pressing/tightening (non-pulsating) 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 more than one of photophobia, phonophobia or mild nausea

2. neither moderate or severe nausea nor vomiting

E. Not attributed to another disorder2;3

Notes:

  1. 2.3 Chronic tension-type headache evolves over time from episodic tension-type headache; when these criteria A-E are fulfilled by headache that, unambiguously, is daily and unremitting within 3 days of its first onset, code as 4.8 New daily-persistent headache. When the manner of onset is not remembered or is otherwise uncertain, code as 2.3 Chronic tension-type headache.

  2. History and physical and neurological examinations do not suggest any of the disorders listed in groups 5-12, or history and/or physical and/or neurological examinations do suggest such disorder but it is ruled out by appropriate investigations, or such disorder is present but headache does not occur for the first time in close temporal relation to the disorder.

3. When medication overuse is present and fulfils criterion B for any of the subforms of 8.2 Medication-overuse headache, it is uncertain whether this criterion E is fulfilled until 2 months after medication has been withdrawn without improvement (see Comments).
Comments:

The introduction of 1.5.1 Chronic migraine into The International Classification of Headache Disorders, 2nd edition, creates a problem in relation to the differential diagnosis between this and 2.3 Chronic tension-type headache. Both diagnoses require headache (meeting the criteria for migraine or tension-type headache respectively) on at least 15 days a month. Therefore it is possible theoretically that a patient can have both these diagnoses. A very small group of patients have 15 or more headaches per month fulfilling the diagnostic criteria for both 1.5.1 Chronic migraine and 2.3 Chronic tension-type headache. This is possible when two (and only two) of the four pain characteristics are present and headaches are associated with mild nausea. In these rare cases, other clinical evidence that is not part of the explicit diagnostic criteria should be taken into account and the clinician should base thereon the best possible choice of diagnosis. When it is uncertain how many attacks fulfil one or other set of criteria it is strongly recommended to use a diagnostic headache diary prospectively.

In many uncertain cases there is overuse of medication. When this fulfils criterion B for any of the subforms of 8.2 Medication-overuse headache, the default rule is to code for 2.4.3 Probable chronic tension-type headache plus 8.2.87 Probable medication-overuse headache. When these criteria are still fulfilled 2 months after medication overuse has ceased, 2.3 Chronic tension-type headache should be diagnosed and 8.2.78.2.8 Probable medication-overuse headache discarded. If at any time sooner they are no longer fulfilled, because improvement has occurred, 8.2 Medication-overuse headache should be diagnosed and 2.4.3 Probable chronic tension-type headache discarded.

It should be remembered that some patients with chronic tension-type headache develop migraine-like features if they have severe pain and , conversely, some migraine patients develop increasingly frequent tension-type-like interval headaches, the nature of which remains unclear.

2.3.1 Chronic tension-type headache associated with pericranial tenderness

Diagnostic criteria:

A. Headache fulfilling criteria A-E for 2.3 Chronic tension-type headache

B. Increased pericranial tenderness on manual palpation



2.3.2 Chronic tension-type headache not associated with pericranial tenderness

Diagnostic criteria:

A. Headache fulfilling criteria A-E for 2.3 Chronic tension-type headache

B. No increased pericranial tenderness



2.4 Probable tension-type headache

Comment:

Patients meeting one of these sets of criteria may also meet the criteria for one of the subforms of 1.6 Probable migraine. In such cases, all other available information should be used to decide which of the alternatives is the more likely.

2.4.1 Probable infrequent episodic tension-type headache

Diagnostic criteria:

A. Episodes fulfilling all but one of criteria A-D for 2.1 Infrequent episodic tension-type headache

B. Episodes do not fulfil criteria for 1.1 Migraine without aura

C. Not attributed to another disorder

2.4.2 Probable frequent episodic tension-type headache

Diagnostic criteria:

A. Episodes fulfilling all but one of criteria A-D for 2.2 Frequent episodic tension-type headache

B. Episodes do not fulfil criteria for 1.1 Migraine without aura

C. Not attributed to another disorder

2.4.3 Probable chronic tension-type headache

Diagnostic criteria:

A. Headache occurring on 15 days per month on average for >3 months (180 days per year) and fulfilling criteria B-D

B. Headache lasts hours or may be continuous

C. Headache has at least two of the following characteristics:

1. bilateral location

2. pressing/tightening (non-pulsating) 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 more than one of photophobia, phonophobia or mild nausea

2. neither moderate or severe nausea nor vomiting

E. Not attributed to another disorder but there is, or has been within the last 2 months, medication overuse fulfilling criterion B for any of the subforms of 8.2 Medication-overuse headache

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