Diagnosing tension headaches

In this video, you will learn how to recognize the characteristics of tension headaches in your patient.

Robert Coni, DO EdS
Robert Coni, DO EdS
13th Aug 2020 • 3m read

Tension headaches are the most common type of primary headache disorder seen by physicians and perhaps the most misunderstood. The name implies that muscle tension or anxious tension is the cause, but this isn't actually true. In this video, we'll explore the criteria for diagnosing tension headaches so that you will be able to recognize the characteristics of tension headaches in your patient.

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Video transcript

Tension headaches are the most common type of primary headache disorder seen in practice, and perhaps the most misunderstood. The name implies muscle tension, or anxious tension is the cause, but this is not accurate. Tension headaches are not related to over contraction of muscles, or anxiety. Rather, the mechanism is an abnormality in neuronal modulation in the trigeminal nerve.

The trigeminal nerve carries the sensory input from the face and cranium to the central nervous system and connects to the muscles of the head and vicinity. The trigeminal nerve connections are reviewed in the Medmastery Neurology Essentials Course but involve pain nociceptors in the cranial structures, blood vessels, mucous membranes, and peri-cranial muscles.

There are central pathways which facilitate pain in the trigeminal nucleus. It is important to note that it is not the brain which feels pain. Rather, it is the peri-cranial tissues, including the bone and meninges that have nociceptors, which are sensitive to pain. Tension headaches are often bilaterally and are described by patients as pressure-like, vice-like, cap-like or merely as a tightness.

Generally this is around the whole head, including the forehead and back of the head. Intensity of tension headaches can vary, but it is rarely severe, and generally is not aggravated by activity. Let's explore the criteria for diagnosing tension headaches. Tension headaches last from 30 minutes to seven days.

Tension headaches have at least two of the following four characteristics: bilateral location, pressing or tightening, in other words non-pulsating quality, mild or moderate intensity, not aggravated by routine physical activity, such as walking or climbing steps. Both of the following characteristics must be met: No nausea or vomiting, photophobia or phonophobia can occur but not both.

These headaches are not better accounted for by other International Classification of Headache Disorders, third edition diagnoses or any other reasonable costs. It is useful to understand the other features which can be seen with tension headache. Peri-cranial tenderness is elicited by palpation around the cranium.

You may need to differentiate trigger points in the temporalis or suboccipital muscles from other cranial structures. There is a close relationship between tension headaches and migraines. The two types of headaches often occur together. The criteria used for tension headache diagnosis is a list of features that excludes the characteristics specific to migraine.

The frequency of tension headache episodes, is used to differentiate the subtypes. infrequent tension headaches occur about once a month, but less than 12 days a year. Frequent tension headaches present with at least 10 episodes of headaches per month for greater than three months. Chronic tension headaches evolved from frequent tension type headaches and present with greater than 15 headache days a month.