Diagnosing tension headaches

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.

Our Headaches Masterclass course outlines an approach that will guide your evaluation of patients with headaches. This course will provide you with the knowledge and skills you need to recognize and categorize primary headaches accurately, the warning signs of ominous headaches (and those caused by medical conditions), and will teach you how to help your patients to help themselves by recognizing their triggers and adopting lifestyle changes.

Cause of tension-type headaches

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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 role of the trigeminal nerve

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The trigeminal nerve carries 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.

Where headache pain originates

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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.

Location, intensity, and duration

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Tension headaches are often bilaterally and are described by patients as pressure-like, vice-like, cap-like, or merely 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. 

Diagnostic criteria for tension-type headache

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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 cause.

Associated features and the overlap with migraine

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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.

Classifying tension-type headache by frequency

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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 evolve from frequent tension type headaches and present with greater than 15 headache days a month.