1. 2008

2. Diagnostic criteria  At least 10 episodes fulfilling following criteria  Headache lasting 30 mins to 7 days  Has 2 at least 2 of the following  Bilateral location  Pressing/tightening (non-pulsating) quality  Mild or moderate intensity  Not aggravated by physical activity such as walking or climbing stairs  No nausea or vomiting  < 2 episodes of photophobia or phonophobia  Not attributable to another disorder

3. Categories  Infrequent episodic tension type headache  Occurs < 1 day per month ( < 12 days/year)  Frequent episodic tension type headache  Occurs > 1 and 12 and <180 days/year)  Chronic tension type headache  Occurs > 15 days/month ( 180 or more days/year)

4. Causes  Uncertain  ? Activation of hyper excitable peripheral afferent neurons from head and neck muscles  Associated with and aggravated by muscle tenderness and psychological tension but do not cause it  Abnormalities in central pain processing and generalised increased pain sensitivity are found in some individuals  Genetic factors

5. People at risk  Prevalence peaks at age 40-49 in both sexes  Mean life time prevalence is 46%  Chronic tension type headache affects 3% of general population  Female to male ratio is 4:5  Prevalence increases with educational level  Can occur in children

6. Presentation  Mild to moderate bilateral pain  Sensation of muscle tightness or pressure  Lasts hours to days  Not associated with constitutional or neurological symptoms  People with chronic tension headache more likely to seek help often have a history of episodic headache but delayed until frequency and disability are high

7. Differential diagnosis  Migraine – in chronic form characteristic features disappear and pain is less severe  Neck problems – muscle tenderness of tension type headache may involve the neck  Medication overuse headache – consider in patients taking opioid or combination analgesics for an average of 10 days/month

8. Examination and investigation  Examination  Neurological examination  Manual palpation of pericranial muscles ( frontal, temporal, masseter, pterygoid, sternomastoid, splenius and trapezius.  Fundoscopy for papilloedema  Investigations  If neuro examination normal none needed

9. Investigation  Neuroimaging should be arranged if  Atypical pattern of headache  History of seizures  Neurological signs or symptoms  Symptomatic illness – acquired immunodeficiency syndrome, tumours or neurofibromatosis

10. Treatment  Infrequent headache  Good results from non prescription medication  May need reassurance  If require drugs on more than 2-3 days/week then medical treatment is indicated to prevent medication misuse headache

11. Treatment  Acute therapy for individual attacks  Simple analgesia  Aspirin 500 – 1000mg  NSAIDS  Paracetamol more effective than placebo less effective than NSAIDS  Combination drugs containing simple analgesics and caffeine are helpful  Opioids or sedatives should not be used as impair alertness and can cause overuse and dependence

12. Treatment  Preventive treatment  Consider when headaches are frequent or acute attacks don’t respond to abortive treatment  Best evidence is for Amitriptyline 75- 150mg/day. It helps both pain and muscle tenderness. Works best when started at low dose and increased weekly  Mirtazipine 15-30mg/day  Unhelpful  SSRI’s  Botulinium toxin

13. Treatment  Preventive treatment  Should be considered when at least 2 headaches/month as risk of chronic headache goes up exponentially when frequency reaches 1/week as does severity of pain  Benefit or preventive treatment is diminished when patients are simultaneously overusing abortive treatments. Withdrawal of medication is advised before starting preventative therapy

14. Treatment  Education, lifestyle and non-pharmacological treatment  Little evidence exists to support or refute most dietary or lifestyle recommendations for tension type headache.

15. Treatment  Referral  Diagnosis is unclear  Does not respond to treatment  Complicated by medication overuse  Require neuroimaging

16. Prognosis  45% of adults with frequent or chronic tension type headache will go into remission  39% will carry on with frequent headaches  16% will carry on with chronic headache

17. Poor prognosis  Associated with  Presence of chronic headache at baseline  Co-existing migraine  Not being married  Sleep problems

18. Good prognosis  Associated with  Older age  Absence of chronic tension type headache at baseline  Important message intervene early before headaches become chronic