Changes

July 2022 — minor update. A minor text change has been made to this topic.

Update

Goals

• To support primary healthcare professionals to:
  • Be aware when to diagnose tension-type headache.
  • Offer management of acute episodic symptoms in primary care.
  • Offer preventative treatment for frequent episodic or chronic tension-type headache if appropriate.
  • Give advice on prevention of medication overuse headache.
  • Arrange specialist referral if appropriate for refractory or atypical symptoms.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

NICE quality standards

The following NICE quality standards are relevant for this CKS topic:

• Statement 1. People diagnosed with a primary headache disorder have their headache type classified as part of the diagnosis.
• Statement 2. People with a primary headache disorder are given information on the risk of medication overuse headache.
• Statement 3. People with tension-type headache or migraine are not referred for imaging if they do not have signs or symptoms of secondary headache.
• Statement 4. People with migraine are advised to take combination therapy with a triptan and either a nonsteroidal anti-inflammatory drug (NSAID) or paracetamol.

[NICE, 2013]

What is it?

• The International Classification of Headache Disorders (ICHD) categorizes headache into [IHS, 2018] [Ahmed, 2019]:
  
  • Primary headaches — these are not associated with another underlying condition, and include tension-type headache.
  • Secondary headaches — these are precipitated by another condition or disorder (local or systemic).
    • See the CKS topic on Headache - assessment for more examples of primary and secondary headache disorders.
• The ICHD categorizes tension-type headache according to the frequency of attacks [IHS, 2018] [Ahmed, 2019]:
  • Infrequent episodic — less than 1 day of headache per month.
  • Frequent episodic — at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months.
  • Chronic — this evolves from frequent episodic tension-type headache, with 15 days or more of headache per month, for more than 3 months, in the absence of medication overuse.

What causes it?

The exact mechanism or cause of tension-type headache is unknown.

• Peripheral pain mechanisms are thought to play a role in episodic tension-type headache, whereas central pain mechanisms and heightened sensitivity to pain may be more important in chronic tension-type headache [Bendtsen, 2010; Steiner, 2019; Steel, 2021].
  • Pericranial muscle tenderness and pain sensitivity may be involved, which increase as the severity and frequency of headache increases. In addition, there may be myofascial 'trigger points' with hypersensitivity to pressure, causing referred pain in a characteristic pattern.
  • Exacerbating environmental factors may include psychological stress, caffeine, or disturbed sleep which lead to central nervous system excitation.
  • Susceptibility to tension-type headache may be influenced by genetic factors, although these are currently not well understood.

How common is it?

Tension-type headache is the most common primary headache disorder [Bendtsen, 2010] [Ahmed, 2019].

• The British Association for the Study of Headache (BASH) guideline states it has a mean global lifetime prevalence of 42%, and chronic tension-type headache has a global prevalence of 0.5–4.8% [Ahmed, 2019].
• It is slightly more common in women than in men, with a female:male ratio of 5:4 [Bendtsen, 2010].
• A Danish population-based cross-sectional survey in 2001 (n = 297) found [Lyngberg, 2005]:
  • The lifetime prevalence of tension-type headache was 89.4%, and the 1-year prevalence was 86.5%.
  • 37.2% of participants had frequent episodic attacks.
  • 4.8% of participants had chronic tension-type headache.
  • The overall prevalence of tension-type headache in two comparable general populations increased over a 12-year period from 1989–2001.
• The average age of headache onset is 25–30 years in cross-sectional epidemiological studies, with prevalence peaking at 30–39 years, and then declining slightly [Bendtsen, 2010].

What are the complications?

• Frequent episodic and chronic tension-type headache can have a significant impact on quality of life, including at work, home, and school [Schwartz, 1998; Steiner, 2019].
• Self-medication is common in the management of tension-type headache, and may lead to medication overuse headache [Steiner, 2019; NICE, 2021].
  • See the CKS topic on Headache - Medication overuse for more information.

What is the prognosis?

• Infrequent episodic tension-type headache is usually self-limiting, and over-the-counter simple analgesia is usually effective [Steiner, 2019].
• Chronic tension-type headache can evolve from frequent episodic tension-type headache, with daily or very frequent episodes [Ahmed, 2019].
• Symptoms of primary headache disorders tend to improve with increasing age [Steiner, 2019].
• A Danish cross-sectional population-based epidemiological follow-up study over 12 years (n = 146 people with frequent episodic symptoms; n = 15 people with chronic symptoms at baseline) found [Lyngberg et al, 2005]:
  • 45% of participants had infrequent or no symptoms (suggesting remission).
  • 39% of participants had frequent episodic symptoms.
  • 12% of participants with episodic symptoms developed chronic tension-type headache.
  • 16% of participants had chronic symptoms and a poor outcome.

What are the typical clinical features of tension-type headache?

Be aware that tension-type headache may co-exist with other headache disorders, such as migraine. See the CKS topic on Headache - assessment for detailed information on the assessment of a person with headache, including exclusion of red flags which may indicate a serious underlying cause.

• The International Classification of Headache Disorders (ICHD) classifies tension-type headache as typically presenting with:
  • Recurrent episodes of headache lasting from 30 minutes to 7 days which are not associated with nausea or vomiting. The headache may also be associated with no more than one of photophobia or phonophobia, and
  • The headache has at least two of:
    • Bilateral location.
    • Pressing, tightening, non-pulsating quality ('like a vice or tight band'). Note: pain often spreads into or arises from the neck, and there may be pericranial tenderness on manual palpation.
    • Mild or moderate intensity.
    • Not aggravated by (and does not cause avoidance of) routine physical activity (such as walking or climbing stairs).
  • Note: neurological examination should be normal and headache should not be better accounted for by another cause.
  • Note: disabling tension-type headache is rare, and is more likely to reflect a diagnosis of migraine. If there are any clinical features of migraine, make a diagnosis of migraine and manage accordingly. See the CKS topic on Migraine for more information.
• The ICHD categorizes tension-type headache according to attack frequency:
  • Infrequent episodic — at least 10 episodes of headache occurring on less than 1 day per month on average (fewer than 12 days per year).
  • Frequent episodic — at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months.
  • Chronic — evolves from frequent episodic tension-type headache, headache occurring on 15 days or more per month on average, for more than 3 months and:
    • Lasting hours to days, or unremitting.
    • At least two of bilateral location; pressing or tightening (non-pulsating) quality; mild or moderate intensity; and not aggravated by routine physical activity such as walking or climbing stairs.
    • Neither moderate or severe nausea nor vomiting and no more than one of photophobia, phonophobia, or mild nausea.
    • Not better accounted for by another cause, such as medication overuse.

What else might it be?

Headache is a common symptom which can be associated with many conditions. The most common alternative diagnosis which can present similarly to tension-type headache is migraine without aura, and both headache disorders may co-exist.

• Other primary headache disorders:
  • Migraine without aura. See the CKS topic on Migraine for more information.
  • Trigeminal autonomic cephalgias, such as cluster headache, paroxysmal hemicrania, and hemicrania continua. See the CKS topic on Headache - cluster for more information.
  • Other — primary cough or exercise headache and cold-stimulus headache.
• Secondary headache disorders:
  • Trauma or injury to the head and/or neck. See the CKS topics on Neck pain - acute torticollis, Neck pain - cervical radiculopathy, and Neck pain - non-specific for more information.
  • Cranial or cervical vascular disorders such as intracerebral haemorrhage, central venous thrombosis, or temporal arteritis. See the CKS topics on Stroke and TIA and Giant cell arteritis for more information.
  • Non-vascular intracranial disorders such as idiopathic intracranial hypertension or brain malignancy. See the CKS topics on Brain and central nervous system cancers - recognition and referraland Head and neck cancers - recognition and referral for more information.
  • Exposure to a substance (such as carbon monoxide, alcohol, cocaine); medication overuse headache (including overuse of ergotamines, triptans, opioids, and/or simple analgesics); substance withdrawal (such as caffeine, opioids, or oestrogen). See the CKS topics on Carbon monoxide poisoning, Alcohol - problem drinking, Headache - medication overuse, and Opioid dependence for more information.
  • Infection (may be intracranial infection such as bacterial or viral meningitis, encephalitis, or cerebral abscess) or systemic infection. See the CKS topic on Meningitis - bacterial meningitis and meningococcal disease for more information.
  • Disorders of homeostasis such as hypoxia or hypertension including pregnancy-induced hypertension and eclampsia. See the CKS topics on Hypertension and Hypertension in pregnancy for more information. 
  • Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures such as acute angle-closure glaucoma, temporomandibular disorders, dental problems, otitis media, or sinusitis. See the CKS topics on Glaucoma, Otitis media - acute, Otitis media with effusion, Sinusitis, and Temporomandibular disorders (TMDs) for more information.
  • Psychiatric disorders such as somatization disorder or psychotic disorder. See the CKS topic on Psychosis and schizophrenia for more information.
• Painful cranial neuropathies, other facial pains, and other headaches — includes conditions such as post-herpetic neuralgia, trigeminal neuralgia, and optic neuritis. See the CKS topics on Post-herpetic neuralgia and Trigeminal neuralgia for more information.

Scenario: Management of tension-type headache

From age 16 years onwards.

Amitriptyline

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of tension-type headache.

Search dates

November 2017 - February 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Headache/, exp Tension-Type Headache/, exp Headache Disorders, Primary/, tension type headache.kw, tension headache.kw
• (?tension adj3 headache$).ti,ab.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.