Diagnosing tension-type headaches requires "think twice" and then act, and "think twice" means...

I believe that every neurologist will encounter patients with complaints of "headache" when they go out of the clinic, so what type of headache does the patient belong to? Tension-type headache (TTH), the most common type of headache, must be "on the list," and the diagnosis directly affects the designation
of treatment.

The annual prevalence of TTH has been reported to be 26 to 38 percent and lifetime prevalence as high as 78 percent ^[1].


However, a study by García-Azorín et al.
^[2] on emergency headache patients found that TTH was overdiagnosed
.

Of the 211 patients discharged with TTH, only 21 met the diagnostic criteria for TTH in the 3rd edition of the International Classification of Headaches (ICHD-3) (5 confirmed and 16 possible), 40 were rediagnosed with migraine, and 64 were rediagnosed with secondary headaches, 13 of which may be life-threatening
.

To learn more about the basics, diagnosis, treatment, prevention and rehabilitation of TTH, click on the image below for a one-click access to the full content
.

TTH is overdiagnosed by doctors not only because it is not related to the incomplete or inconsistent history of the patient, the above research results always remind us that the diagnosis of TTH needs to "think twice" and then act, so the question is, "three thoughts" What exactly does "three thoughts" mean?

Thoughts: Have you had a detailed consultation, physical examination and examination for headache patients?

1.
Key points of consultation

Headache warnings include:

The diagnosis of TTH is based primarily on the patient's medical history
.

(1) The doctor should ask the patient in detail whether there are any of the above "red flags", such as: (1) sudden headache, gradually aggravating headache, headache with fever, neck rigidity, rash, papilledema, focal nerve dysfunction; (2) Pregnancy or postpartum period; (3) New headache after the age of 50; Patients with cancer or AIDS, etc.
, and reasonable arrangements for testing to rule out secondary headaches ^[3,4
].

(2) The doctor needs to ask the patient in detail about the location, extent, nature, frequency of attacks, accompanying symptoms, and factors that induce, aggravate and alleviate the headache
.

(3) Doctors should also pay attention to inquiring about the patient's comorbidities, such as sleep quality, snoring/apnea, anxiety and depression
.

(4) Doctors should pay attention to asking patients about the dose, frequency, efficacy and side effects of painkillers
.

2.

ICHD-3 recommends that doctors perform manual palpation to assess tenderness of the patient's pericranial muscles
.

Peripheral muscle tenderness is assessed by applying pressure to the patient's pericranial muscles with the index and middle fingers and moving slightly (preferably with a palpation manometer
).

Pericranial muscles include masseter, temporal, frontal, extraterial, intrawing, sternocleidomastoid muscle (including mastoid segment), hypooccipital paraspine, and trapezius
.

Each muscle tenderness is rated on a scale of 0 to 3, and the total score is calculated (Figure 1).


A tender score helps doctors diagnose TTH and guide treatment
.

Doctors should note that pericranial muscle tenderness can also occur between episodes of the disease, is further exacerbated during the onset of the disease, and is associated
with the degree and frequency of headaches.

Figure 1 Schematic diagram of manipulation palpation to assess pericranial muscle tenderness (Photo courtesy of: Wu Jiang, Jia Jianping.
Neurology (3rd ed.
)[M].
Beijing: People's Medical Publishing House, 2015: 355-357.
)

3.
Auxiliary inspection points

Table 1 Ancillary tests needed to diagnose TTH

Second thought: Do you master the diagnostic process and standards of TTH?

In order to avoid over-diagnosis of TTH, doctors need to master the diagnostic criteria and procedures of TTH, the diagnostic process of TTH is shown in Figure 2, and the diagnostic criteria of TTH are shown in Table 2
.

Note: ¹ Headache warning: sudden headache, gradually aggravated headache, headache with fever, neck rigidity, rash, papilledema, focal nerve dysfunction; pregnancy or postpartum period; New headaches after the age of 50; Cancer or AIDS patients, etc
.

Figure 2 TTH diagnostic process ^[1,6].

Table 2 TTH diagnostic criteria (ICHD-3)[1]

Think twice: Is the differential diagnosis of TTH well remembered?

TTH needs to be distinguished from
new daily persistent headache (NDPH), headache due to somatization disorder, medication overuse headache (MOH), and other primary headaches.

1.
New daily persistent headache

NDPH is a special type of headache that begins with a daily persistent headache and typically no previous history of
headache.

A previous history of headache (migraine or TTH) does not exclude a diagnosis of NDPH, but there should be no increase
in the frequency of headaches before an NDPH attack.

Patients with NDPH may have migraine or TTH features
.

Even if a patient's headache meets the diagnostic criteria for chronic migraine and/or chronic TTH, the latter
should be diagnosed as long as the diagnostic criteria for NDPH are met.

It should be noted, however, that persistent migraine should be diagnosed when patients have both NDPH and persistent migraine ^[1,7
].

2.
Headache due to somatization disorders

Headache attacks can be one
of the clinical manifestations of somatization disorders.

Somatization disorder is characterized
by multiple uncomfortable symptoms and over- or maladaptation to these symptoms or health problems.

These symptoms include gastrointestinal disorders or dysfunction, back pain, pain in the extremities or joints, headaches, chest pain and/or difficulty breathing, dizziness, fatigue and/or weakness, and sleep disturbances
.

Whether medically explained or not, the patient's painful feelings are real
.

3.
Headache of drug overdose

About 50% of headache patients with headaches that last for 15 days or more per month and persist for more than 3 months are MOH
.

When a patient with primary headache develops a new headache or worsens the original headache as a result of taking an overdose of the drug and meets the diagnostic criteria for MOH, they need to be diagnosed with both MOH and their pre-existing primary headache ^[1].

4.
Other primary headaches

The differential diagnosis of TTH from other primary headaches is shown in Table 3
.

Table 3 Differential diagnosis of common primary headache

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