Headache Education Center




Last updated on April 8th, 2020 at 02:02 am

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Tension-type headache is an episodic headache lasting 30 minutes to 7 days. There must be 2 of the following 4 features present: bilateral (both sides) location, pressing/tightening (non-pulsating/non-pounding/non-throbbing) quality, mild or moderate pain intensity, and it should not be aggravated by routine physical activity. If there is any pulsating, pounding, or throbbing pain, migraine is the most likely diagnosis since tension-type headache cannot have this pain quality. Neither nausea nor vomiting are allowed (if present, migraine is the more likely diagnosis). There can only be 1 or none of either photophobia (sensitivity to light) or phonophobia (sensitivity to sound) (either or neither, not both). Notably, when comparing these diagnostic criteria to migraine, each one is the opposite of the criteria for migraine headache and this helps to differentiate migraine from tension-type headache.

Chronic tension-type headache is defined by headaches on 15 or more days per month for 3 or more months. Patients that have a prior or current history of headaches such as migraine or tension-type headaches tend to be much more susceptible to developing medication overuse headache (rebound headache). However, this tends to occur more often with migraine rather than tension-type headache. Medication overuse headache is one of the most common causes of chronic daily headache (more than 15 days of headache per month) in the form of chronic migraine or chronic tension-type headache. This medication overuse factor must be eliminated if present, and the headaches will never improve until a weaning detoxification from the overused medications happens. It can take 2-3 months for significant improvement to occur following detoxification, depending on medicine used, duration of use, frequency of use, and quantity of use. Preventive (daily medicines used to lessen the frequency and/or severity of headaches) and abortive (“as-needed” at headache onset) pain medications are also generally less effective in the setting of medication overuse headache. The overused medications are often taken for the headaches. However, these medicines are also commonly being used for some other type of body pain such as back pain, but inadvertently convert an infrequent headache to a frequent or daily headache.

As discussed above, overuse of certain medications will typically convert underlying episodic headache (especially if there is a history of migraine) to chronic daily headache over time. Research has shown that medication overuse can transform episodic headache (less than 15 days of headache per month) to chronic daily headache (greater than 15 days of headache per month) if the following medications are used at the following frequencies:

  1. 10 or more days per month for at least 2-3 consecutive months of over the counter (OTC) pain medications (Tylenol, Excedrin, Acetaminophen, Aleve, Naproxen, Motrin, Advil, Ibuprofen, or other non-steroidal anti-inflammatories (NSAIDs))
  2. 10 or more days per month for at least 2-3 consecutive months of triptans (Sumatriptan, Rizatriptan, Zolmitriptan, Almotriptan, Frovatriptan, Naratriptan, Eletriptan)
  3. 8 or more days per month for at least 2-3 months of any narcotic, opioid, or opiate medication (Vicodin, Norco, Hydrocodone, Oxycodone, Oxycontin, Percocet, Tramadol, Ultram, Ultracet, Morphine, Codeine)
  4. 5 or more days per month for at least 2-3 months of any butalbital containing medication (Fioricet, Fiorinal, Esgic)