Elsevier

The Lancet Neurology

Volume 5, Issue 3, March 2006, Pages 268-274
The Lancet Neurology

Review
Tension-type headache in childhood and adolescence

https://doi.org/10.1016/S1474-4422(06)70376-3Get rights and content

Summary

The prevalence of non-migrainous headache is 10–25% in childhood and adolescence. Although tension-type headache and migraine are the two most common types of headache in children and adolescents, most articles address migraine headache. The distinction of tension-type headache from migraine can be difficult; use of The International Classification of Headache Disorders criteria helps. However, these criteria might be too restrictive to differentiate tension-type headache from migraine without aura in children. The pathophysiology of tension-type headache is largely unkown. The smaller genetic effect on tension-type headache than on migraine suggests that the two disorders are distinct. However, many believe that tension-type headache and migraine represent the same pathophysiological spectrum. Some indications of effective treatment exist. For children with frequent headache, the antidepressant amitriptyline might be beneficial for prophylaxis, although no placebo-controlled studies have been done. Restricted studies have suggested the efficacy of psychological and cognitive behavioural approaches in the treatment of childhood tension-type headache.

Introduction

Headache is the most commonly reported pain in childhood after musculoskeletal and abdominal pain.1, 2, 3, 4, 5 However, research interest for paediatric headache was low until the middle of the previous century. In 1962 Bille6 published a large epidemiological study of paediatric migraine. Since then, the amount of research on paediatric migraine has increased substantially. During the past 15 years, the interest in tension-type headache in children has also increased.

Research on pain and headache is associated with methodological problems, because precise measurement methods are not available, especially in children whose description and understanding of pain depend on previous experiences and cognitive level. The diagnosis of headache can be unreliable because of variation in information obtained and in the interpretation of information.7 Young children can have difficulties in describing and recalling headache symptoms.8 Therefore, some headache symptoms, such as phonophobia and photophobia, may be inferred from their behaviour.9

Headache definitions based on location and features have varied remarkably. In 1962, the Ad Hoc Committee on Classification of Headache10 published descriptions of 15 types of headache, not definite criteria for headache. According to the committee, tension headache or muscle-contraction headache was described as an ache or a sensation of tightness, pressure, or constriction, widely varying in intensity, frequency, and duration, it is long-lasting, commonly suboccipital, and associated with sustained contraction of skeletal muscles—usually as part of a reaction to a life-stress event. In 1988, the International Headache Society formulated strict criteria for different types of headache.11 Tension-type headache is the term designated by the International Headache Society to describe what was previously called tension headache, muscle-contraction headache, psychomyogenic headache, stress headache, ordinary headache, and psychogenic headache. The standard classification criteria for tension-type headache are based on the first edition of the International Classification of Headache Disorders (ICHD-1) criteria.11 These criteria have been formulated for adults, and the only modification for children is shortening the duration criterion for migraine without aura to a minimum of 2 h in children under age 15 years. ICHD-2 criteria were published in 2004;9 according to these criteria, the bilateral location and the minimum duration of 1 h are accepted in children with migraine without aura. The ICHD-2 criteria might need further revisions.12, 13

Section snippets

Epidemiology

Epidemiological statistics vary with the criteria used by researchers. Metsahonkala and Sillanpaa14 compared the ICHD-1 criteria for migraine11 with six other criteria including the Vahlquist definition.15 The investigators concluded that the ICHD-1 criteria gave lower estimates of prevalence than the Vahlquist definition. In studies that use the ICHD-1-criteria,11 tension-type headache is at least as common as migraine, affecting 10–25% of schoolchildren and adolescents (table 1).16, 17, 18, 19

Diagnosis

The standard classification criteria for tension-type headache are based on individual symptoms and the ICHD-1 criteria.11 These criteria for tension-type headache essentially include non-migrainous features. Absence of pulsing or pounding quality, unilaterality, aggravation by activity, and autonomic symptoms indicate tension-type headache. The ICHD-1 criteria11 are formulated for adults, and the only modification for children is shortening the duration criterion for migraine to a minimum of 2

Pathophysiology

The pathophysiology of tension-type headache is largely unknown. The basic mechanisms of the different headache types are unclear and overlapping symptoms are frequent. The distinction between tension-type headache and migraine may, therefore, be difficult, especially in children. The ICHD-1 criteria state that episodic tension-type headache and migraine are distinct disorders.11 However, according to the concept of the continuum model, tension-type headache and migraine are part of the same

Treatment

Most tension-type headache is best managed by primary care. Episodic tension-type headache is self-limiting, but children and their parents generally consult doctors when headaches become frequent and are no longer responsive to analgesics. Medication overuse can also be a common problem in patients with frequent headache. The treatment of migraine and tension-type headache overlap. Both require acute treatment, either behavioural or pharmaceutical. Preventive pharmaceutical treatment is needed

Conclusions

In schoolchildren and adolescents, tension-type headache is at least as common as migraine. The diagnosis of tension-type headache requires exclusion of secondary headaches. The same ICHD-2 criteria are used to identify tension-type headache in both children and adults. In children, however, these criteria may be too restrictive to differentiate tension-type headache from migraine without aura, and further revisions are needed to reliably make this distinction. Overlapping approaches to the

Search strategy and selection criteria

References for this review were identified by searches of MEDLINE and the Cochrane database from 1975 up to September, 2005, and of references from relevant articles; numerous articles were identified from the authors' own files. The search terms “tension headache”, “child”, and “adolescent” were used. Only papers published in English were reviewed. The final reference list was generated on the basis of originality and relevance to the topics covered in the review.

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