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Differential Diagnosis of Tension-Type Headache Print

Differential Diagnosis of Tension-Type Headache

Sacco S. Diagnostic issues in tension-type headache. Curr Pain Headache Rep. 2008; 12:437-441.

Dr. Sara Sacco provides an excellent review of classification and differentiation of tension-type headache (TTH), reminds practitioners that it is a challenge to diagnose, and establishes how it differs from other types of headache and migraine disorders.

TTH is highly prevalent, may be episodic, frequent or chronic in nature, and is classified as a primary headache, one that originates without secondary cause, by the International Headache Society (IHS). TTH is usually defined by using a diagnosis of exclusion based on what it is not rather than what it is: head pain without distinctive symptoms. To perform this type of comprehensive diagnostic work-up, adequate time must be allotted. A table of IHS diagnostic criteria for all three subtypes of TTH is included in the article.

Dr. Sacco provides common headache types and other conditions that may mimic TTH. These include:

  • Cervicogenic headache
  • Temporomandibular joint disease/disorders
  • Migraine without aura, probable migraine

She also suggests that there are features of TTH which may overlap with other types of headache. She refers to Lipton, et al., and the 2002 spectrum study. [1] Lipton and colleagues suggested that migraineurs may experience a ‘spectrum of headaches,’ each type developed by its own unique biomechanism which results in poor response by the patient to commonly prescribed headache and migraine therapies. [1]

Chronic tension-type headache (CTTH) is perhaps most challenging to accurately diagnose. It is essential to ensure the primary nature of the headache to be certain the pain is not resulting from a secondary cause, such as head trauma, spinal and vascular disorders, infections (sinus and brain), intracranial pressure or lesions. Dr. Sacco reminds practitioners that any of the following signs or symptoms should be considered red flags for secondary headache: fever, stiff neck, personality change, and/or abnormal neurological signs, as well as tenderness over the temporal arteries (this sign is often indicative of giant cell arteritis). Assessment using the SNOOP pneumonic is also a helpful means of distinguishing primary from secondary headache. Table 1. [3]

Table 1. SNOOP Assessment Pneumonic [3, Adapted]






Systemic symptoms or secondary risk factors

Neurologic symptoms or abnormal signs

Onset; sudden or abrupt; thunder-clap; split-second

Older; new onset and progressive in patients >50 years of age

Previous history of headache; first headache or different in nature

Chronic daily headache (CDH) falls into four major subtypes: medication-overuse headache, new daily persistent headache, hemacrania continua, and chronic migraine. CTTH may often be misdiagnosed as medication overuse headache (MOH) or vice versa. Recent evidence by Bigal, et al., found that the use of barbiturates ≥ 5 days per month, opioids ≥ 10 days per month, and triptans ≥ 13 days per month can lead to MOH. [2] This type of information serves as a reminder to practitioners about the importance of obtaining a comprehensive profile of medication use, both prescribed and over-the-counter, in order to exclude MOH.

New daily persistent headache (NDPH) may be differentiated from CTTH by means of accurate recall of onset, as NDPH occurs every day and is reported as unremitting from less than three days after onset. If the patient relates a history of progression, the diagnosis would be CTTH. Hemicrania continua (HC) should also be ruled out prior to a diagnosis of CTTH. A history of autonomic symptoms that occur during exacerbation of head pain may be used as a reliable indicator of HC versus CTTH. Chronic migraine (CM) is perhaps the most difficult chronic daily headache subtype to differentiate from CTTH. This may, in part, be due to the addition of nausea as a new criterion of CTTH. Some migraine specialists feel that migraine evolves into CDH, but without the standard features of migraine. This transformation gives rise to a clinical dilemma. If CTTH can only exist in isolation, the patient can’t be diagnosed with both CTTH and migraine.  Silberstein and colleagues suggest other criteria to improve differentiation of CDH and propose a new category of CDH termed transformed migraine. It is defined as a headache with duration of more than four hours per day for 15 days per month, for more than one month. It also includes one or more of the following:

  • History of episodic migraine
  • History of increasing headache frequency accompanied by decreasing frequency of severity of migrainous features for a period of at least three months
  • Headache that meets IHS criteria for migraine other than duration

By using this set of criteria, Silberstein and colleagues found that CDH evolved from episodic migraine in most patients. It improved diagnosis and treatment response. In children, the reverse is seen: CDH worsens to episodic migraine. Either way, migraine is transformed. Using this model, Dr. Sacco suggests that perhaps basic tenets of migraine pathophysiology need to be reconsidered.


  1. Lipton RB, Cady RK, Stewart SR, et al. Diagnostic lessons from the spectrum study. Neurology. 2002;58:S27-S31.
  2. Bigal ME, Serrano D, Buse D, Scher A, et al. Acute migraine medications and evolution from episodic to chronic migraine: A longitudinal population-based study. Headache. 2008;48(8):1157-1168.
  3. Silberstein SD, Lipton RB. Chronic daily headache including transformed migraine, chronic tension-type headache and medication-overuse headache. In: Wolff’s Headache and Other Head Pain, 8th edition.Silberstein SD, Lipton LB, Dodick DW, eds. New York: Oxford University Press, 2008:315-377.
Last Updated on Monday, 12 January 2009 16:17