Tension-type headache in children

INTRODUCTION — Headache is a common complaint of children and adolescents. When a child presents with headache, it is important to determine whether the cause is due to primary disorder, as in migraine or tension-type headache (TTH), versus secondary, due to a brain lesion or infection. TTH is characterized by a bilateral, non-throbbing head pain typically of mild to moderate intensity. The term "tension-type headache" replaces the previous terms "muscle contraction headache" and "tension headache."

This topic will review TTH in children. Other aspects of pediatric headache are reviewed elsewhere.

●(See "Headache in children: Approach to evaluation and general management strategies".)

●(See "Types of migraine and related syndromes in children".)

●(See "Pathophysiology, clinical features, and diagnosis of migraine in children".)

NEUROBIOLOGY AND PATHOPHYSIOLOGY — There are several proposed mechanisms and multiple factors that may explain the underlying pathophysiology of TTH [1-4]. However, studies focusing on TTH in children and adolescents are limited, and the proposed mechanism is based on research in adults. These reports suggest a pain susceptibility due to genetics and sex that involves both the central and peripheral nervous systems. Heightened sensitivity of pain triggered by stress or emotion suggests activation of nociceptive pathways in the central nervous system, including pathways mediated by serotonin and endogenous neuropeptides. Peripheral activation of nerve and striatal muscle may also occur. Neurotransmitters and many related neuromodulators such as nitric oxide, calcitonin gene-related peptide, substance P, neurokinin A, glutamate, serotonin, beta-endorphin, and met-enkephalin have all been implicated in triggering nociceptive systems leading to pain [5,6].

The earlier concept of muscle contraction producing vasoconstriction and ischemia is no longer considered the most important factor in pathogenesis. These issues are discussed in greater detail separately. (See "Tension-type headache in adults: Etiology, clinical features, and diagnosis", section on 'Etiology'.)

In support of the hypothesis that patients with TTH may be overly sensitive to pain, one group of investigators found decreased mechanical pain thresholds in both trigeminal and other peripheral nerves in children with frequent episodic TTH [7,8].

In contrast with migraine, hereditary factors seem to play a minor role in the pathogenesis of TTH. (See "Tension-type headache in adults: Etiology, clinical features, and diagnosis", section on 'Genetic contributors'.)

EPIDEMIOLOGY — TTH can develop in children under the age of six [9,10]. A review of population-based studies reported that the prevalence of TTH in children was approximately 30 percent [11]. In individual studies, the overall prevalence of pediatric TTH ranged from 0.9 to 73 percent [12-16], while the prevalence of chronic TTH ranged from 0.1 to 6 percent [13,16,17]. The mean age of onset for episodic TTH was 7 years [18,19]. This wide variation among studies is likely due to different diagnostic criteria and varying methods of data collection as well as differences among populations involving school-age children, with limited data on children under the age of 7 years.

The prevalence of TTH increases with age and is higher in females [20-22]. In one survey of more than 37,000 Dutch children 12 to 18 years of age, the incidence of headache (including all types) in females was twice that of males [21].

Most reports in children suggest that TTH is two to three times more common than migraine [11,23,24]. As an example, a study of nearly 4000 Finnish schoolchildren found that 26 percent had a history of TTH, compared with 10 percent with migraine [23].

CLINICAL FEATURES — The signs and symptoms of infrequent, frequent, and chronic TTH are similar. The headache is typically bifrontal, although band-like or temporal pain can occur. The pain usually is described as a continuous pressure, although the intensity may vary. Light-headedness and fatigue may occur. TTH is generally considered to be less painful than migraine [25].

Daily activities, such as school attendance, are typically not affected by TTH [26]. However, in one report, 15 percent of children with chronic daily headaches missed more than 10 days of school, although it is unclear whether this group had concurrent migraine, which tends to be debilitating [27].

Sensitivity to light and noise may occur but are not as common in TTH as in migraine [28]. The presence of photophobia or phonophobia may lead to an erroneous diagnosis of migraine. Abdominal pain, nausea or vomiting, and changes in appetite are uncommon.

Children with headache and their parents or caregivers may be overly sensitive to pain. One study evaluated 96 children (age six years), including 58 with migraine and 38 with TTH [29]. Compared with matched-control children, those with headache were more likely to become excited about a physical examination, cried more during blood sampling or immunization, avoided play because they were afraid of hurting themselves, and had recurrent abdominal and growing pains. More children with tension-type than migraine headaches had challenging home environments, an unhappy family atmosphere, or a distant relationship between the parents. In one study, maternal depression was associated with headache in preschool children [30].

EVALUATION AND DIAGNOSIS — The diagnosis of TTH is made when the description of the attacks is consistent with the typical features of TTH, the diagnostic criteria (see 'Diagnostic criteria' below) are fulfilled, and the general and neurologic examinations are normal, with the possible exceptions that increased tenderness of pericranial myofascial tissues and the presence of trigger points are compatible with the diagnosis of TTH.

The proper evaluation of a child with chronic headaches requires sufficient time to obtain a detailed medical and social history. Nevertheless, the diagnosis of TTH can be limited by the inability of young children to communicate reliable information about the headaches and inciting factors [31,32]. In a cohort of 989 children evaluated for headache in a pediatric neurology clinic, a specific headache syndrome was unable to be identified by diagnostic criteria in 42 percent [33]. In addition, there is some overlap between the features of TTH and those of migraine without aura, since episodes of migraine can present as bilateral short-lasting headache resembling TTH. In one study of 200 children with recurrent or chronic primary headache, diagnostic criteria could not distinguish between migraine without aura and TTH in 16 percent [34]. Thus, a precise diagnosis is not possible in a substantial minority of children.

Diagnostic criteria — The International Classification of Headache Disorders, 3^rd edition (ICHD-3) specifies diagnostic criteria for episodic (table 1) and chronic (table 2) TTH [35].

The ICHD-3 criteria for episodic TTH (table 2) require at least 10 episodes of headache, each lasting 30 minutes to seven days, which fulfill the following conditions [35]:

●At least two of the following:

•Bilateral location

•Pressing or tightening (non-pulsating) quality

•Mild or moderate intensity

•Not aggravated by routine physical activity such as walking or climbing stairs

●Both of the following:

•No nausea or vomiting

•No more than one of photophobia or phonophobia

These diagnostic criteria can be viewed as based more upon what TTH is not: localized, throbbing, severe, or aggravated by activity.

The infrequent episodic TTH subform is diagnosed if the headache episodes occur on <1 day per month on average (<12 days per year). The frequent episodic TTH subform is diagnosed if the headache episodes occur on 1 to 14 days per month on average (≥12 and <180 days per year).

The ICHD-3 criteria for chronic TTH (table 2) require headaches lasting hours to days, or unremitting, occurring on ≥15 days per month on average for more than three months (≥180 days per year), that fulfill the following conditions [35]:

●At least two of the following:

•Bilateral location

•Pressing or tightening (non-pulsating) quality

•Mild or moderate intensity

•Not aggravated by routine physical activity such as walking or climbing stairs

●Both of the following:

•No more than one of photophobia, phonophobia, or mild nausea

•Neither moderate or severe nausea nor vomiting

Each of the subforms of TTH is additionally classified as occurring with or without pericranial muscle tenderness [35].

The ICHD-3 criteria were designed to distinguish between TTH, migraine, and cluster headache. There are no auras with TTH, whether visual, language, sensory, motor, or coordination. Similarly, other features typically associated with migraine headache, such as nausea, vomiting, or sensitivity to light and noise, are not features of episodic TTH. However, the presence of photophobia or phonophobia (but not both) does not exclude the diagnosis [35]. There is an exception for chronic TTH that allows mild nausea as long as there is no photophobia or phonophobia [35].

Clinical evaluation

History — A description of the headaches is obtained by interviewing the child and caregivers. Observation of the interaction between the child and examiner or the child and caregivers may suggest stress factors in the home. Answers to essential questions about the headache provide a database that assists in the diagnosis and management (table 3) [36]. Some clinicians recommend use of a headache diary that is kept by the child [37]. As noted above, the history can be limited by the inability of young children to communicate reliable information about the headaches and inciting factors [31,32].

School performance, home and family dynamics, psychosocial stressors, and coping skills should be assessed [38]. Obtaining a family history of chronic headaches or pain syndromes may be helpful. A history should be obtained of prescription or over-the-counter medications, as these can initiate a new type of headache or exacerbate a preexisting headache disorder [39,40]. In a survey of 10,506 reports to the World Health Organization (WHO) Collaboration Centre for International Drug Monitoring, indomethacin, nifedipine, cimetidine, ranitidine, and trimethoprim-sulfamethoxazole were among the drugs most frequently associated with headache [39].

Examination — The physical and neurologic examination of a child with a history of TTH is typically normal. Some may have tightness and/or tenderness of the muscle at the base of the occiput or in the paracervical region. One study found a positive correlation between referred pain trigger points in the head and shoulder regions and duration of headache [41]. This finding suggests that identification of painful trigger points can be helpful in supporting the diagnosis of TTH. Decreased cervical range of motion, particularly with flexion/extension and lateral flexion, has also been described by the same investigators [42].

Careful examination of the following areas should be performed to exclude pathologic causes of headache:

●Measurement of height, weight, and head circumference

●Blood pressure and pulse

●Auscultation of the neck, eyes, and head for bruit (a sign of arteriovenous malformation)

●Funduscopy and otoscopy

●Examination and palpation of the head, neck, shoulders, and spine

In addition, children should have a functional neurologic examination including getting up from a seated position without any support, walking on tiptoes and heels, cranial nerve examination, tandem gait and Romberg test, and symmetry of motor, sensory, reflex, coordination, and ataxia testing. (See "Headache in children: Approach to evaluation and general management strategies", section on 'Physical examination'.)

The role of diagnostic testing — Routine neuroimaging and laboratory studies are not necessary for the evaluation of a child with recurrent headaches when the neurologic exam is normal [43]. In patients with suspected TTH who lack signs or symptoms of neurologic dysfunction or increased intracranial pressure, the yield of clinically significant abnormalities with diagnostic testing is low [43-45]. In addition, neuroimaging may detect incidental findings that require additional evaluation or follow-up [44-47]. Other potential adverse effects of neuroimaging include radiation exposure, exposure to anesthesia if sedation is required, and false reassurance from an inadequate study [48].

Neuroimaging — Although most headaches in children and adolescents are benign, there are certain clinical features or "red flags" (table 4) that would prompt one to consider imaging. In general, neuroimaging should be performed for an individual with an abnormal neurological exam or change in historical features or neurological function [43]. (See "Headache in children: Approach to evaluation and general management strategies", section on 'Worrisome findings'.)

In some cases, caregiver or parental concern that their child's headache is caused by a brain tumor may make treatment of TTH difficult. In these cases, brain imaging may be sought to relieve apprehensions.

Predictors for intracranial pathology (ie, space-occupying lesion or central nervous system infection) have been identified in small observational studies. As an example, a retrospective study of 315 children with headache and no neurologic disorder observed that the presence of a surgical lesion on neuroimaging with computed tomography (CT) and magnetic resonance imaging (MRI) was associated with the following clinical features [49]:

●Sleep-related headache

●No family history of migraine

●Presence of vomiting

●Absence of visual symptoms

●Headache of less than six months' duration

●Confusion

●Abnormal neurologic examination

Many clinicians prefer MRI for imaging children who have chronic headaches, because MRI has a better resolution than CT and does not expose the child to radiation. However, CT is more readily available for emergent evaluation and is useful for identifying intracranial bleeding and a variety of other structural lesions, including associated calcification that may occur with vascular malformations, tumors, chronic subdural hematomas, and congenital viral infections. In addition, contrast-enhanced CT can demonstrate brain abscess.

As noted, there is an increased risk of radiation-induced cancer associated with CT as compared with MRI. Every effort must be made to minimize the radiation dose to children from CT examinations. This concern is discussed in detail elsewhere. (See "Ischemic stroke in children: Clinical presentation, evaluation, and diagnosis", section on 'CT safety considerations'.)

Other diagnostic testing — Laboratory testing is not necessary in the evaluation of a child who meets criteria for TTH [43]. Likewise, electroencephalography (EEG) is not necessary or recommended for the routine evaluation of recurrent headaches, and there is no evidence to support performing a lumbar puncture unless there is concern about increased intracranial pressure or infection.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of TTH includes other primary headaches such as migraine without aura, as well as secondary headaches such as transformed migraine from overuse of analgesic medication. Rare but potentially dangerous causes of secondary headache that might resemble TTH include increased intracranial pressure, infection, and tumor [19].

Infrequent episodic TTH is unlikely to be a presenting chief complaint in clinical practice. Because of the association of TTH-like symptoms with secondary headaches, such as those due to medication overuse or structural brain lesions, we suggest that practitioners consider the possibility of a secondary headache disorder when patients present for clinical care with presumed TTH.

Though only a small minority of children with headaches have a brain tumor, it is crucial to make the correct diagnosis in such cases. The features of brain tumor headache are generally nonspecific and vary widely with tumor location, size, and rate of growth. The headache is usually bilateral but can be ipsilateral the tumor. Brain tumors may cause chronic daily headache because of increased intracranial pressure or traction on pain sensitive structures and may also mimic TTH, migraine, or a variety of other headache types. However, headache associated with brain tumors tends to get worse progressively and tends to be associated with occipital head pain; the neurologic examination is usually abnormal [50]. (See "Brain tumor headache".)

Chronic daily headache may also evolve from TTH or chronic migraine. (See "Headache in children: Approach to evaluation and general management strategies", section on 'Migraine'.)

Anomalies such as Chiari I malformation can cause chronic headaches with painful muscles at the cranial-cervical junction but are typically associated with other neurologic manifestations (eg, obstructive hydrocephalus, cranial neuropathies, abnormal eye movements, cerebellar dysfunction) that are not associated with TTH. (See "Chiari malformations", section on 'Clinical manifestations'.)

Distinguishing episodic TTH from migraine without aura may be difficult. Some experts argue that patients with a stable pattern of episodic, disabling headache and a normal physical examination should be considered to have migraine in the absence of contradictory evidence [51]. Unlike migraine, TTH is not accompanied by nausea or vomiting, though TTH may be associated with either photophobia or phonophobia. However, some individuals may have overlapping features of both migraine and TTH. Those patients are hard to satisfactorily label with a single diagnosis, but generally should be treated as TTH sufferers. The clinical features that appear to be most predictive of migraine compared with TTH include nausea, photophobia, phonophobia, and exacerbation by physical activity [52]. Food triggers are also more common with migraine than with TTH.

TREATMENT — The treatment of TTH encompasses a systematic approach that includes pharmacologic intervention, such as acute treatment and/or preventive medication options, and nonpharmacological therapies, such as biobehavioral management and patient and family or caregiver education regarding lifestyle modifications to develop and/or maintain healthy habits. Patients and caregivers should continue to receive emotional support as indicated.

It is important that the pain of TTH be validated as real to the patient and caregivers. At the same time, they should be reassured those pathologic processes, such as brain tumor, have been excluded.

Sources of stress for the child should be identified and minimized to the extent possible. Successful long-term management of both episodic and chronic headache depends upon decreasing or removing the source of stress. Counseling may be indicated for the patient and caregivers.

A headache calendar (diary) can be used to document the frequency of headaches and to monitor treatment success.

Caregivers should be instructed to count the number of pain pills used and to use the minimal effective dose. It is important to clarify how access to pain medication will be achieved and, depending upon age, whether the child will be permitted to self-medicate.

Acute treatment — The acute treatment of infrequent episodic TTH can be accomplished using simple over-the-counter analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are used commonly in adults and may be used to treat headache in children, although little information is available on long-term use in this population.

Studies directly comparing ibuprofen and acetaminophen for pediatric headache are limited. A 2010 systematic review found only one randomized controlled trial that included children with TTH [53]. The trial enrolled 154 children and adults age 12 and older (mean age 40 years) with episodic TTH and found that complete relief at three hours was significantly higher for ibuprofen than for acetaminophen or placebo (75 versus 32 versus 13 percent, respectively) [54].

Aspirin use should be avoided in children because of its association with Reye syndrome. (See "Acute toxic-metabolic encephalopathy in children", section on 'Reye syndrome'.)

Combination drugs containing ergotamine, caffeine, butalbital, and codeine should be avoided due to the potential for drug dependency and rebound headaches.

Preventive treatment

Lifestyle modification — Patients and caregivers should be counseled on the importance of a structured approach to maintain healthy habits and avoid potential triggers for headache [55]. Lifestyle modifications include maintaining adequate hydration, weight management, limiting caffeine intake, avoiding hunger and not skipping meals, especially breakfast, and eating a well-balanced diet that includes green leafy vegetables. Adapting good sleeping habits, including adequate and consistent sleep schedules [56], and engaging in high physical activity and activities that minimize stress are also important in managing headaches. Other measures may include addressing mental health problems and counseling on smoking cessation as applicable [57-59].

Pharmacotherapy — Treatment of frequent episodic TTH or chronic TTH is more difficult than the treatment of infrequent headaches, as the evidence supporting prophylactic medications is limited. In addition, children have a high placebo responder rate, which confounds interpretation of the available data [60].

●Initial medication options – As with episodic headache, initial treatment with over-the-counter analgesic medication is suggested. Other drugs, particularly tricyclic antidepressants, may be helpful if simple analgesics are ineffective [50]. In this situation, low-dose amitriptyline is commonly used first. Our suggested starting dose is 5 to 10 mg (or 0.25 mg/kg) at bedtime. Depending on the response, the dose may be increased every two to three weeks by 0.25 mg/kg to a maximum dose of 1 mg/kg a day. Daytime drowsiness often occurs with doses above 30 to 40 mg per day, even when the medication is given at bedtime. Other side effects include orthostatic hypotension and anticholinergic effects.

The use of antidepressant medication in children is supported by studies in adults. In a randomized, controlled trial of 203 outpatients with chronic TTH (mean 26 headache days/month), patients randomly assigned to receive a tricyclic antidepressant (amitriptyline up to 100 mg/day or nortriptyline up to 75 mg/day) experienced a significantly greater reduction in headache activity, analgesic medication use, and headache-related disability than those receiving placebo [61]. However, only one-third of patients who took tricyclic antidepressants had substantial (≥50 percent) reductions in headache activity. A meta-analysis also concluded that antidepressants (tricyclics and serotonin blockers) are effective in preventing chronic headaches [62]. The efficacy of the selective serotonin reuptake inhibitors is unclear.

●Alternative medication options – There are few data regarding other drugs for frequent episodic or chronic pediatric TTH. Gabapentin and topiramate are reasonable options for adolescents with frequent or chronic TTH who are refractory to or unable to tolerate analgesics and tricyclic medications. However, no controlled studies are available regarding their effectiveness in children. Adverse effects with topiramate include anorexia, upper respiratory tract infections, weight loss, gastroenteritis, paresthesia, and somnolence. Topiramate may also cause cognitive impairment and concentration difficulty. It should be used with great caution in adolescents suspected of anorexia. Gabapentin may cause dizziness, drowsiness, respiratory depression, emotional lability, and restlessness. (See "Preventive treatment of migraine in children", section on 'Antiseizure medications'.)

Nutraceuticals have gained increasing popularity because of public perception as a safer alternative to prescription medications. Limited data are available to support their efficacy. A single uncontrolled study of nine children with episodic or chronic TTH reported that treatment with magnesium pidolate for two months was associated with headache improvement [63]. Another study of 22 children with headache reported that melatonin at bedtime was associated with improvement in 4 of the 8 children with chronic TTH [64]. In an observational study of 91 children with TTH in Italy, a preparation containing CoQ10 20 mg, riboflavin 4.8 mg, magnesium 169 mg, Tanacetum parthenium 150 mg, and Andrographis paniculata 100 mg administered for 16 weeks was associated with a reduction in headache frequency and intensity [65].

Alternative therapies

Behavioral treatments — Evidence for behavioral interventions such as psychotherapy, relaxation therapy, and biofeedback specifically for children with TTH is limited, of low quality, and conflicting [66]. In a study of five children, 8 to 14 years of age, with TTH, thermal biofeedback was associated with clinically significant reductions in one or more headache parameters (frequency, duration, intensity) [67]. Four of the five children were free of headache six months later. In another report, a randomized trial of biofeedback-assisted relaxation was performed in 35 children with chronic daily headache [68]. Patients assigned to biofeedback had greater improvement at 6- and 12-month follow-up (86 versus 50 percent) compared with control.

Biobehavioral techniques may be useful for managing chronic TTH, though the supporting evidence is largely indirect and based upon studies that evaluated children with migraine, unspecified primary headaches, and other types of chronic or recurrent pain; these reports suggest that psychological interventions, including relaxation techniques and cognitive behavioral therapy (CBT) are effective in reducing headache frequency and severity in children and adolescents with primary headaches [69-72]. CBT involves the use of cognitive and coping strategies to assist in replacing maladaptive thoughts and behaviors with positive thoughts and behaviors for managing chronic pain [71,73]. However, even in pediatric migraine where there is evidence for its efficacy, few children and adolescents receive treatment with CBT for reasons that include lack of awareness that such treatment exists, lack of therapists skilled in providing CBT, and patient/caregiver misconceptions around having to see a therapist [74].

In some cases, a psychologic evaluation may be helpful in the evaluation of children and adolescents with frequent or chronic headaches and may assist in monitoring treatment. The patient and caregivers should participate in the evaluation. Input from a family counselor, psychologist, or psychiatrist may be useful. The evaluation should include an assessment of the patient's personality, depression, anxiety, caregiver or parental anxiety, family history of pain, global family functioning, pain rating, and relevant social factors. Structured professional interviews may be required to obtain this information.

Standardized tests can be used to evaluate psychologic function. The tests that are used most often are the Children's Depression Inventory [75], The Beck Depression Inventory [76], the Personality Inventory for Children (PIC) [77,78], and the Minnesota Multiphasic Personality Inventory (MMPI) [79,80]. (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis".)

Invasive and non-invasive techniques and procedures — A growing number of techniques, device, and procedures are being used to treat headache in adults [81-83]. However, there are few data regarding the safety and effectiveness of these methods for treating headache in the pediatric population.

Inpatient management — Few studies have evaluated inpatient treatment of TTH in children and adolescents. However, hospital admission may be warranted for rare patients with frequent episodic or chronic headache who do not respond to outpatient treatment and are disabled from their headache [50]. Both patient and caretaker must be clear of the goals and expectations, which are to reduce disability and improve function and not necessarily become pain free. Admission is an opportunity to consult multiple disciplines including psychology to assist with cognitive behavioral and relation treatments, psychiatry to address comorbid mood issues, social work to address school or home concerns, and integrative medicine to provide cranial/cervical message. Though data are limited, analgesics and narcotics should be avoided, while intravenous dihydroergotamine may be a reasonable option [84].

PROGNOSIS — Headache that begins in childhood often changes in its characteristics with time and may either transform into a different headache phenotype or improve or remit, especially in males [18,32,85]. In one study, 100 children and adolescents with headache were seen eight years after the initial visit [86]. Between the initial presentation and follow-up visit, TTH was more likely to remit than migraine (44 versus 28 percent). Migraine without aura persisted in the same form in 44 percent and became episodic TTH in 26 percent. Episodic TTH persisted in the same form in 26 percent and changed to migraine without aura in 11 percent. Psychiatric comorbidity at the initial visit was associated with worsening or unchanged clinical status at follow-up [87].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Migraine and other primary headache disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Headaches in children (The Basics)")

●Beyond the Basics topic (see "Patient education: Headache in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Tension-type headache (TTH) is characterized by a bilateral pressing tightness that occurs anywhere on the cranium or suboccipital region. (See 'Introduction' above.)

●Clinical features – The signs and symptoms of infrequent, frequent, and chronic TTH are similar. The headache is typically frontal, although band-like or temporal pain can occur. The pain usually is described as a continuous pressure, although the intensity may vary. Light-headedness and fatigue may occur. Daily activities, such as school attendance, are typically not affected by TTH. Sensitivity to light and noise may occur but are not as common in TTH as in migraine. The presence of photophobia or phonophobia may lead to an erroneous diagnosis of migraine. Abdominal pain, nausea or vomiting, and changes in appetite are uncommon. (See 'Clinical features' above.)

●Diagnosis and evaluation – The diagnosis of TTH is based upon clinical criteria (table 1 and table 2). (See 'Evaluation and diagnosis' above and 'Diagnostic criteria' above.)

Most patients with suspected TTH who lack evidence of neurologic dysfunction or increased intracranial pressure do not need neuroimaging. In such children and adolescents, neuroimaging is unlikely to reveal clinically significant abnormalities and may detect incidental findings that require additional evaluation or follow-up. However, many caregivers are concerned that the child's headache is caused by a brain tumor. In these cases, brain imaging may be sought to relieve apprehensions. (See 'Neuroimaging' above.)

●Differential diagnosis – The differential diagnosis of TTH includes migraine without aura and other primary headaches. Rare but potentially dangerous causes of secondary headache that might resemble TTH include increased intracranial pressure, tumor, and infection. Such secondary headaches are unlikely in the presence of a reassuring clinical history and normal neurological exam. (See 'Differential diagnosis' above.)

●Treatment – Treatment of TTH includes emotional support and the judicious use of non-addicting analgesic medications. Patients with frequent episodic or chronic TTH may also benefit from tricyclic medications such as amitriptyline, other medications used for prevention of migraine in children, or biobehavioral techniques such as cognitive behavioral therapy. (See 'Treatment' above.)

●Prognosis – Headache that begins in childhood often changes in its characteristics with time and may either transform into a different headache phenotype or improve or remit, especially in males. (See 'Prognosis' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert Cruse, DO, who contributed to earlier versions of this topic review.