Research Review By Dr. Shawn Thistle©


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Date Posted:

August 2011

Review Title:

Tension-Type Headache in Children

Studies Included:

  1. Monteith TS, Sprenger T. Tension Type Headache in Adolescence and Childhood: Where Are We Now? Curr Pain Headache Rep; 2010: 14:424–430.
  2. Fernández-Mayoralas DM, Fernandez-de-las-Peñas C, Palacios-Ceña D et al. Restricted neck mobility in children with chronic tension type headache: a blinded, controlled study. J Headache Pain 2010; 11: 339-404.

Background Information:

We are all aware that neck pain and headaches, whether as distinct or coexisting clinical conditions, are very common. Tension-type headache (TTH) is a primary headache disorder that is prevalent in both adults and younger patients. In fact, despite variable estimates, TTH is thought to occur in about 30% of children. Prevalence increases with age, and many patients seek our assistance with this problem.

Theories regarding the interplay between cervical spine structures and tension-type headaches (TTH) seem logical from both anatomical and neurological perspectives, despite varying degrees of supporting evidence. Headaches (in general) and neck pain can arise from numerous pain generators – muscles/fascia, facet joints/articular capsules, intervertebral discs or nerves, intracranial structures etc. As manual therapists, our interventions can positively influence pain syndromes of the head and neck by modulating soft tissue tension, improving aberrant or reduced mobility, correcting posture or faulty movement patterns, or facilitating pain reduction.

For headache patients in particular, holistic clinicians will also counsel patients regarding contributing factors for their headaches such as: hydration, fitness, prescription eyewear, ergonomic issues, food or allergen triggers, and so on. Those in practice would likely agree that most patients with headache will experience at least some relief with treatment directed to dysfunctional soft tissue structures or joints in the head/neck region.

As evidence-informed clinicians, it is very important for us to be up to date on recent developments that can enhance our understanding of what we do, and the relationship between musculoskeletal structures and pain syndromes. As such, I thought it would be appropriate to combine these two studies into one review. One updates us on the state of the literature surrounding TTH in children and the other reports on some clinical data regarding neck mobility in younger TTH patients.

Pertinent Results:

Diagnostic Criteria for Tension-Type Headache:

To quickly review, the diagnosis of TTH is based on the International Classification of Headache Disorders, second edition (ICHD-II) as follows:
  1. At least 10 episodes occurring on < 1 day/month on average (12 days/year) and fulfilling criteria 2-4
  2. Headache lasting 30 min to 7 days
  3. Two of the following characteristics: a) Bilateral location b) Pressing/tightening (non-pulsating) quality c) Mild to moderate intensity d) Not aggravated by routine activity
  4. At least one of the following associated symptoms: a) No nausea or vomiting b) Photophobia or phonophobia
Subtypes of TTH:
  1. Episodic - may occur with or without pericranial muscle tenderness – there are 2 types:
    • Infrequent: at least 10 episodes occurring on < 1 day/month on average (<12 days/year and fulfilling criteria 2-4 above)
    • Frequent: at least 10 episodes occurring on ? 1 but < l5 days/month for at least 3 months
  2. Chronic: ? 15 days/month on average for > 3 months
TTH in Children & Adolescents:

Childhood and adolescence are periods of rapid growth, emotional maturation, physiological perturbations and hormonal changes, all of which may influence the expression of primary headache disorders in those who are predisposed. It is not surprising then that the prevalence of TTH increases with age in adolescents.

Classification & Diagnostic Challenges:
There are some obvious limitations in diagnosing any type of headache in children. Sometimes it may be difficult to obtain an accurate history, particularly in younger children. In these cases, some suggest that behavior may be a better measure of pain intensity. Look for or ask a parent about changes in social interaction, a need for more sleep, or an appearance of decreased school involvement. Aside from the practical aspects, the primary clinical challenge in properly diagnosing TTH in children or adults is the frequent symptom overlap and similarity to migraine. Migraines commonly present as a bilateral, short-lasting headache, with episode-to-episode differences in associated features resembling TTH. A further problem is that the phenotype may not be fully developed with age because the phenotype of migraine without aura can evolve in adolescence or early adulthood from a bilateral to unilateral headache. When the headache is unclassifiable, it may be helpful to evaluate further information to determine a diagnosis. Parents usually accompany their children and make it plausible to obtain a detailed family history of headache.

Typically, TTH lacks the circadian rhythmicity seen in other primary headache disorders such as migraine or cluster headache. A history of motion sickness and ice cream headaches in childhood may be useful markers for migraine in unclear diagnostic circumstances. Further, a history of cyclical vomiting or recurrent abdominal pain in an unclassifiable patient is suggestive of an evolution to migraine.

Clinicians should remember that in general, recurrence of headache symptoms is reassuring in confirming the benign nature of a headache disorder. Regarding headache triggers, it is generally accepted that migraine headaches have more reliable triggers than TTH, despite the commonly held belief that TTH can be related to posture, stress, hydration and so on.

Clinicians should also remember that high rates of headache transformation between TTH and migraine can occur. In practice, it is often difficult to distinguish the two entities, and this does not even take into consideration that the two types of headaches can coexist! (CLINICAL NOTE: From a practical perspective, it is arguable whether a distinction needs to be made between TTH and migraine from our perspective, as manual therapists typically assess and treat similar structures in both conditions.)

Nociceptive/Neurological Considerations:
While nociception from myofascial structures in the neck/head region is considered important in TTH, the exact contribution of peripheral versus central mechanisms has not been precisely determined. It is within reason that both are important, with muscle/joint/fascia pain itself (peripheral) potentially contributing to central sensitization (central), which likely has a distinct role to play in chronic TTH (we should also remember that these factors could and likely do contribute to migraines as well). The exact roles of biological substances like nitric oxide (NO) and calcium-gene-related-peptide (CGRP) in TTH have not been fully established and at this point, there is no definitive biomarker to identify TTH.

The literature pertaining to manual treatment of childhood and adolescent TTH is essentially non-existent. Again, it is within reason that addressing soft tissue and joint dysfunction, postural strain, stress, sleep, hydration etc. could be of great benefit to younger TTH patients, however exact recommendations cannot be made at this point. For the sake of perspective, it is important to keep in mind that there is not conclusive evidence to support any other form of therapy for this condition either. Manual therapy, lifestyle interventions, biofeedback, and judicious minimal use of NSAIDs or other pain medications may be of benefit, but more research is required.

Cervical Spine ROM in Children with TTH – some clinical data:

From a clinical perspective, dysfunction in the cervical spine has been tied to many types of headaches. This blinded, controlled study investigated the relationship between cervical ROM and headache intensity by comparing ROM values in a group of children with chronic TTH to those in control subjects. Fifty children, 13 boys and 37 girls (average age 8.5 ± 1.6 years) with CTTH and 50 age- and gender-matched children without headache (13 boys, 37 girls, average age 8.5 ± 1.8 years) participated. Cervical ROM was objectively assessed with a cervical goniometer by an assessor blinded to the children’s condition. Children completed a headache diary for 4 weeks to confirm the diagnosis. Pertinent results of this study include:
  • Children with CTTH demonstrated significantly reduced cervical ROM in flexion, extension and left/right lateral bending compared to controls without CTTH (all directions, P < 0.001)
  • Interestingly, there was no significant difference in rotation between groups.
  • In the CTTH group, cervical ROM was not correlated to headache intensity, frequency or duration.
The authors of this study speculated that the differences noted in flexion/extension but not in rotation might be due to tightening or trigger point formation (or both) in the sternocleidomastoid (restricting extension) and splenius capitus (restricting flexion) – a plausible theory that requires further study. It should also be noted that the authors did not evaluate facet joint play in the cervical spine as many of us do in practice so we cannot clarify this association based on this study. It would seem reasonable that joint restrictions may accompany the reduced ROM, but again further research is required.

Clinical Application & Conclusions:

Tension-type headache is a common problem affecting patients of all ages. Keeping the limitations of the existing literature in mind, particularly in the area of management, prudent clinicians should continue to employ a holistic approach to all headache patients. Investigating for dysfunction in the cervical spine is currently a reasonable approach, provided that the remaining aspects of the clinical encounter are performed comprehensively.

There is likely a lot we can do for TTH patients with manual techniques but don’t forget to address other triggers and contributing factors such as sleep, stress management, exercise, hydration, prescription eyewear, ergonomics, tissue-sparing strategies, and so on.

In time, the literature should continue to define the relationship between cervical spine structure and headaches, helping us better explain the benefits our patients experience each day under our care for TTH and other headache conditions.