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Neurosciences
In pediatric neurology, tension-type headache (TTH) represents a very common type of primary headache during the pediatric age. Despite the high prevalence of TTH, this diagnosis is often underestimated in childhood, with relevant difficulties in the differential diagnosis of TTH from secondary and primary headache manifestations. Even among primary headaches, a clinical overlap is not so infrequent in children: migraine attacks could present tension headache-like features while tension-type headaches may display migraine-like symptoms as well. Several variables play a role in the complex trajectory of headache evolution, such as hormonal changes during adolescence, triggers and genetic and epigenetic factors.
- primary headache
- tension-type headache
- pediatric neurology
1. Introduction
Primary headache is one of the ten most disabling medical conditions in the general population [1] and is one of the most common causes of pain among children and adolescents, with a relevant impact on the quality of life of patients and their families [2].
Headache in children and adolescents is the third most common disease-related cause of school absenteeism and can lead to impairment in the quality of life, both in family life and in leisure activities and school/work productivity [3]. Furthermore, affected young people may be at greater risk of developing both further physical problems in adulthood and psychopathological problems such as anxiety and depression [4,5,6]. In particular, it was recently estimated that children with a headache diagnosis cause considerable excess costs in public health care systems (up to 400 € per capita) [3].
Tension-type headache (TTH) is one of the most prevalent neurological disorders in the world [7,8]. Despite its relevance, this condition in pediatric neurology is often underestimated or misdiagnosed, due to its vague symptoms in childhood, with significant difficulties in the differential diagnosis with other primary or secondary headaches. Nevertheless, it is a type of primary headache that is relatively less researched in the literature, probably because of its less disabling nature than other types of primary headaches (e.g., migraine and cluster headache) [1,9,10,11].
During the pediatric age, there is often an overlap of symptoms between TTH and migraine; moreover, in the transition from childhood to adulthood, the clinical presentation of headaches often changes, usually from migraine to TTH or vice versa [6].
Thus, a timely and effective diagnostic framework and therapeutic approach is also aimed to prevent the chronicization of headaches into more severe and highly disabling forms.
2. Developmental Trajectories in Children and Adolescents
Studying the progression over time of primary headaches is important, both from a clinical and a public health perspective. As previously mentioned, the characteristics of early-onset primary headache tend to change over time, with possible switching from one headache form to another [6].
Many studies have investigated the evolution of headache from childhood to adulthood, most of them being prospective studies on follow-up pediatric populations. Overall, approximately 25% of migraine patients were found to switch to TTH and vice versa [6]. The presence of neurodevelopmental disorders correlates with the persistence of the headache [6]. Furthermore, the male gender is more associated with remission. The consequent predominance of females during adolescence could be, in part, explained by the hormonal changes that may influence the pathophysiology of pediatric migraine, as in adult migraine. In this regard, some authors found an increased risk of headaches was found in girls who had menarche earlier [63,64,65,66], which could be explained by a common pathogenic factor such as estrogen sensitivity [67].
With aging, some triggers (such as stress) tend to be less frequent, while alcohol, smoking and neck pain usually become more prominent; a decrease in the frequency of some characteristics such as photophobia, phonophobia and vertigo was also observed [68].
In patients followed up for 10 years, it has been shown that headaches improve or regress in 60–80% of cases [69]. As for TTH specifically, it is more likely to improve in the transition from adolescence to adulthood than migraine [70].
A positive family history of headache was significantly more frequent in children with an early onset [70]. An early onset of the disease probably reflects a greater biological predisposition or increased susceptibility to specific environmental risk factors, thus potentially leading also to a worse prognosis [6,66].
Hormonal changes, different levels of stress exposure, life events and circumstances may be some of the factors that contribute to the change in the migraine phenotype over time [71,72,73]. Moreover, the prognosis of pediatric headache is adversely affected by initial diagnosis of migraine and by changes in the localization of the headache [33].
Primary headaches can indeed tend to chronicization. According to the ICHD-3 classification, chronic primary headache (CPH), tension-type or migraine-type, is defined by the presence of head pain on at least 15 days per month for more than 3 months [8].
There are little data available concerning CPH in the pediatric population and the ICHD-3 does not include notes for diagnosing pediatric CPH [8], so most of our knowledge comes from experience in adulthood.
The prevalence of CPH in children is estimated to be 0.78% to 1.5%. If the patient has been using regular and excessive headache medications for at least 3 months, the diagnosis of Medication-Overuse Headache should be considered [7]. It has been claimed that up to half of the subjects diagnosed with CPH are affected by this type of headache [74]. Most patients with this disorder improve after discontinuation of the abused drug and, moreover, respond better to prophylactic treatments.
Many studies suggest that medication abuse is lower in adolescents than in adults, this may be because adolescents are more likely to depend on their caregivers for access to medication [8,74].
3. Treatment Strategies
Given the high prevalence and the important impact on the quality of life of young patients, tension headache requires adequate management. Treatment of TTH is based on pain resolution (acute therapy) and the prevention of recurrence of headache episodes (chronic or prophylactic therapy).
Literature data concerning the treatment of primary headaches in childhood are still scarce, especially as regards TTH. Furthermore, there are no guidelines about the developmental age. In clinical practice, therapeutic strategies are based both on non-pharmacological therapies, including lifestyle modifications, as well as on pharmacological therapy [21].
The therapeutic choice must be weighed after a careful assessment of the patient and the impact that the headache has on the patient’s quality of life. Therefore, non-pharmacological approaches should be considered as first-line treatments.
Lifestyle recommendations should play a crucial role in headache management. Children and adolescents suffering from primary headache should be advised to maintain a balanced lifestyle including regular sleep and meals, adequate hydration, limited caffeine consumption, not smoking, very limited alcohol consumption and regular physical activities, which should be promoted to prevent metabolic disorders and to avoid stressors. In addition, the use of video games and electronic devices should be limited [75].
Among the other non-pharmacological approaches, behavioral treatments include relaxation techniques, biofeedback, cognitive behavioral therapy (CBT) or combinations of these treatments [76]. Relaxation-based therapy embraces interventions that focus on progressive muscle relaxation and similar strategies such as hypnosis. CBT comprises a multitude of interventions, such as family CBT, parent–operant strategies, multicomponent CBT and pain coping skills [76]. Finally, biofeedback techniques help patients to control functions of their autonomic nervous system (e.g., heart rate, blood pressure, muscle tension) by observing monitoring devices and reproducing desired behaviors [77].
These techniques have demonstrated efficacy in the treatment of pediatric headache [78] and are well accepted by patients and parents because of the very low risk of adverse effects in comparison with pharmacological treatments [79]. A recent interdisciplinary multimodal therapy program (which involved eight modules regarding headache education, stress management, relaxation techniques, physical activation, mindfulness and sensory training) showed reduced headache frequency and disability at six and twelve months after completion [80]. The best-known behavioral treatments for TTH are electromyographic (EMG) biofeedback and thermal biofeedback [81,82], which have shown greater responses in children than in adults [77].
Psychosocial stressors related to social and economic status, family conditions and academic performance, as well as psychiatric and somatic comorbidities and behavioral problems, can contribute to or worsen TTH. When these dynamics are detected, a biopsychosocial approach to care should be adopted [45,83]. Such an approach may also be useful considering that children with TTH in some cases live with negative parental relationships or in disadvantaged family environments from emotional, economic, or socio-cultural points of view [83,84]. Management of stressors, anxiety and mood disorders should take precedence over pharmacological management of headache [27].
Acute pharmacological therapy is based on paracetamol and NSAIDs. In particular, paracetamol should be the first-line medicine, feasible even for the youngest [85]. On the other hand, despite being recommended for the treatment of pediatric migraine, ibuprofen has not obtained the same consensus in TTH [27].
Other NSAIDs (ketoprofen, diclofenac, naproxen) have shown efficacy in the treatment of headache in adults, but definitive data on their use in pediatric TTH are not available [86].
Prophylactic therapy aims to reduce the frequency, intensity and duration of headache episodes, with an improvement in the quality of life. Pharmacological approaches should be considered only if non-pharmacological therapies have not been effective [27,85,87].
There are currently no clear recommendations for the prophylactic treatment of pediatric patients with primary headache [88]; the use of preventive drugs in pediatric tension headaches is therefore completely “off-label” [26,87].
Amitriptyline, in relatively low doses, is generally the first choice for TTH prophylaxis [89]. Common side effects include drowsiness, weight gain, dry mouth, dizziness, sweating, constipation and increased appetite [10].
In a prospective double-blind study of patients aged 14 to 76 years, valproate was superior to placebo in the prophylactic treatment of chronic primary headache (albeit more so in chronic migraine than in chronic tension-type headache) [90].
Tolerability issues of valproate include dizziness, abdominal pain, nausea, somnolence, tremor, impotence and hair loss [90].
More recently, the efficacy of magnesium as a prophylactic treatment for TTH has been considered, with a significant improvement in symptoms and reduction in the frequency of attacks, thus improving the disabling aspects of the headache itself [87,91]. Table 2 summarizes the treatment approaches for TTH in children and adolescents.
Table 2. Tiered treatment approaches to tension-type headache in children and adolescents. CBT, cognitive behavioral therapy; h, hour; y, year.
| Treatment Approaches | Ref. | |
|---|---|---|
| First line: Lifestyle modifications |
|
[75] |
| Second line: Non-pharmacological treatments |
|
[76,79] |
| Third line: Pharmacological therapy | Acute/abortive treatment:
|
[27] |
Preventive/prophylaxis:
|
[89] [90] [91] |
This entry is adapted from the peer-reviewed paper 10.3390/life13030825
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