Tension-Type Headache and Other Primary Headache Disorders

Abstract

　This paper reviews tension-type headache (TTH) and other primary headache disorders for the next revision of the Japanese Clinical Practice Guideline for Headache Disorders and proposes restructuring the Clinical Questions (CQs) and their presentation. TTH is the most prevalent primary headache disorder, yet evidence regarding its pathophysiology and treatment is far more limited than that for migraine. Rather than assigning formal recommendation grades to every intervention, we propose separating background questions from clinical questions and clarifying each option’s specific clinical role.
　For TTH, the items on classification and diagnosis, epidemiology, and pathophysiology should be reorganized as Background Questions (BQs) , and the treatment overview should be presented as a Good Practice Statement (GPS) . Diagnosis follows the International Classification of Headache Disorders, 3rd edition (ICHD-3) , distinguishing infrequent episodic, frequent episodic, and chronic TTH. Prospective population-based data identify younger age, female sex, poor self-rated health, difficulty relaxing after work, and short sleep duration as factors associated with onset, and chronic TTH at baseline, coexisting migraine, not being married, and sleep disturbance as prognostic factors, although no causal risk factors have been established. Pathophysiology is best presented as a multifactorial model integrating genetic, molecular, muscular, vascular, and central mechanisms with psychosocial factors.
　Acute treatment centers on acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) ; ibuprofen and acetaminophen have consistent supporting evidence, whereas triptans and gepants are migraine-specific and should not be used for TTH. Amitriptyline remains the first-line preventive drug, with mirtazapine and venlafaxine as second-line options supported by limited evidence; selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) as drug classes are not established as standard preventive therapies. Preventive drugs should be evaluated after about three months and reassessed by about six months. Patient education—including a headache diary, appropriate use of acute medications, prevention of medication-overuse headache, sleep and lifestyle adjustment, and stress management—is a foundational intervention. Non-pharmacological therapies such as electromyographic biofeedback, cognitive behavioral therapy, physical therapy, and acupuncture should be considered selectively according to patient characteristics, preferences, cost, access, and feasibility of continued treatment. Routine use of botulinum toxin is not supported; it may be considered only for selected patients with refractory chronic TTH at specialized centers.
　For other primary headache disorders, which are individually uncommon and for which high-quality evidence is limited, exclusion of secondary headaches, diagnostic and imaging algorithms, and clarification of disease concepts should be emphasized. Topics include possible sex-related differences in primary exercise headache; subtyping and recurrence of primary stabbing headache; exclusion-first management and exploratory calcitonin gene-related peptide (CGRP) -targeted therapies for headache associated with sexual activity; an exclusion-oriented algorithm for thunderclap headache; and persistent headache after COVID-19, together with the conceptualization of new daily persistent headache (NDPH) as a heterogeneous syndrome. Chronic daily headache is not a single disorder but an umbrella term encompassing chronic migraine, chronic TTH, medication-overuse headache, and NDPH, and should be addressed in a general headache section rather than under other primary headache disorders.