| IHS | Diagnosis | ICD-10 |
|---|---|---|
| 2.3 | Chronic tension-type headache | G44.2 |
| Coded elsewhere | 4.8 New daily-persistent headache | |
Description:
A disorder evolving from episodic tension-type headache, with daily or very frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There may be mild nausea, photophobia or phonophobia.
Diagnostic criteria:
- Headache occurring on ≥15 days per month on average for >3 months (≥180 days per year)1 and fulfilling criteria B-D
- Headache lasts hours or may be continuous
- Headache has at least two of the following characteristics:
- bilateral location
- pressing/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
- Not attributed to another disorder2;3
Notes:
- 2.3 Chronic tension-type headache evolves over time from episodic tension-type headache; when these criteria A-E are fulfilled by headache that, unambiguously, is daily and unremitting within 3 days of its first onset, code as 4.8 New daily-persistent headache. When the manner of onset is not remembered or is otherwise uncertain, code as 2.3 Chronic tension-type headache.
- History and physical and neurological examinations do not suggest any of the disorders listed in groups 5-12, or history and/or physical and/or neurological examinations do suggest such disorder but it is ruled out by appropriate investigations, or such disorder is present but headache does not occur for the first time in close temporal relation to the disorder.
- When medication overuse is present and fulfils criterion B for any of the subforms of 8.2 Medication-overuse headache, it is uncertain whether this criterion E is fulfilled until 2 months after medication has been withdrawn without improvement (see Comments).
Comments:
The introduction of 1.5.1 Chronic migraine into The International Classification of Headache Disorders, 2nd edition, creates a problem in relation to the differential diagnosis between this and 2.3 Chronic tension-type headache. Both diagnoses require headache (meeting the criteria for migraine or tension-type headache respectively) on at least 15 days a month. Therefore it is possible theoretically that a patient can have both these diagnoses. A very small group of patients have 15 or more headaches per month fulfilling the diagnostic criteria for both 1.5.1 Chronic migraine and 2.3 Chronic tension-type headache. This is possible when two (and only two) of the four pain characteristics are present and headaches are associated with mild nausea. In these rare cases, other clinical evidence that is not part of the explicit diagnostic criteria should be taken into account and the clinician should base thereon the best possible choice of diagnosis. When it is uncertain how many attacks fulfil one or other set of criteria it is strongly recommended to use a diagnostic headache diary prospectively.
In many uncertain cases there is overuse of medication. When this fulfils criterion B for any of the subforms of 8.2 Medication-overuse headache, the default rule is to code for 2.4.3 Probable chronic tension-type headache plus 8.2.8 Probable medication-overuse headache. When these criteria are still fulfilled 2 months after medication overuse has ceased, 2.3 Chronic tension-type headache should be diagnosed and 8.2.8 Probable medication-overuse headache discarded. If at any time sooner they are no longer fulfilled, because improvement has occurred, 8.2 Medication-overuse headache should be diagnosed and 2.4.3 Probable chronic tension-type headache discarded.
It should be remembered that some patients with chronic tension-type headache develop migraine-like features if they have severe pain and , conversely, some migraine patients develop increasingly frequent tension-type-like interval headaches, the nature of which remains unclear.
