2.3 Chronic tension-type headache

Coded elsewhere:
4.10 New daily persistent headache.

Description:
A disorder evolving from frequent episodic tension-type headache, with daily or very frequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting hours to days, or unremitting. The pain does not worsen with routine physical activity, but may be associated with mild nausea, photophobia or phonophobia.

Diagnostic criteria:
A. Headache occurring on ≥15 days per month on average for >3 months (≥180 days per year), fulfilling criteria B-D
B. Lasting hours to days, or unremitting
C. At least two of the following four characteristics:

    1. bilateral location
    2. pressing or tightening (non-pulsating) quality
    3. mild or moderate intensity
    4. not aggravated by routine physical activity such as walking or climbing stairs

D. Both of the following:

    1. no more than one of photophobia, phonophobia or mild nausea
    2. neither moderate or severe nausea nor vomiting

E. Not better accounted for by another ICHD-3 diagnosis.

Comments:
2.3 Chronic tension-type headache evolves over time from 2.2 Frequent episodic tension-type headache; when these criteria A-E are fulfilled by headache that, unambiguously, is daily and unremitting from less than 24 hours after its first onset, code as 4.10 New daily persistent headache. When the manner of onset is not remembered or is otherwise uncertain, code as 2.3 Chronic tension-type headache.

Both 2.3 Chronic tension-type headache and 1.3 Chronic migraine require headache on at least 15 days per month. For 2.3 Chronic tension-type headache, headache on at least 15 days must meet the criteria for 2. Tension-type headache and for 1.3 Chronic migraine headache on at least eight days must meet the criteria for 1. Migraine. Therefore a patient can fulfil criteria for both these diagnoses, for example by having headache on 25 days per month meeting migraine criteria on eight days and tension-type headache criteria on 17 days. In these cases, only the diagnosis 1.3 Chronic migraine should be given.

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 and the criteria for 2.3 Chronic tension-type headache are also fulfilled, the rule is to code for both 2.3 Chronic tension-type headache and 8.2 Medication-overuse headache. After drug withdrawal, the diagnosis should be re-evaluated: not uncommonly the criteria for 2.3 Chronic tension-type headache will no longer be fulfilled, with reversion to one or other episodic subtype.