Chronic tension-type headache: where are we?

Abstract

Primary headache syndromes may generally be distinguished as being either episodic, such as typical migraine or cluster headache, or chronic, such as chronic tension-type headache (CTTH) or hemicrania continua. In truth it is chronic headache, and most particularly chronic daily headache (CDH) in its various forms, that gives the sub-speciality of headache a bad name. Daily headache in all its manifestations probably effects 5% of the population (Scher et al ., 1998; Castillo et al ., 1999), of which about half is clear-cut, at least on clinical grounds, CTTH. If neurology is to take headache into the next century, as either necessity or interest dictate, then the common headache syndromes must be adequately understood and it is timely to think about daily headache. It is on this background that we can greet the positive observations that Olesen's group report in this issue of Brain (Ashina et al. , 1999 a ), and the similarly challenging therapeutic data recently reported in The Lancet (Ashina et al. , 1999 b ). Two fundamental issues need to be answered in regard to CTTH: the first is its nature or basis, and the second, related issue is how TTH should be handled in terms of nosology. This new work contributes in some measure to both questions. Crucial to any attempt to improve the management of CTTH in clinical practice is to develop an understanding of what the syndrome actually represents. The International Headache Society (IHS) Diagnostic Classification (Headache Classification Committee of the International Headache Society, 1988) sets out clear operational criteria, but they are essentially nihilistic. The IHS classification says more of what CTTH is not than of what it is: preferably …