Tension-type headache: clinical guidelines

List of Abbreviations

BF – Biofeedback

VAS – visual analog scale

WHO – World Health Organization

GBN – tension-type headache

GB – headache

IIH — idiopathic intracranial hypertension

CT – computed tomography

MOH – medication-overuse headache

ICD-10 – International Classification of Diseases, 10th Revision

ICHD-3 – International Classification of Headache Disorders, 3rd edition

MRI – magnetic resonance imaging

NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs

CDU – color duplex ultrasonography

HGBN – chronic tension-type headache

CNS – central nervous system

EGBN – episodic tension-type headache

EEG – electroencephalography

ECG – electrocardiography

Terms and Definitions

Tension-type headache (TTH) is one of the most common forms of primary headache. It presents with prolonged episodes of bilateral headache of mild to moderate intensity, with a constricting, pressing, or aching character.

Headache (HA) is a pathological condition that occurs with various types of primary headaches (migraine, tension-type headache, cluster headache, and others) or as a secondary manifestation of underlying diseases.

Trigger factors can provoke a headache attack. Trigger factors are often confused with the causes of HA.

Sensitization is an increased response of excited nociceptive neurons to normal and/or subthreshold stimulation.

Allodynia is pain resulting from a stimulus that does not normally provoke pain. Thermal or mechanical injuries often lead to allodynia at the site of injury. Allodynia should be distinguished from hyperalgesia, which is an increased pain sensitivity to stimuli that usually cause pain.

Paroxysmal state is a generalized concept that includes convulsive and non-convulsive paroxysms of epileptic and non-epileptic nature. A paroxysmal state is a seizure of cerebral origin manifesting against a background of apparent health or sudden worsening of a chronic pathological condition, characterized by short duration, reversibility of emerging disorders, tendency to recurrence, and stereotypy.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Tension-type headache (TTH) is one of the most common forms of primary headache (HA). It manifests as prolonged episodes of bilateral headache of mild to moderate intensity, with a constricting, pressing, or aching character. The duration of the attack ranges from 30 minutes to several days (with some fluctuation in pain intensity), but less than a week. TTH may be accompanied by photophobia or phonophobia (but not both at the same time), is not aggravated by routine physical activity, and is not accompanied by vomiting [1].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Both peripheral (muscle spasm) and central pain mechanisms (central sensitization and disinhibition) are involved in the pathogenesis of TTH. TTH is associated with pericranial muscle tension that pulls on the epicranial aponeurosis, arising as a response to acute or chronic emotional stress. Central mechanisms of pain amplification play a dominant role in the development of frequent episodic and chronic TTH, although the initial links in the pathogenesis of TTH are associated with pericranial muscle tension that occurs in response to stress.

TTH is triggered by chronic psycho-emotional overstrain, stress, and conflict situations [2]. A pathogenetic feature of TTH in children is the immaturity of psychological defense mechanisms, which causes the manifestation of the disease when exposed to minor stress factors from an adult's perspective. Anxiety disorders are formed under the influence of psychological trauma [3].

Predisposing factors for the development of TTH include a high level of patient anxiety, the presence of a significant psychotraumatic situation, difficulties in adapting to a new environment, inability to achieve psychological and muscle relaxation, and sleep disorders. Mental exhaustion, visual strain (including related to studying, work, or computer games), and static (posturotonic) tension (prolonged forced awkward posture of the head and neck), which are common in modern children and adolescents, should also be considered.

These situations lead to uncontrolled myofascial phenomena referred to as increased sensitivity of the pericranial musculature. The influence of psychological status in patients with TTH is mediated through changes in the state of the limbic-reticular complex, which is involved in the regulation of autonomic functions, muscle tone, and pain perception via common neurotransmitter mechanisms. Central mechanisms of TTH pathogenesis are associated with the disafferentation of antinociceptive relay systems. Hyperexcitability of the central nervous system due to repetitive and prolonged pericranial myofascial impulses is postulated as a possible cause for episodic TTH and their transition into chronic forms [4].

1.3 Epidemiology of the Disease or Condition

TTH is a frequent disorder, with a lifetime prevalence in the general population ranging from 30% to 78% according to various studies [1].

According to modern data, TTH is the most common form of primary headache. The average age of onset is 7 years. TTH affects 5% to 20.5% of children and adolescents, with the number of patients and medical consultations increasing during the transition from childhood to adolescence [5]. Subsequently, the incidence of TTH continues to rise: among the adult population, it reaches 30–80%, which is associated with significant socioeconomic consequences [6].

According to Budchanova N.Yu. et al. [7], the structure of TTH is as follows: infrequent TTH was observed in 21.8% of pediatric and adolescent patients, frequent TTH in 53.3%, chronic TTH in 15.2%, and probable TTH in 9.7%.

Epidemiological studies of headache in young children are significantly complicated by the children's inability to clearly describe their pain and recall the features of associated symptoms.

1.4 Features of Coding the Disease or Condition

G44 Other headache syndromes

G44.2 Tension-type headache

G44.3 Chronic post-traumatic headache

G44.8 Other specified headache syndrome

G90.8 Other disorders of the autonomic [vegetative] nervous system

1.5 Classification of the disease or condition

In clinical practice, it is most convenient to use the International Classification of Headache Disorders (ICHD-3). According to the latest version of ICHD-3 (2018), TTH belongs to primary (benign) cephalalgias (part I of ICHD-3), which are not associated with organic lesions of the brain, cerebral vessels, and other structures located in the head and neck area, nor with systemic diseases [1].

According to ICHD-3, depending on the frequency of attacks, TTH is divided into the following variants:

1) infrequent episodic – TTH occurs with a frequency of no more than once a month (no more than 12 days per year), with at least 10 previously experienced episodes meeting diagnostic criteria;

2) frequent episodic – TTH occurs with a frequency of 1 to 15 days per month on average for more than three months (12 to 180 days per year);

3) chronic – TTH occurring 15 days or more per month on average for more than three months (or more than 180 days per year).

Each variant of TTH can occur with or without pericranial muscle tenderness [1].

1.6 Clinical presentation of the disease or condition

The pain in TTH is described as constant and pressing [1]. In most cases, it is localized in the frontal and temporal regions with radiation to the occipital region and the back of the neck, and may then become diffuse, described as a sensation of the head being squeezed by a band, or a "helmet" or "cap" symptom [8]. Although the pain is usually bilateral and diffuse, the location of its greatest intensity during the day may alternately shift from one half of the head to the other. Persistent unilateral headache (hemicrania) is usually associated with increased sensitivity of the pericranial musculature. Typically, the pain appears during the day (after the 2nd or 3rd class) or in the second half of the day and lasts until evening. It may occur in the morning upon waking if a headache was noted the previous evening. Headache in TTH is not aggravated by routine daily physical activity. Patients may exhibit various temporal patterns of headache ranging from rare, short-lived episodic attacks with long remissions to a fluctuating course characterized by prolonged periods of daily headaches alternating with short-lived remissions. Transient neurological symptoms are not characteristic [1].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Comments: Diagnostic criteria for infrequent episodic TTH according to ICHD-3 include:

A. At least 10 headache episodes occurring on no more than 1 day per month on average (< 12 days per year) and fulfilling criteria B–D.

B. Headache lasting from 30 minutes to 7 days (may be up to 30 minutes in children).

C. At least 2 of the following characteristics:

- bilateral location;

- pressing or tightening (non-pulsating) quality;

- mild or moderate intensity (does not inhibit daily activities);

- not aggravated by routine physical activity such as walking or climbing stairs.

D. Both of the following:

- no nausea or vomiting (anorexia may occur);

- photophobia or phonophobia, but not both.

E. The headache is not better accounted for by another ICHD-3 diagnosis.

If manual palpation reveals increased tenderness of the pericranial muscles in such patients, the diagnosis of infrequent episodic tension-type headache associated with pericranial tenderness is established [1].

Diagnostic criteria for frequent episodic tension-type headache according to ICHD-3 include:

A. At least 10 episodes of headache occurring on 1 to 14 days per month on average for >3 months (≥12 and <180 days per year) and fulfilling criteria B–D.

B. Headache lasting from 30 minutes to 7 days (may be up to 30 minutes in children).

C. At least 2 of the following characteristics:

- bilateral location;

- pressing or tightening (non-pulsating) quality;

- mild or moderate intensity (does not inhibit daily activities);

- not aggravated by routine physical activity such as walking or climbing stairs.

D. Both of the following symptoms:

- no nausea or vomiting (anorexia may occur);

- photophobia or phonophobia, but not both.

E. The headache is not better accounted for by another ICHD-3 diagnosis.

If manual palpation reveals increased tenderness of the pericranial muscles in such patients, the diagnosis of frequent episodic tension-type headache associated with pericranial tenderness is established [1].

Diagnostic criteria for chronic tension-type headache according to ICHD-3 include:

A. Headache occurring on ≥15 days per month on average for >3 months (≥180 days per year), fulfilling criteria B–D

B. Headache lasting from 30 minutes to 7 days (may be up to 30 minutes in children)

C. At least 2 of the following characteristics:

- bilateral location

- pressing or tightening (non-pulsating) quality;

- mild or moderate intensity (does not significantly impair daily activities)

Headache is not aggravated by routine physical activity such as walking or climbing stairs.

D. Both of the following symptoms:

- no nausea or vomiting (anorexia may occur);

- photophobia or phonophobia, but not both.

E. The headache is not better accounted for by another ICHD-3 diagnosis.

If manual palpation reveals increased tenderness of the pericranial muscles in such patients, the diagnosis of chronic tension-type headache associated with pericranial tenderness is established [1].

2.1 Complaints and Anamnesis

When taking the medical history and assessing complaints in a child, it is necessary to pay attention to the age of headache onset, frequency, triggering factors, duration and location of the headache, as well as a description of its characteristics (TTH is typically characterized by recurring episodes of bilateral, diffuse, pressing or tightening, non-pulsating headache described as a "helmet" or "band" in the frontal, temporal, parietal, or possibly occipital region or the entire head, of mild to moderate intensity (4–7 points on the visual analogue scale of pain), which is not aggravated by routine physical activity; on the contrary, a walk in the fresh air may alleviate the headache) [4]. It is also important to note the presence or absence of accompanying symptoms (mild nausea and decreased appetite may occur in TTH, while photophobia and phonophobia are rare and do not occur simultaneously) [1].

Comment. In children, the assessment of headache intensity during an attack using the VAS should be carried out together with parents to obtain more objective results.

2.2 Physical Examination

Comment. Neurological examination in TTH does not reveal general cerebral or focal neurological signs, but manual palpation may show increased tenderness of the pericranial muscles. To detect pericranial muscle tension and identify "trigger points," palpation of the temporal, frontal, occipital regions, posterior neck muscles, trapezius, and sternocleidomastoid muscles is performed.

Comment. Consultations with an ophthalmologist, otolaryngologist, trauma surgeon/orthopedist, endocrinologist, neurosurgeon, and other specialists are most frequently utilized.

Comment. Emotional-personal, somatoform, and cenesthopathic-hypochondriacal disorders can lead to an increased frequency of headaches, significantly reduce quality of life, and often require special therapeutic correction.

Comment. Comorbid disorders contribute to an increased frequency of TTH and must be taken into account when planning therapeutic interventions. The most frequent comorbid disorders in children with TTH include anxiety and/or depressive disorders, behavioral disorders, attention deficit hyperactivity disorder, asthenic syndrome, sleep disorders, and other pain syndromes.

2.3 Laboratory Diagnostics

Comments: laboratory tests are not informative in the diagnosis of TTH because they do not reveal changes specific to this disease.

Comment. Laboratory and instrumental investigations are indicated only when a symptomatic headache is suspected. The Russian Headache Study Group proposes the following indications for additional investigations in patients presenting with headaches [12]:

1. Suspicion of a symptomatic (secondary) headache:

doubt regarding the probable clinical diagnosis of primary headache (atypical complaints or headache course, failure to meet more than one primary headache criterion);

fulfillment of diagnostic criteria for secondary headache;

presence of one or more warning signs—"red flags".

2. Request of the patient or their relatives.

Among additional methods, the most commonly used are: complete blood count (clinical) (B03.016.002) to rule out anemia and signs of inflammation, and serial blood pressure monitoring (A02.12.002) outside of and during headache attacks.

2.4 Instrumental Diagnostics

Comment. According to the guidelines of the American Academy of Neurology and the Child Neurology Society, neuroimaging is not warranted in the routine evaluation of patients with recurrent headaches and a normal neurological examination [13, 14]. Performing an EEG in children with recurrent headaches (primarily primary headaches) is not advisable, as the role of this study in determining the etiology of the headache is unlikely.

Comment. Brain MRI and CT reveal focal or structural brain lesions. There are "red flags" that necessitate additional patient evaluation and sometimes hospitalization [10, 15]:

1. Sudden-onset, first-ever severe headache;

2. Progressively increasing headache intensity over time without periods of remission;

3. Change in the characteristics of a chronic headache;

4. Headache combined with focal neurological signs lasting more than 1 hour;

5. Headache combined with altered consciousness and behavioral disturbances;

6. Strictly unilateral headache, signs of intracranial hypertension, and systemic disease.

7. It is recommended to perform a fundoscopic examination (A12.26.012) in children with headaches to rule out a secondary etiology [4].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment. Fundoscopy is important to rule out papilledema and elevated intracranial pressure. Ophthalmological evaluation may also include visual acuity testing, visual field defect detection, and accommodation spasm assessment.

2.5 Other Procedures

Comment. To determine the number of headache days per month (defining the TTH subtype) and the number of days with painkiller intake, it is advisable for the patient to keep a headache diary (Appendix A3) [10]. Maintaining a headache diary for 1–3 months helps both the patient and the physician differentiate one headache variant from another (e.g., a migraine attack from a TTH episode), determine the number of headache days per month, and the number of days with analgesic intake per month. Using a headache diary is mandatory for patients referred to specialized headache centers.

Comment. Idiopathic intracranial hypertension (IIH) is a symptom complex in which episodes of elevated intracranial pressure are combined with normal neuroimaging findings—brain CT (A06.23.004) or MRI (A05.23.009). The headache is often diffuse, with maximum pain in the frontal region. As a rule, the pain is constant, though periods of decreased or increased intensity may occur. The headache worsens with coughing, sneezing, and bending the head forward. Simultaneously, the patient with IIH experiences diplopia and eye pain, as well as tinnitus. Examination reveals papilledema and sixth cranial nerve palsy. Due to the presence of these symptoms, diagnosis is generally straightforward, but in rare cases, patients with IIH lack significant papilledema, which complicates diagnosis [16].

When cervicogenic headaches are suspected, radiography of the cervical spine with functional tests, an image of the atlanto-occipital joint, or cervical MRI is indicated. Headaches associated with a prior cervical spine injury are characterized by: onset of pain following load on the cervical spine (somersaults, head bumps, sudden head movements), localized pain in the neck, occipital region, and mastoid processes of the temporal bones, aggravated by head movement and palpation, a forced head position, restricted head mobility, and often asymmetric tension of the neck muscles.

Headache in chronic rhinosinusitis is prolonged and distinguished by several features. It is characterized by periodicity with peak pain severity by midday. In frontal sinusitis, the headache is localized in the frontal region, with maximum pain intensity occurring in the bridge of the nose. The pain is constant, in most cases quite intense, especially when the outflow of secretions is impaired. The pain worsens with pressure or tapping on the anterior wall of the frontal sinus, physical exertion, coughing, sneezing, head turns, and lying in the prone position. Children often complain of photophobia, lacrimation, and profuse discharge from the corresponding nasal passage, especially in the morning when transitioning from a horizontal to a vertical position. The diagnosis is confirmed by rhinoscopy and radiography of the frontal sinuses [9].

Particular attention should be paid to symptoms indicating a symptomatic headache, for which neurological disorders (intracranial space-occupying lesions—tumor, abscess; neuroinfections—meningitis, encephalitis) and somatic pathology must be ruled out. These symptoms include [10]:

- changes in the level of consciousness (stupor, confusion);

- diffuse headache progressing steadily day by day;

- constant, non-remitting headaches lasting many months and refractory to treatment;

- morning headaches accompanied by repeated vomiting without nausea;

- dependence of headache intensity on head and body position;

- sudden onset of a new, severe headache unusual for the given patient;

- development of focal neurological deficits;

- progression of headache parallel to a rise in temperature;

- symptoms of a systemic disease (fever, arthralgia, myalgia).

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Treatment of TTH includes pharmacotherapy and non-pharmacological methods. The therapeutic strategy largely depends on the frequency of headache attacks, the presence of comorbid disorders, and their severity [2].

Pharmacotherapy for TTH employs agents for both acute headache relief and prophylaxis. For episodic TTH with a frequency of more than two attacks per week, prophylactic treatment is preferred over acute relief with analgesics. In chronic TTH, painkillers have questionable efficacy and increase the risk of medication-overuse headache; therefore, prophylactic therapy becomes paramount [3, 4].

3.1 Conservative Treatment

Comment. Paracetamol** is administered at the very onset of the attack. Repeat administration of the drug is possible after 6–8 hours.

Comment. Ibuprofen** is usually prescribed at the onset of a headache attack. Ibuprofen** is comparable to paracetamol** in its analgesic and antipyretic effects, as well as its impact on the gastrointestinal tract and kidneys, but lacks hepatotoxicity [19].

Comment. The recommended starting dose is 5–10 mg (or 0.25 mg/kg) at bedtime. Depending on the treatment response, the dose of #amitriptyline** can be increased every 2–3 weeks by 0.25 mg/kg up to a maximum dose of 1 mg/kg/day. Daytime drowsiness often occurs at doses above 30–40 mg per day, even if the medication is taken at bedtime. Other side effects include orthostatic hypotension and anticholinergic effects [20]. Therefore, an electrocardiogram (A05.10.006) must be recorded before prescribing #amitriptyline**.

Comment. Potential adverse endocrine effects must be taken into account when prescribing #valproic acid** preparations to pre- and pubertal girls.

3.2 Non-pharmacological treatments

3.2.1 Cognitive behavioral therapy

Comment. The basis of cognitive behavioral therapy is the identification and elimination of chronic stress situations. A crucial part of treatment is explaining the nature of TTH to the patient, including the role of emotional factors and pericranial muscle strain; therefore, necessary components of therapy include eliminating headache triggers, maintaining proper diet and sleep hygiene, rational distribution of physical, mental, and psychoemotional loads, regular health-improving sports activities, and training in psychological and muscle relaxation techniques.

3.2.2 Biofeedback therapy

3.3 Other treatments

Evaluation of therapy efficacy

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Rehabilitation measures for children with TTH have not been developed.

5. Prevention and Dispensary Observation

6. Organization of Medical Care

Indications for scheduled hospitalization in a medical organization:

1. Progressive headache;

2. Refractory headache;

3. When a symptomatic nature of the headache is suspected in a child presenting with "red flags".

Indications for emergency hospitalization:

1. Headache accompanied by altered consciousness;

2. Headache accompanied by fever and meningeal signs;

3. Headache with progressive focal neurological symptoms;

4. Headache with progressive general cerebral symptoms;

5. Extremely high-intensity headache – 10 points on the VAS.

Indications for discharging a patient from a medical organization:

1. Abortion of headache;

2. Reduction of headache to 3–4 points on the visual analog scale;

3. Clarification of the cause of secondary headache and selection of an adequate therapeutic approach.

7. Additional Information

Outcomes and prognosis

According to population studies, the lifetime prevalence of TTH reaches 78% [6]. These data indicate a substantial increase in the frequency of TTH cases during the transition from childhood and adolescence to adulthood. Thus, the course of TTH can be prolonged and multi-year, with a potential for chronification of the disease. With timely diagnosis and adequate therapy, clinical remission can be achieved in many pediatric patients with TTH [2, 4, 25].

Criteria for Evaluating the Quality of Medical Care

Quality criteria for specialized medical care for children and adolescents with tension-type headache [4, 8, 25, 29].

References

Appendix A1. Working Group Composition

1. Ada R. Artemenko, MD, PhD, Professor, Department of Nervous Diseases, Institute of Professional Education, FSAEI HE I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University).

2. Bella I. Bursagova, PhD, Neurologist, Department of Psychoneurology and Psychosomatic Pathology, Senior Research Fellow, Laboratory of Nervous Diseases, Center for Pediatric Psychoneurology, FSBI "National Medical Research Center for Children's Health" of the Russian Ministry of Health.

3. Valentina I. Guzeva, MD, PhD, Professor, Head of the Department of Neurology, Neurosurgery, and Medical Genetics, Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia; Chief Freelance Pediatric Neurologist of the Russian Ministry of Health.

4. Victoria V. Guzeva, MD, PhD, Professor at the Department of Neurology, Neurosurgery, and Medical Genetics, Saint Petersburg State Pediatric Medical University.

5. Oksana V. Guzeva, MD, PhD, Professor at the Department of Neurology, Neurosurgery, and Medical Genetics, Saint Petersburg State Pediatric Medical University.

6. Nikolay N. Zavadenko, MD, PhD, Professor, Head of the Academician L.O. Badalyan Department of Neurology, Neurosurgery, and Medical Genetics, Institute of Neurosciences and Neurotechnologies, Pirogov Russian National Research Medical University, Russian Ministry of Health.

7. Lyudmila M. Kuzenkova, MD, PhD, Professor, Head of the Center for Pediatric Psychoneurology and Psychosomatic Pathology, National Medical Research Center for Children's Health, Russian Ministry of Health.

8. Aleksey L. Kurenkov, MD, PhD, Head of the Laboratory of Nervous Diseases, Center for Pediatric Psychoneurology, National Medical Research Center for Children's Health, Russian Ministry of Health.

9. Yury E. Nesterovsky, MD, PhD, Associate Professor at the Academician L.O. Badalyan Department of Neurology, Neurosurgery, and Medical Genetics, Institute of Neurosciences and Neurotechnologies, Pirogov Russian National Research Medical University, Russian Ministry of Health.

10. Inna V. Okhrim, MD, PhD, Associate Professor atтні Department of Neurology, Neurosurgery, and Medical Genetics, Saint Petersburg State Pediatric Medical University.

11. Natalia V. Petrova, MD, PhD, Clinical Pharmacologist, Head of the Department of Clinical Pharmacology, National Medical Research Center for Children's Health, Russian Ministry of Health.

12. Andrey P. Rachin – MD, PhD, Professor, Deputy Director for Research, Head of the Department of Neurorehabilitation and Clinical Psychology, National Medical Research Center for Rehabilitation and Balneology, Ministry of Health of the Russian Federation.

13. Aleksey V. Sergeyev, MD, PhD, Associate Professor at the Department of Nervous Diseases and Neurosurgery, Faculty of General Medicine, I.M. Sechenov First Moscow State Medical University, Russian Ministry of Health (Sechenov University).

14. Elena M. Shipilova, MD, PhD, Associate Professor at the Academician L.O. Badalyan Department of Neurology, Neurosurgery, and Medical Genetics, Institute of Neurosciences and Neurotechnologies, Pirogov Russian National Research Medical University, Russian Ministry of Health. Member of the International Child Neurology Association.

Conflict of interest: the authors confirm no financial support or conflicts of interest that need to be disclosed.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Pediatricians;

2. Neurologists;

3. Psychiatrists;

4. Psychologists;

5. Neonatologists;

6. General practitioners (family physicians);

7. Radiologists (X-ray)

8. Medical students;

9. Residents and postgraduate students;

10. Infectious disease specialists

11. Functional diagnostics physicians

12. Radiologists

13. Clinical laboratory diagnostic physicians

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing levels of evidence (LE) for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Table 3. Levels of Evidence (LE) grading scale for methods of prevention, diagnostics, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The guideline update mechanism provides for their systematic review—at least once every three years or upon the emergence of new information on the management tactics of patients with this disease. The decision to update is made by the Russian Ministry of Health based on proposals submitted by professional medical non-profit organizations. The submitted proposals must take into account the results of a comprehensive assessment of medicinal products and medical devices, as well as the results of clinical approbation.

Appendix A3. Reference Materials

1. Order of the Ministry of Health and Social Development of the Russian Federation No. 366n dated April 16, 2012 "On approval of the Procedure for providing pediatric care"

2. Information on medicinal products: State Register of Medicines: https://grls.rosminzdrav.ru

3. Federal Law No. 323-FZ dated November 21, 2011, "On the Basics of Protecting the Health of Citizens in the Russian Federation" (Collected Legislation of the Russian Federation, 2011, No. 48, Art. 6724);

4. International Statistical Classification of Diseases and Related Health Problems (ICD-10);

5. Order of the Ministry of Health of the Russian Federation No. 541n dated July 23, 2010. "Unified Qualification Handbook of Positions of Managers, Specialists, and Employees, Section: Qualification Characteristics of Positions of Healthcare Workers."

6. Federal Law No. 489-FZ dated December 25, 2018, "On Amendments to Article 40 of the Federal Law 'On Compulsory Medical Insurance in the Russian Federation' and the Federal Law 'On the Fundamentals of Public Health Protection in the Russian Federation' regarding Clinical Guidelines".

7. Order of the Russian Ministry of Health No. 103n dated February 28, 2019, "On approval of the procedure and timelines for the development of clinical guidelines, their revision, the standard template of clinical guidelines, and requirements for their structure, composition, and scientific validity of the information included in the clinical guidelines."

8. Order of the Russian Ministry of Health No. 804n dated October 13, 2017, "On approval of the nomenclature of medical services."

9. Order of the Ministry of Labor and Social Protection of the Russian Federation No. 585n dated August 27, 2019, "On Classifications and Criteria Used in Medical and Social Expertise of Citizens by Federal State Institutions of Medical and Social Expertise";

10. Order of the Ministry of Health and Social Development of the Russian Federation "On the procedure for using medicinal products in patients for vital indications" dated August 9, 2005, No. 494.

11. Information Letter of the Ministry of Health of Russia on the possibility of procuring a medicinal product by trade name (https://www.rosminzdrav.ru/news/2019/12/18/13043-minzdrav-podgotovil-informatsionnoe-pismo-po-vozmozhnosti-zakupki-lekarstvennogo-preparata-po-torgovomu-naimenovaniyu).

Examples of diagnoses:

Infrequent episodic tension-type headache without pericranial tenderness

Frequent episodic tension-type headache with pericranial tenderness

Chronic tension-type headache with pericranial tenderness

Headache diary

A headache diary is not a universally accepted validated method; however, maintaining a headache diary improves monitoring of the patient's well-being and helps the attending physician determine the frequency, onset time, duration of attacks, headache triggers, and the efficacy of ongoing therapy.

With the help of parents, the following are recorded in the diary:

1. date and day of the week when the headache occurred

2. onset time and duration of the headache (how long the attack lasted)

3. factors that may have triggered the headache

4. headache severity (how strong the attack was). A headache can be mild, moderate, or severe depending on its impact on the patient's daily activities. Alternatively, headache is assessed using the VAS on a scale from 1 to 10, where 10 is the worst pain imaginable

5. any other symptoms if noted along with the headache (e.g., nausea, vomiting, dizziness, sensitivity to light, sound, odors, visual disturbances, sensory symptoms, etc.).

6. medications taken to relieve the headache (name, time of administration, dose) and their efficacy.

A template for a monthly headache diary that can be used is presented here.

Appendix B. Physician Action Algorithms

Management algorithm for a patient with TTH

GB – headache

GBN – tension-type headache

ICHD-3 – International Classification of Headache Disorders, 3rd edition

EGBN – episodic tension-type headache

HGBN – chronic tension-type headache

Appendix C. Patient Information

Tension-type headache (TTH) is one of the most common forms of primary (benign) headache, meaning it is not associated with any focal or structural brain abnormalities.

TTH affects 5% to 20.5% of children and adolescents, with the number of patients and medical consultations increasing during the transition from childhood to adolescence. The average age of onset is 7 years.

TTH presents with prolonged (from 30 minutes to 7 days; in children, it can be from 30 minutes) attacks of bilateral headache of mild to moderate intensity.

The headache is most commonly described as constant, pressing, or tightening. In most cases, it is located in the frontal and temporal regions, sometimes radiating to the occipital region and the back of the neck, making the headache diffuse and described as a band-like tightness around the head, or a "helmet" or "cap" sensation. TTH is often associated with pericranial muscle tenderness, which can be detected upon muscle palpation. Typically, the headache appears during the day (after the 2nd or 3rd lesson) or in the afternoon and lasts until evening. Importantly, in TTH, the headache is not aggravated by routine physical activity (walking, climbing stairs). Patients may exhibit various temporal patterns of headache ranging from rare, short-lasting episodic attacks with long periods of remission to a fluctuating course characterized by prolonged periods of daily pain alternating with short remissions.

According to the International Classification of Headache Disorders, 3rd edition (ICHD-3), depending on the frequency of TTH attacks, they are classified into the following types:

1) infrequent episodic – TTH occurs with a frequency of no more than once a month (no more than 12 days per year), with at least 10 previously experienced episodes meeting diagnostic criteria;

2) frequent episodic – TTH occurs with a frequency of 1 to 15 days per month on average for more than three months (12 to 180 days per year);

3) chronic TTH – occurring 15 days or more per month on average for more than three months (or more than 180 days per year).

Each type of TTH can occur with or without pericranial tenderness.

According to the recommendations of the American Academy of Neurology and the Child Neurology Society, neuroimaging is not warranted in the routine evaluation of children with recurrent headaches and a normal neurological examination. However, if a child exhibits warning signs – the so-called "red flags" – further evaluation is necessary, and hospitalization may sometimes be indicated:

1. Sudden onset of severe headache for the first time;

2. Progressively worsening headache intensity over time without periods of remission;

3. Change in the pattern of a chronic headache;

4. Combination of headache with focal neurological signs lasting more than 1 hour;

5. Combination of headache with altered consciousness and behavioral disorders;

6. Strictly unilateral headache, signs of intracranial hypertension, and systemic disease.

Conducting a thorough differential diagnosis when TTH is suspected is essential, as TTH is essentially a diagnosis of exclusion.

All children and adolescents with TTH are advised to keep a headache diary to allow the physician to adequately assess the frequency, duration, and intensity of headaches. In younger children, the headache diary should be maintained together with the parents.

Over time, TTH may lead to the development or worsening of so-called comorbid disorders – conditions frequently observed in TTH patients that can contribute to increased headache frequency and must be taken into account when planning therapeutic interventions. The most common comorbid disorders in children with TTH include anxiety and depressive disorders, behavioral disorders, attention deficit hyperactivity disorder (ADHD), asthenic syndrome, sleep disturbances, and other pain syndromes.

The first and critically important step in the treatment of TTH is cognitive-behavioral therapy, which is necessary to explain the benign nature of the condition and the need for lifestyle modification to eliminate headache triggers.

The second step in treatment should involve non-pharmacological techniques to reduce pain during mild TTH episodes (fresh air walks, moderate physical exercise, warm showers, adequate sleep hygiene, etc.) and non-pharmacological methods aimed at enhancing the adaptive capacity of the central nervous system and reducing muscle tone (post-isometric muscle relaxation, neck and collar zone massage, breathing relaxation training, biofeedback techniques, autogenic training, etc.).

In children with infrequent episodic and frequent episodic TTH, but not exceeding a frequency of twice a week, paracetamol and ibuprofen (or other NSAIDs approved for use in pediatric practice) may be recommended for the relief of moderate and severe attacks.

In children with frequent episodic and chronic forms of TTH, preventive treatment must be considered in order to reduce the frequency of headache days per month.

During the transition from childhood to adolescence, the prevalence of TTH increases significantly, largely due to increased psychological and academic workload, stressful events, and interpersonal relationship difficulties. In this situation, the course of TTH can be long-term and chronic, and chronification of the disease is possible with a significant increase in the frequency of headache days and a marked decrease in quality of life. However, with timely diagnosis, adequate planning, and comprehensive therapy, a substantial reduction in headache frequency or even clinical remission can be achieved in many pediatric patients with TTH.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.