TTH is the most common type of primary headache in adults. Epidemiology studies of TTH in children have been variable and have ranged from 0.9% (1) to 73% (4). Two recent studies in Turkey and Norway revealed prevalence rates of 25% and 18%, respectively (13,16). In a Swedish study (12), TTH was reported in 9.8% of 7- to 16-year-olds, and the prevalence of TTH increased to 23% if the history of recurrent headaches and duration of the headaches were excluded. In a Finnish study (2), 12% of 12-year-olds had TTH. Many of these children had migrainous features, while muscle tenderness was not a characteristic of TTH but was for migraine (3). Recently the International Headache Society (IHS) criteria have been revised (10), and new epidemiology studies will be necessary to help better characterize the frequency of TTH in children. In addition, the specificity and sensitivity of these new criteria need to be analyzed in terms of their usefulness in childhood TTH.

The pathophysiology of TTH in children should be similar to that seen in adults. Stressors that are related to TTH in children are problems at school, in the family, and in peer relations (11).

The clinical features of TTH are similar in children, adolescents, and adults. A cross-sectional study in referral patients showed an increasing headache frequency and duration, an increasing variability of headache location, and an increasing frequency of nausea with increasing age. More importantly, the analgesic intake increased markedly from children to adults (15).

No large-scale treatment studies have been performed in children with TTH. Recommendations for the treatment are different in Europe and the United States. In the European view, emphasis is on nonpharmacologic measures such as distraction (in mild TTH) and relaxation training, biofeedback, and cognitive behavioral therapy (for frequent or chronic TTH), whereas in the United States, pharmacotherapy is recommended. Small-scale studies have suggested that analgesics and nonsteroidal antiinflammatory medications may be useful in the acute treatment of episodic TTH, while amitriptyline may be useful for prophylaxis of chronic TTH. The dosages, adverse effects, and contraindications of acetaminophen, ibuprofen, and amitriptyline are summarized in Table 131-1. A recent meta-analysis showed that there is very good evidence that psychologic treatments, principally relaxation and cognitive behavioral therapy, are effective
in reducing the severity and frequency of chronic headache in children and adolescents (5).