Pain Management Nursing xxx (xxxx) xxx

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Pain Management Nursing

journal homepage: www.painmanagementnursing.org

Original Article

Factors Influencing Pain Dimensions in Patients with Chronic

Tension-Type Headache: An Exploratory Survey
Lakshmanan Gopichandran, RN, PhD, Associate Professor *,
Kanniammal C, RN, PhD, Dean y, Valli G, PhD, Professor z, Jaideep M, PhD, Professor z,
Achal Srivastava, DM, Professor x, P. Vanamail, PhD, Additional Professor k,
Manju Dhandapani, RN, PhD, Lecturer ¶
*
College of Nursing, All India Institute of Medical Sciences (AIIMS), New Delhi, India
y
College of Nursing, Sri Ramaswami Memorial (SRM) University, Chennai, India
z
Mednakshi Ammal Dental College, Meenakshi University, Chennai, India
x
Neurology Department, All India Institute of Medical Sciences (AIIMS), New Delhi, India
k
Obstetrics and Gynecology (OBG) Department, All India Institute of Medical Sciences (AIIMS), New Delhi, India
¶
National Institute of Nursing Education (NINE), Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: Chronic tension type headache (CTTH) is one of the common cause of hospital visits among
Received 30 December 2018 adolescents and adults. Chronic tension type headache produces pain, sleep disturbances, and disability
Received in revised form among patients leading to a poor quality of life. Knowledge pattern of headache and various associated
13 October 2019
factors will aid appropriate management.
Accepted 15 February 2020
Aims: To identify the headache dimensions and their various influencing factors among patients of
chronic tension-type headache.
Methods: Using consecutive sampling techniques, 169 patients with chronic tension-type headache were
recruited in this cross-sectional survey. Approval was obtained from the Institute's Ethics Committee. The
Wong-Baker Foundation Pain intensity scale was used to assess the pain severity.
Results: A pain severity score of 6 out of 10 was reported by 56% of the patients, and the mean pain score
reported by the patients was 6.62 ± 1.16. The mean weekly headache frequency was 4.95 ± 0.38, and the
mean daily headache duration was 8.68 ± 1.68 hours. Significantly more patients who are married, patients
who had a duration of illness less than two years, and patients who were treated with only analgesics re-
ported higher headache severity. Higher headache frequency was reported by significantly more patients
who were male, married, from a nuclear family, educated, unskilled laborers or employed, urban inhabitants,
or only on analgesics, or had illness duration less than two years. Headache duration was significantly higher
in patients who were unskilled laborers or only on analgesics, or had illness duration less than two years.
Conclusions: Patients with chronic tension-type headache experience moderate to high severity of
headache, along with substantial duration and frequency, an outcome that was associated with various
lifestyle-related factors that can result in stress. Lifestyle modification and nonpharmacological man-
agement are thus essential to reduce the severity, frequency, and duration of headache in patients with a
chronic tension-type headache and medication overuse.
© 2020 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Chronic tension-type headache (CTTH) is a common cause of

Address correspondence to Manju Dhandapani, RN, PhD, National Institute of
Nursing Education, Post Graduate Institute of Medical Education and Research,
Sector-12, Chandigarh, India, 160012.
E-mail addresses: pravigopi@gmail.com (L. Gopichandran), manjuseban@gmail.
com (M. Dhandapani).
hospital visits among adolescents and adults. Chronic tension-type
headache produces pain, sleep disturbance, and disability among
children, adolescents, and adults, resulting in poor quality of life
with adverse socioeconomic impact among patients and their
families (Kulkarni et al., 2015). Knowledge of headache patterns
and associated factors will aid in the appropriate management of
patients with CTTH.

https://doi.org/10.1016/j.pmn.2020.02.066
1524-9042/© 2020 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Gopichandran, L et al., Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An
Exploratory Survey, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.02.066
2 L. Gopichandran et al. / Pain Management Nursing xxx (xxxx) xxx
Background
Tension-type headache is the most common type of primary
headache, and its chronic form is known as CTTH. Tension-type
headache is the third most prevalent disorder worldwide,
affecting 1.89 billion people globally, with a lifetime prevalence in
the general population ranging in different studies between 30%
and 78%. Chronic tension-type headache affects 0.5% to 4.8% of the
worldwide population and is an umbrella term used for a group of
headache disorders (Headache Classification Committee of the
International Headache Society, 2018; Stovner et al., 2018;
Kulkarni et al., 2015; Chowdhury et al., 2012; Rasmussen et al.,
1991). As per the International Headache Society, chronic tension-
type headache is defined as the occurrence of bilateral tension-
type headache at a frequency of 15 days per month with press-
ing or tightening quality, mild to moderate intensity, lasting hours
to days or unremitting and not worsening with routine physical
activity; it may be associated with mild nausea, photophobia, or
phonophobia (Headache Classification Committee of the
International Headache Society, 2018).
The mechanisms of chronic tension-type headache may be
multifactorial, including peripheral mechanisms, central mecha-
nisms, and genetic and psychological factors. Numerous studies
have revealed that central pain mechanisms play a dominant role in
chronic tension-type headache (Blaschek et al., 2012; Cathcart
et al., 2012; Fernandez-de-Las-Penas et al., 2007; Martin-Herrero
et al., 2012; Wager et al., 2013). Although it is believed that
chronic tension-type headache is due to muscle tension in head,
neck, or face (Martin-Herrero et al., 2012), its exact cause is not
known and may be associated with stimulating or precipitating
factors such as poor vision, stress, or hunger (Lebedeva, Kobzeva,
Gilev, Kislyak, & Olesen, 2016; Zarei et al., 2016). Increased mus-
cle tenderness may also predispose the patients to headache epi-
sodes (Dhandapani et al., 2016). Literatures show that stress and
emotional disturbances also play a major role in the occurrence of
chronic tension-type headache. It is assumed that some individuals
react to stress with sustained contraction of the head and neck
muscles, which may lead to a muscle contraction headache.
Chronic tension-type headache is reported to affect the activities
of daily living, increase stress, reduce cognition, reduce the quality of
sleep, impair functional status, and increase medication overuse
(Dhandapani et al, 2016, 2017). Self-medication is common in pa-
tients with a chronic tension-type headache owing to the easy
availability of over-the-counter drugs. Medication overuse may
chronify the headache by paradoxically aggravating pain, leading to
medication overuse headache and a cycle of intensified analgesic use.
Intensified analgesic use results in adverse effects of drugs, wors-
ening withdrawal headache, and long-term disability (Koushede
et al., 2011; Westergaard et al., 2016). Various dimensions of head-
ache such as severity, duration, and frequency can affect health-
related quality of life owing to headache's repercussions on the in-
dividual and their family, work, social relations, and activities of daily
living (Simic et al., 2008). The perception of headache by the patient
and its different dimensions must be assessed in patients with CTTH
to identify patients at high risk for disability and poor quality of life.
Chronic tension-type headache is reported to be associated with lost
working days, reduced work efficiency (Schwartz et al., 1997), and
impaired relationships with family, friends, and colleagues and has a
high socioeconomic impact. Other than pain and impaired sleep
quality (Gopichandran et al., 2018), sociodemographic and clinical
factors also may influence disability in patients (Chabriat et al., 1999).
Because personal, familial, and socioeconomic effects of head-
aches may be directly proportional to their severity (Gopichandran
et al., 2017), duration, and frequency, it becomes imperative to study
various pain dimensions and their associated factors. It is essential
Please cite this article as: Gopichandran, L et al., Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An
Exploratory Survey, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.02.066
for nurses to be aware of the pain pattern and its associated factors in
CTTH patients to arrange proper pharmacological or non-
pharmacological treatment, including lifestyle modification.
Materials and Methods
A cross-sectional exploratory survey was conducted in a tertiary
care center in North India to assess the various dimensions of
headache and its associated factors in patients of CTTH. Using
consecutive sampling techniques, 169 adult patients who were
diagnosed with CTTH for more than 6 months but less than 3 years
were recruited in the study. Patients with known central nervous
system disorders, psychiatric illness, major comorbid illnesses, or
communication deficits were excluded from the study. Patients
were recruited from the neurology outpatient department.
Informed written consent was taken from the patients, a patient
information sheet was given, and the confidentiality of obtained
data was ensured. Approval was obtained from the institute's ethics
committee. The demographic and clinical data were collected using
a data collection tool with the help of interviews and records. The
tool included questions related to pain frequency, duration, and
other aspects. The Wong-Baker Foundation Pain Intensity Scale,
which is a valid and reliable pain assessment tool, was used to assess
the severity of pain (Wong & Baker, 1988). The pain scale rates pain
level among the following options: face 0 (doesn't hurt at all), face 2
(hurts just a little bit), face 4 (hurts a little bit more), face 6 (hurts
even more), face 8 (hurts a whole lot), and face 10 (hurts as much as
you can imagine). To determine pain frequency, subjects were asked
how many headaches they had in the previous week and how long
each headache lasted. The average duration was calculated.
Statistical Analysis
Appropriate descriptive and inferential statistical measures
were used for analysis. Chi-square testing was used to assess the
association between categorical variables, the Pearson correlation
coefficient was used to find correlation between two continuous
variables, the independent t test was used to assess the influence of
binary variables on pain severity, and one-way anova was used to
assess the influence of multicategorical variables. An independent t
test was used to find the association between the continuous and
categorical variables of two groups, and one-way anova was used to
find the association between the continuous and categorical vari-
ables of three or more groups.
Results
Sociodemographic and Clinical Profile of Patients with CTTH
The sociodemographic and clinical profile of CTTH patients
enrolled in the present study is given in Table 1. The mean age of
CTTH patients was 45.05 ± 10.93 years, with a minimum of 18 years
and a maximum of 72 years. Most of the patients (85%) were
married, and 57% of the patients were female. Approximately half
of the patients were suffering from systemic illnesses such as dia-
betes mellites or hypertension. Duration of CTTH since diagnosis
was between 1 year to 2 years in 70 (41.4%) of the patients. Most of
the patients (64.5%) were treated with both analgesics and beta-
blockers, and the rest (35.5%) were treated only with analgesics.
Upon diagnosis of CTTH, analgesics such as paracetamol or
nonsteroidal antiinflammatory drugs (NSAIDs) are started as an
initial treatment strategy in our setting. If the pain management is
inadequate with this treatment, a beta-blocker (propranolol) or
amitriptyline is added.
 L. Gopichandran et al. / Pain Management Nursing xxx (xxxx) xxx 3

Table 1 patients was 6.62 þ 1.16. Per the patients’ reports, the mean weekly
Sociodemographic and Clinical Profile of Patients headache frequency was 4.95 ± 0.38, and the mean daily headache
Demographic and Clinical Variables n ¼ 169 duration was 8.68 ± 1.68 hours. Most of the patients (87%) reported
of Patients with CTTH Mean ± SD or f (%) five headache episodes per week.
Age 45.18 ± 10.93
Sex Factors Influencing Pain Characteristics
Female 96 (57)
Male 73 (43)
Various sociodemographic and clinical variables that could in-
Marital status
Unmarried 15 (9) fluence the pain characteristics of patients with CTTH were
Married 143 (85) analyzed and are shown in Tables 3e5.
Divorced 5 (3)
Widowed 6 (4)
Association of Various Factors with Headache Severity
Type of family
Nuclear 99 (59)
Joint 70 (41) The association between sociodemographic variables and clinical
Religion variables of patients with headache severity is shown in Table 3.
Hindu 150 (89) Headache severity reported by patients with CTTH ranged from 4 to 6
Muslim 9 (5.3)
out of 10. Headache severity varied by marital status, with significantly
Christian 4 (2.4)
Sikh 6 (3.6) more married patients (41.5%) reporting a severity of 8, compared with
Education unmarried (13%) and divorced/widowed (18%; p ¼ .017).
Illiterate/Primary 22 (13) Also, significantly more patients with duration of illness less
Secondary 21 (12.4) than 2 years (80%) reported higher headache severity of 8 as
Higher-secondary 57 (34)
Graduation &above 69 (40.8)
compared to patients with illness duration more than 2 years (1%;
Occupation p < .001). Most of the patients (90%) with an illness duration of
Student/unemployed 75 (44.4) more than 2 years had reported headache severity of 6. Although
Unskilled laborer 17 (10) significantly more patients on analgesics (88%) reported severity of
Salaried/Self employed 64 (38)
8, only 9% of patients on both analgesics and beta-blockers had
Retired/Pensioner 13 (7.7)
Income (Rs/Month)* reported the same. Most patients (82%) taking both analgesics and
10,000-15,000 30 (17.8) beta-blockers reported headache severity of 6 (p < .001). Other
>15,000 139 (82.2) variables of the patients, such as age, sex, type of family, education,
Habitat habitat, family income, occupation, and associated systemic ill-
Rural 18 (10.7)
Semi-urban 22 (13)
nesses, did not have any significant influence on pain duration.
Urban 129 (76.5)
Illness duration Association of Various Factors with Headache Frequency
6 months-1 year 7 (4.1)
>1 yr-2 yrs 70 (41.4)
The association between sociodemographic variables and clin-
>2 yrs-3 yrs 60 (35.5)
>3 yrs 32 (18.9) ical variables of patients with monthly headache frequency is
Systemic illness shown in Table 4. Headache frequency reported by patients with
No 88 (52) CTTH ranged from four to six per week. Significantly more male
Yes 81 (48) patients (7%) reported higher headache frequency of six per week
Type of systemic illness
Hypertension 32 (39.5)
as compared to females (2%). Significantly more females (16%) re-
Diabetes mellitus 28 (34.6) ported lower headache frequency of four (p < .001). Significantly
Hypertension and Diabetes mellitus 21 (25.9) more patients who are divorced or widowed (36%) reported lower
Medications headache frequency of four as compared to unmarried (7%) or
Analgesics 60 (35.5)
married patients (7%). Significantly more patients from a nuclear
Analgesics and beta-blockers 109 (64.5)
family (14%) reported lower headache frequency of four, as
*
In India, the average monthly salary of regular workers was at ₹13,562; non- compared to patients from a joint family (1.5%; p ¼ .013).
regular workers earned ₹5,853 per month.
Significantly more patients who are not educated or have only
primary education (18%) reported lower headache frequency of 4 as
Headache dimensions of patients with CTTH during and 1 week compared to patients with higher levels. Correspondingly, 6% of
before the assessment are shown in Table 2. A pain severity score of patients with high school and 4% of the patients with graduate
6 out of 10 was reported by 56% of the patients, followed by a score degrees reported higher headache frequency of six per week as
of 8 by 37% of the patients; the mean pain score reported by the compared to none with primary education or less (p ¼ .038).
Significantly more patients who are retired (38.5%) reported lower
Table 2 headache frequency of four as compared with students or unem-
Dimensions of Headache in Patients with CTTH
ployed (5%) patients, unskilled laborers (12%), and employed pa-
Dimensions of Headache f (%) n ¼ 169 tients (on regular salary) (6%); (p ¼ .003). Significantly more rural
Mean ± SD inhabitants (28%) reported lower headache frequency of four as
Severity compared with semiurban (9%) and urban inhabitants (6%;
Face 4 (Hurts little more) 11 (7) 6.62 ± 1.16 p ¼ .025). The patients were classified into rural, suburban, and
Face 6 (Hurts even more) 95 (56)
urban inhabitants based on place of residence. “Urban” denotes a
Face 8 (Hurts whole lot) 63 (37)
Frequency (episode per week) place that is densely populated. “Rural” denotes a place that is
4/week 15 (9) 4.95 ± 0.38 sparsely populated and located outside the boundaries of a city,
5/week 147 (87) commercial, or industrial area.
6/week 7 (4) Significantly more patients (8%) with a duration of illness less
Duration (Hours per day) 8.6805 ± 1.68
than 2 years reported higher headache frequency of five per week,

Please cite this article as: Gopichandran, L et al., Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An
Exploratory Survey, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.02.066
4 L. Gopichandran et al. / Pain Management Nursing xxx (xxxx) xxx

Table 3
Association of Various Factors with Headache Severity

Variables of Patients with CTTH Prevalence Based on Pain Severity Score f (%) n ¼ 169
Chi2 (p Value)
4 6 8

Age
18-40 years 3 (5) 41 (68) 16 (27) 7.73 (.1)
41-60 years 8 (8) 46 (48) 43 (44)
60 years 0 (0) 8 (67) 4 (33)
Gender
Females 7 (7) 60 (63) 29 (30) 4.75 (.09)
Males 4 (5.5) 35 (48) 34 (46.5)
Marital status
Unmarried 0 (0) 13 (87) 2 (13) 10.22 (.037*)
Married 9 (6) 75 (52.5) 59 (41.5)
Divorced/widowed 2 (18) 7 (64) 2 (18)
Type of family
Nuclear 8 (8) 58 (59) 33 (33) 2.14 (.34)
Joint 3 (4) 37 (53) 30 (43)
Education
Illiterate & primary 2 (9) 11 (50) 9 (41) 2.94 (.57)
Up to higher secondary 5 (6.5) 40 (51) 33 (42.5)
Graduation & above 4 (6) 44 (64) 21 (30)
Occupation
Student/unemployed 5 (7) 37 (49) 33 (44) 4.15 (.66)
Unskilled laborer 1 (6) 9 (53) 7 (41)
Salaried/self-employed 4 (6) 42 (66) 18 (28)
Retired/Pensioner 1 (8) 7 (54) 5 (8)
Income
10,000-15,000 4 (13) 13 (43.5) 13 (43.5) 4.04 (.13)
>15,000 7 (5) 82 (59) 50 (36)
Habitat
Rural 1 (5.5) 10 (55.5) 7 (39) 1.94 (.75)
Semi-urban 1 (7) 10 (58) 11 (35)
Urban 9 (7) 75 (58) 45 (35)
Illness duration
6 months to 2 years 3 (4) 12 (16) 62 (80) 113.97 (<.001*)
>2 years 8 (9) 83 (90) 1 (1)
Systemic illness
No 6 (7) 52 (59) 30 (34) 0.79 (.67)
Yes 5 (6) 43 (53) 81 (48)
Medications
Analgesics 1 (2) 6 (10) 53 (88) 103.74 (<.001*)
Analgesics and beta-blockers 10 (9) 89 (82) 10 (9)
*
Significant at p value less than or equal to .05.

as compared to only 1% of patients with illness duration more than
2 years (p ¼ .008). Significantly more patients with other systemic
illnesses (15%) reported lower headache frequency of four as
compared to patients without systemic illnesses (3.5%; p ¼ .027).
Significantly more patients taking only analgesics (10%) reported
higher headache frequency of six as compared to patients who
were on both analgesics and beta-blockers (1%). Correspondingly,
although 11% of the patients on both analgesics and beta-blockers
reported a lower headache frequency of four per week, only 5% of
the patients on analgesics reported the same (p ¼ .009).
Other variables of the patients, such as age and family income,
did not show any significant influence on headache frequency.
Association of Various Factors with Headache Duration
Association of demographic and clinical variables of patients
with daily duration of headache is shown in Table 5.
The mean daily headache duration of 9.86 ± 1.8 hours was
significantly higher in patients who were unskilled laborers as
compared to 8.98 ± 1.72 hours in students and unemployed pa-
tients, 8.68 ± 1.68 hours in patients who were retired, and
8.1 ± 1.55 hours in patients who were employed (p ¼ .011).
A significantly higher mean daily headache duration of
10.88 ± 1.13 hours was reported by patients with illness duration less
than 2 years, as compared to 7.42 ± 0.76 hours in patients with illness
duration more than 2 years (p < .001). The mean duration of headache
was significantly higher in patients who are on analgesics:
10.38 ± 1.02 hours as compared with 7.74 ± 1.16 hours in patients who
are on both analgesics and beta-blockers (p < .001). Other variables of
the patient, such as age, gender, marital status, type of family, edu-
cation, habitat, occupation, family income, and associated systemic
illnesses, did not show any significant influence on pain duration.
Discussion
The present study aimed to identify various dimensions of
headache and associated factors among patients with CTTH. As in
previous reports (Gururaj et al., 2014), the mean age of the patients
in the present study was 45.18 ± 10.93; the majority were female,
married, and employed. Although the exact causes and mecha-
nisms of CTTH are unclear, stress is considered to be one of the
primary triggering factors. Stress could be high among women who
are married and employed, as they need to balance professional
responsibilities along with family responsibilities.
Contrary to previous reports (Gururaj et al., 2014; Kulkarni et al.,
2015), a majority of the patients in the present study were from an
urban area. That could be due to the enrollment of patients only from
a single city-based tertiary care center. Health access among the fe-
male population in villages is limited. Almost half of the patients had
a systemic illness. Illnesses such as hypertension, allergy, asthma,

Please cite this article as: Gopichandran, L et al., Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An
Exploratory Survey, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.02.066
 L. Gopichandran et al. / Pain Management Nursing xxx (xxxx) xxx 5

Table 4
Association of Various Factors with Frequency of Headache

Variables of Patients with CTTH Prevalence Based on Headache Frequency f (%) n ¼ 169

4/week 5/week 6/week Chi2 (p Value)

Age
18-40 years 4 (7) 54 (90) 2 (3) 2.03 (.73)
41-60 years 9 (9) 84 (87) 4 (4)
60 years 2 (17) 9 (75) 1 (8)
Sex
Female 15 (16) 79 (82) 2 (2) 14.24 (.001*)
Males 0 (0) 68 (93) 5 (7)
Marital status
Unmarried 1 (7) 14 (93) 0 (0) 12.07 (.017*)
Married 10 (7) 126 (88) 7 (5)
Divorced/widowed 4 (36) 7 (64) 0 (0)
Type of family
Nuclear 14 (14) 82 (83) 2 (2.8) 8.65 (.013*)
Joint 1 (1.5) 65 (93) 5 (5.5)
Education
Illiterate and primary 4 (18) 18 (82) 0 (0) 14.22 (.038*)
Upto Higher secondary 5 (6) 70 (90) 3 (4)
Graduation and above 6 (9) 59 (86) 4 (6)
Occupation
Student/unemployed 4 (5) 69 (92) 2 (3) 20.04 (.003*)
Unskilled laborer 2 (12) 13 (76) 2 (12)
Salaried/Self employed 4 (6) 58 (91) 2 (3)
Retired 5 (38.5) 7 (54) 1 (7.5)
Income
10,000-15,000 3 (10) 25 (83) 2 (7) 0.67 (.72)
>15,000 12 (8.5) 122 (88) 5 (3.5)
Habitat
Rural 5 (28) 12 (67) 1 (5) 11.14 (.025*)
Semi-urban 2 (9) 18 (82) 2 (9)
Urban 8 (6) 117 (91) 4 (3)
Illness duration
6 months-2 year 5 (6.5) 66 (85.5) 6 (8) 9.67 (.008*)
>2 yrs 10 (11) 81 (88) 1 (1)
Systemic illness
No 3 (3.5) 82 (93) 3 (3.5) 7.23 (.027*)
Yes 12 (15) 65 (80) 4 (5)
Medications
Analgesics 3 (5) 51 (85) 6 (10) 9.33 (.009*)
Analgesic and Betablockers 12 (11) 96 (88) 1 (1)
*
Significant at p value less than or equal to .05.

arthritis, diabetes, obesity, and hypothyroidism have been proven to
be associated with chronic dailyheadache (CDH) in clinical series
(Negm et al., 2017; Myers, Wittrock, & Foreman, 1998; Schwartz,
Stewart, Simon, & Lipton, 1998). The majority of patients were pre-
scribed low-dose amitriptyline or propranolol along with analgesic.
Per the literature, beta-blockers (Propranolol) or tricyclic antide-
pressants (Amitriptyline) have to be initiated along with analgesics
to reduce the pain and improve the well-being of patients with
chronic tension-type headache (Westergaard et al., 2014).
Dimensions of headache included in the present study among
patients with CTTH include headache severity, duration, and fre-
quency, as they are considered prognostic factors for predicting the
recovery of patients with headache. Headache severity in patients
with chronic tension-type headache in literature is reported as
moderate to severe (Ashina et al., 2010; Castien et al., 2011; Rains &
Poceta, 2010). In the present study, patients with CTTH reported
moderate severity of 6.62 ± 1.16 out of 10, daily headache duration
of 8.68 ± 1.68 hours, and weekly frequency of 4.95 ± 0.38, a finding
that was congruent with previous report of Castien et al. (2011),
who reported a mean (SD) headache duration 13.0 ± 9.1 hours,
frequency of 5.5 days per week and severity of 7.6 ±1.7. The ma-
jority of the patients in the present study reported a headache
frequency of five per week, and 4% of the patients reported six per
week. The weekly frequency of headaches may correspond to the
number of lost working days or days with reduced work efficiency.
Personal, professional, and socioeconomic consequences may be
caused by lost workdays or days with reduced work efficiency
(Schwartz et al., 1998).
Multiple factors influencing various dimensions of headache
were analyzed in the present study, and few of the social de-
terminants such as gender, education, and living conditions were
found to adversely influence the pain. As in previous studies
(Gururaj et al., 2014), women were found to have more prevalence
of CTTH. Women are reported to have low pain threshold and pain
tolerance (Smitherman & Ward, 2011). Higher social and family role
expectations from women in our culture may be a stress-inducing
factor and can lead to a high prevalence of CTTH in women.
Women in our culture also are reported to have poor health-
seeking and may use fewer coping strategies (Koushede et al.,
2011; Smitherman & Ward, 2011). Though the prevalence of CTTH
is high in women, it was found in our study that significantly more
male patients had reported higher weekly frequency of headaches.
Contradicting this finding, previous literature shows that headache
characteristics, including frequency, duration, and severity, are
similar in male and female patients (Marcus, 2000; Marcus, 2001).
Significantly higher headache severity and frequency were re-
ported by patients who were married as compared to patients who
were unmarried or divorced. Chronic tension-type headache is,
however, considered to be a stress-related disorder (Bakhshani
et al., 2015; Dhandapani et al., 2015; Omidi & Zargar, 2015;

Please cite this article as: Gopichandran, L et al., Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An
Exploratory Survey, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.02.066
6 L. Gopichandran et al. / Pain Management Nursing xxx (xxxx) xxx

Table 5
Association of Various Factors with Headache Duration

Patients' Variables Headache Duration Mean ± SD n ¼ 169

Test Value (p Value)

Age 0.01 (.89)

Sex
Female 8.54 ± 1.66 1.23 (.22)
Male 8.8 ± 1.72
Marital status
Unmarried 8.2 ± 1.2 1.59 (.19)
Married 8.7 ± 1.72
Divorced 9 ± 2
Widowed 7.5 ± 0.83
Type of family
Nuclear 8.56 ± 1.64 1.05 (.64)
Joint 8.84 ± 1.73
Education
Illiterate& primary 8.8 ± 1.77 1.14 (.34)
Upto Highersecondary 8.47 ± 1.64
Graduation&above 8.46 ± 1.65
Occupation
Student/unemployed 8.98 ± 1.72 3.81 (.011*)
Unskilled laborer 9.86 ± 1.8
Salaried/Self employed 8.1 ± 1.55
Retired/Pensioner 8.68 ± 1.68
Income
10,000-15,000 8.93 ± 1.93 1.67 (.31)
>15,000 8.6 ± 1.68
Habitat
Rural 9.11 ± 1.93 2.07 (.129)
Semi-urban 9.18 ± 1.56
Urban 8.53 ± 1.65
Illness duration
<2 yrs 10.88 ± 1.13 18.36 (<.001*)
>2 yrs 7.42 ± 0.76
Systemic illness
No 8.7 ± 1.74 0.74 (.46)
Yes 8.58 ± 1.63
Medications
Analgesics 10.38 ± 1.02 14.75 (<.001*)
Analgesic and Betablockers 7.74 ± 1.16
*
Significant at p value less than or equal to .05.

Westergaard et al., 2016), and pressure related to meeting role
expectation from family members, demanding interpersonal re-
lationships (Myers et al., 1998), conflicts among family members,
poor coping, and lack of time for self-care could explain the reason
for higher severity of headache among patients with chronic
tension-type headache who are married. The association between
marital status and chronic tension-type headache may be related to
the occurrence of stressful life events or significant life changes
(Gururaj et al., 2014; Myers et al., 1998; Westergaard et al., 2014).
Significantly higher pain frequency was reported by patients
with higher educational status. In the present study, the majority of
the patients were educated but unemployed. Although there is an
increase in literacy rate, the existence of unemployment among
educated people could affect their psychological well-being,
resulting in chronic tension-type headaches (Gonzalez-Ramirez
et al., 2017).
Significantly longer headache duration was reported among
patients who were unskilled laborers, unemployed, or students.
Though the present study could not elicit any relationship between
income and headache characteristics, pain characteristics in pa-
tients with chronic tension-type headache are adversely influenced
by low income and poor socioeconomic status (Gururaj et al., 2014;
Westergaard et al., 2014). The socioeconomic burden due to un-
employment could precipitate headaches in patients, as they may
not be able to comfortably make ends meet for their families.
Chronic tension-type headache reduce the productivity of in-
dividuals and can result in socioeconomic burden on families. In
developing countries like India, increasing population density, ur-
banization, modernization, and industrialization lead to unem-
ployment accompanied by financial burden and can adversely
affect pain characteristics (Westergaard et al., 2014). An unhealthy
lifestyle was found to be a possible confounder in the relationship
between headache and socioeconomic position.
Rural inhabitants are also reported to have a high prevalence of
headache, inclusive of all types (Gururaj et al., 2014). But in the
present study, the majority of the patients were urban inhabitants,
as the sample was selected from a city-based tertiary care center.
The rural inhabitants in the present study reported a significantly
lower frequency of headaches as compared to patients who are
urban dwellers. The rural inhabitants are also reported to have a
high prevalence of CTTH associated with medication overuse owing
to the easy availability of over-the-counter medications and diffi-
cult access to a healthcare facility, and this finding may explain the
reduced frequency of headache among rural inhabitants in the
initial period of diagnosis.
Illnesses such as hypertension, allergy, asthma, arthritis, dia-
betes, obesity, and hypothyroidism have been proven to be asso-
ciated with CTTH (Bigal et al., 2002; Gipponi et al., 2010). But in our
sample, significantly lower headache frequency was reported by
patients with systemic illnesses. Almost one-third of our patients
with systemic illness were known cases of hypertension or diabetes
mellitus. Lower frequency of headache in patients with systemic
illness in our study could be an effect of the existing management of
hypertension with beta-blockers in some cases. Our study included

Please cite this article as: Gopichandran, L et al., Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An
Exploratory Survey, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.02.066
 L. Gopichandran et al. / Pain Management Nursing xxx (xxxx) xxx
patients with chronic tension-type headaches who are on analge-
sics along with beta-blockers or low-dose antidepressants. As re-
ported in previous literature (Monteith & Sprenger, 2010; Stephens
et al., 2016), significantly higher headache severity was reported by
patients who had a duration of illness less than 2 years. In the
present study, significantly higher headache severity was also re-
ported by patients who were on only analgesics as compared to
patients who were on both analgesics and beta-blockers. Upon
diagnosis of chronic tension-type headache, pharmacological
management is initiated with analgesics. The efficiency of analge-
sics such as acetaminophen or NSAIDs in controlling headache in
patients with chronic tension-type headache is uncertain
(Koushede, Holstein, Andersen, & Hansen, 2011; Krishnan & Silver,
2009). The inefficiency of these drugs in managing symptoms leads
to medication overuse during this period that can adversely influ-
ence headache severity and headache-associated disability. This
outcome may lead to the initiation of beta-blockers or tricyclic
antidepressants to reduce pain and improve the well-being of the
patients. Most patients would hence be prescribed any of these
drugs for better pain control along with analgesics as the illness
progresses to a chronic stage. Pharmacological and therapeutic
management also should be modified according to the severity of
the pain reported by the patients to avoid medication overuse and
side effects (Dhandapani et al., 2013; Monteith & Sprenger, 2010;
Stephens, Derry, & Moore, 2016).
We have explored the clinical characterization of headache in a
large sample of CTTH patients and studied the influence of various
social and clinical determinants associated with pain characteris-
tics in CTTH. Few of the social determinants of CTTH identified in
the study are found to be connected with stress. The preventive and
management strategies for stress may thus enhance coping among
individuals who are at risk for or suffering from CTTH. CTTH not
only affects the family and social system, but also has repercussions
in the public health system. A high average number of appoint-
ments are made in health facilities due to CTTH, substantially
increasing demand for medical treatment.
Nursing Implications
Although CTTH is a lesser-known condition, its impact on lives is
significant. As monitoring of various pain dimensions in patients of
CTTH may aid in the modification of pharmacological and non-
pharmacological management, it is important for nurses to interact
with patients and identify pain severity, frequency, and duration
during their follow-up hospital visits or even telephonic follow-up.
The present study has identified some of the social and clinical
factors that may influence pain dimensions. Nurses have an
important role in monitoring pain and identifying the influencing
factors in each patient so that the interventions can be individu-
alized for patients with chronic tension-type headache (Thakur,
Dhandapani, Mohanty , Ghai, & Sivashanmugam, 2019). Perform-
ing such evaluation will also help them to refer the patients for
appropriate health-promoting behavior. Special attention should
be given to patients of CTTH who are married and patients with
high educational qualifications, as these factors were found to in-
fluence headache. Further evidence must be obtained to explore
the role of stress-inducing factors on CTTH. Future studies must
explore various nonpharmacological interventions that can alle-
viate the burden of pain in patients of CTTH.
Conclusion
Tension-type headache is the second most prevalent disabling
condition and one of the costliest neurological illnesses, one which
is proven to have repercussions on patients’ quality of life, families,
Please cite this article as: Gopichandran, L et al., Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An
Exploratory Survey, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.02.066
7
and social roles. Patients with CTTH experience moderate to high
severity of headache along with substantial duration and fre-
quency, and these outcomes are associated with various lifestyle-
related factors that can result in stress. The association of CTTH
with stress-inducing factors and adverse effects of medication
overuse needs to be considered among these patients. Lifestyle
modification and nonpharmacological management are essential to
reducing the recurrence of CTTH and medication side effects that
cause disability.
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