Summary

Tension-Type Headache (TTH) is the most common primary headache disorder globally, affecting up to 80% of the population. It is characterised by bilateral, pressing or tightening ("band-like") pain of mild-to-moderate intensity. Unlike migraine, it is NOT aggravated by routine physical activity and is NOT associated with vomiting (though mild nausea may occur). Photophobia OR phonophobia may be present, but not both. TTH is classified into Infrequent Episodic (<1 day/month), Frequent Episodic (1-14 days/month), and Chronic (≥15 days/month). Pathophysiology involves pericranial muscle tenderness and, in chronic cases, central sensitisation of pain pathways. Management focuses on reassurance, simple analgesics (Paracetamol/NSAIDs) for acute attacks, and tricyclic antidepressants (Amitriptyline) for prophylaxis. Non-pharmacological strategies (physiotherapy, stress management) are crucial.

Key Facts

• Prevalence: Lifetime prevalence 30-78%. The most common headache.
• Gender: F:M = 5:4 (Slight perponderance).
• The "Featureless" Headache: Defined by what it lacks (No vomiting, No aura, No severe throbbing).
• Chronic TTH: Can be extremely disabling despite "mild" pain description due to constancy.
• Top Trigger: Stress (Mental or Physical/Posture).
• Examination: Normal neuro exam. Pericranial tenderness is the only common finding.

Clinical Pearls

"The Vice-Like Grip": Patients often gesture with both hands pressing on their temples or forehead. "It feels like a tight hat."

"Migraine Mimic": 90% of patients attending headache clinics diagnose themselves with "Tension Headache" but actually have Migraine. If it forces them to lie down in a dark room, it's probably Migraine. TTH patients usually carry on with their day ("Walking Wounded").

"Touch the Neck": Palpate the trapezius, temporalis, and occipital muscles. Active Trigger Points reproduce the headache. This validates the patient's pain ("Yes! That's it!").

"No Opioids": Codeine causes Medication Overuse Headache (MOH) and transforms episodic TTH into Chronic TTH. Avoid at all costs.

Diagnostic Criteria

A. Infrequent Episodic TTH

• less than 1 day/month (less than 12 days/year).
• Lasts 30 mins to 7 days.
• At least 2 of 4 characteristics:
  1. Bilateral location.
  2. Pressing/Tightening (non-pulsating) quality.
  3. Mild or Moderate intensity.
  4. Not aggravated by routine physical activity.
• Both of:
  1. No nausea or vomiting.
  2. No more than one of Photophobia or Phonophobia.

B. Frequent Episodic TTH

• 1-14 days/month.

C. Chronic TTH

• ≥ 15 days/month for > 3 months.
• Often associated with Medication Overuse.

         TENSION-TYPE HEADACHE DIAGNOSED
                     ↓
        ASSESS FREQUENCY AND MEDICATION USE
                     ↓
      ┌──────────────┼───────────────┐
  EPISODIC (<15d)          CHRONIC (≥15d)
      ↓                          ↓
  ACUTE THERAPY           PROPHYLACTIC THERAPY
  + Reassurance           + Withdrawal of Overuse
                          + CBT / Physio

1. Acute Management

• First Line:
  • Aspirin 600-900mg (Soluble is faster).
  • Ibuprofen 400mg.
  • Paracetamol 1000mg (Less effective than NSAIDs).
• Adjuncts: Caffeine (often included in OTC headache meds) enhances analgesia but risks overuse.
• Avoid: Opioids (Codeine, Tramadol), Triptans (Do not work for TTH).
• Limit: Use to less than 2 days/week to prevent MOH.

2. Prophylactic Management (Chronic TTH)

Indicated if frequent Episodic or Chronic TTH.

• First Line: Amitriptyline (Tricyclic Antidepressant).
  • Dose: Start 10mg nocte. Titrate up to 75mg.
  • Mechanism: Modulates pain pathways (Independent of antidepressant effect).
  • Side Effects: Drowsiness, dry mouth, weight gain.
• Second Line: Mirtazapine or Venlafaxine.
• Third Line: Gabapentin / Topiramate (Limited evidence).

3. Non-Pharmacological (Crucial)

• Physiotherapy: To correct posture, treat cervical muscle dysfunction, dry needling for trigger points.
• CBT / Relaxation: Biofeedback, progressive muscle relaxation to reduce underlying tension/stress.
• Ergonomics: Workstation setup (Screen height, chair support).
• Dentist: Rule out Bruxism (Night guard may help).

Why does the headache become chronic? In Chronic TTH, the pain is no longer just "muscle tightness". The central nervous system changes.

• Wind-Up Phenomenon: Repetitive firing of C-fibres leads to amplification of signals in the dorsal horn.
• Lowered Threshold: Nerves fire at lower stimuli.
• Expanded Receptive Fields: Pain spreads from neck to head to shoulders.
• Implication: treating the muscle alone won't work. We must treat the nerves (Amitriptyline) and the mind (CBT).

How to find a Trigger Point:

1. Palpate the Upper Trapezius and Sternocleidomastoid with pincer grip.
2. Feel for a "taut band" (ropey muscle).
3. Press firmly.
4. Positive Sign:
   • Local pain.
   • "Jump Sign" (Patient winces/withdraws).
   • Referred Pain: Pressing the neck reproduces the specific headache pattern (e.g. SCM referral to above eye).

Is it placebo?

• Cochrane Review (2016): "Acupuncture is effective for treating frequent episodic or chronic tension-type headaches."
• Results:
  • Reduces headache frequency by 50% in roughly half of patients.
  • Effect is small but statistically significant over sham acupuncture.
  • Effects persist for months after treatment course.
• Mechanism: Release of endogenous opioids/endorphins? Gate control theory?

The "Computer Headache".

Ergonomic Checklist

1. Monitor Height: Top of screen at eye level. Looking down strains the suboccipitals.
2. Distance: Arm's length.
3. Shoulders: Relaxed, not hunched. Elbows at 90 degrees.
4. Breaks: "20-20-20 Rule" (Every 20 mins, look 20 feet away, for 20 seconds). Stretch neck.

Stress Management

• Diaphragmatic Breathing: Chest breathing uses accessory muscles (Scalenes/SCM), causing neck tension. Belly breathing relaxes them.
• Progressive Muscle Relaxation: Tense and release muscle groups to learn what "relaxed" feels like.

Key Guidelines

• NICE CG150 (Headaches): Recommends Amitriptyline for Chronic TTH. Explicitly advises AGAINST opioids. Acupuncture as valid option.
• BASH (British Association for Study of Headache): Guidelines for diagnosis and management.

Key Reviews

• Cochrane: Ibuprofen and Paracetamol are effective for acute TTH. Amitriptyline effective for chronic.

What is a Tension Headache?

It feels like a tight band squeezing your head or a heavy weight on top of it. It's often caused by tight muscles in your neck and scalp, usually linked to stress, posture, or tiredness.

Is it a Migraine?

Probably not, if you can still walk around, watch TV, and eat dinner. Migraines usually make you feel sick and need to lie down in the dark. Tension headaches are annoying but you can usually "push through".

Can I just take Codeine?

NO. Codeine is the worst thing for these headaches. It works briefly, but then causes "Rebound Headaches" (Medication Overuse), making the problem 10 times worse and harder to treat. Stick to Paracetamol or Ibuprofen, and not for more than 2 days a week.

How do I stop them coming back?

Fix the root cause:

1. Posture: Fix your desk setup.
2. Stress: Learn to relax your jaw and shoulders.
3. Sleep: Keep regular hours.
4. Medicine: If they are daily, your doctor might prescribe a low-dose antidepressant (Amitriptyline) – not for depression, but to relax the pain nerves.