Tension-Type Headache
Summary
Tension-Type Headache (TTH) is the Most Common Primary Headache Disorder, affecting up to 80% of the population at some point in their lives. It is characterised by Bilateral, Non-Pulsating, Pressing or Tightening ("Band-Like") pain of Mild to Moderate Intensity that does NOT worsen with routine physical activity. Unlike migraine, TTH is typically NOT associated with nausea, vomiting, photophobia, or phonophobia (Though mild versions of one of these may be present). The pathophysiology involves Peripheral Mechanisms (Myofascial tenderness, Pericranial muscle dysfunction) and Central Sensitisation in chronic forms. TTH is classified as Episodic (Infrequent or Frequent) or Chronic based on frequency. The International Classification of Headache Disorders (ICHD-3) provides diagnostic criteria. Management includes Simple Analgesics (Paracetamol, NSAIDs) for acute episodes and Amitriptyline as first-line prophylaxis for chronic TTH. Non-Pharmacological approaches (Stress management, Physiotherapy, Relaxation techniques) are essential components of treatment. Although benign, TTH can significantly impact quality of life and productivity, with chronic TTH being particularly disabling. [1,2,3]
Key Facts
| Fact | Value |
|---|---|
| Definition | Bilateral, non-pulsating, pressing/tightening headache of mild-moderate intensity |
| Prevalence | Lifetime ~80%, 1-year ~40-60% |
| Peak Age | 30-40 years |
| Sex Ratio | Female > Male (Slight predominance) |
| Gold Standard Diagnosis | Clinical – ICHD-3 Criteria |
| First-Line Acute Treatment | Paracetamol 1g or Ibuprofen 400mg |
| First-Line Prophylaxis | Amitriptyline 10-75mg nocte |
| Prognosis | Generally good. Chronic TTH more challenging |
Clinical Pearls
"Band-Like Pressure Around the Head": Classic description. Not pulsating.
"No Nausea, No Throbbing, No Worsening with Activity": Key distinctions from migraine.
"Amitriptyline for Chronic TTH": Low-dose tricyclic is first-line prophylaxis.
"Rule Out Medication Overuse Headache": In frequent TTH patients using regular analgesics.
"Pericranial Tenderness": Often present on examination – useful supporting sign.
Why This Matters Clinically
Tension-type headache is the most prevalent headache disorder and a leading cause of disability worldwide. While individual episodes are typically not severe, the cumulative burden of frequent or chronic TTH significantly impacts quality of life, work productivity, and healthcare utilisation. Accurate diagnosis prevents unnecessary investigations and inappropriate treatments. Recognition of chronic TTH and medication overuse headache is essential to prevent treatment escalation and analgesic dependency. TTH is frequently examined in postgraduate assessments as part of headache classification and differential diagnosis.
Incidence & Prevalence
| Measure | Value | Notes |
|---|---|---|
| Lifetime Prevalence | ~80% | Most common headache type |
| 1-Year Prevalence (Global) | 40-60% | Higher in developed countries |
| 1-Year Prevalence (Europe) | 60-80% | Highest prevalence region |
| 1-Year Prevalence (Asia) | 20-40% | Lower than Western countries |
| Episodic TTH (Infrequent) | 60-70% of TTH | Most have infrequent episodes |
| Episodic TTH (Frequent) | 20-30% of TTH | May require management |
| Chronic TTH | 2-3% global population | Significant disability burden |
| Chronic TTH (Europe) | 3-4% | Highest chronic rates |
Demographics
| Factor | Details | Clinical Significance |
|---|---|---|
| Age of Onset | Can begin at any age | Peak prevalence 30-40 years |
| Childhood TTH | Prevalence 10-30% | Often underdiagnosed |
| Adolescent TTH | Prevalence 15-30% | Academic stress contributor |
| Adult Peak (30-40) | Highest prevalence | Work/family stress peak |
| Elderly TTH | Decreases after 50-60 | May transition to other types |
| Sex Ratio | Female:Male ~1.2-1.5:1 | Less marked than migraine (3:1) |
| Socioeconomic Status | Higher with stress | Work-related factors important |
| Occupation | Office workers, Students, Professionals | Sedentary, stress, posture |
| Geographic Variation | Higher in Western/Developed countries | Lifestyle factors |
Global Burden
| Metric | Details |
|---|---|
| Disability-Adjusted Life Years (DALYs) | 6th leading cause of disability globally |
| Years Lived with Disability (YLDs) | 2nd leading cause after low back pain |
| Economic Impact | Billions per year in lost productivity |
| Healthcare Utilisation | Accounts for ~4-5% of GP consultations |
Risk Factors and Associations
Non-Modifiable Risk Factors:
| Factor | Relative Risk | Mechanism |
|---|---|---|
| Female Sex | RR 1.2-1.5 | Hormonal factors, Pain processing differences, Psychosocial factors |
| Family History | RR 2-4 | First-degree relatives with TTH. Genetic predisposition to pain sensitivity |
| Age 30-50 | Peak incidence | Life-stage stressors, Work demands |
| Genetics | Under investigation | Polygenic. Serotonin transporter gene variants. COMT polymorphisms |
Modifiable Risk Factors:
| Factor | Relative Risk | Mechanism | Intervention |
|---|---|---|---|
| Psychological Stress | RR 2-3 | HPA axis activation, Muscle tension, Central sensitisation | Stress management, CBT, Relaxation |
| Anxiety | RR 2-3 | Increased muscle tension, Hypervigilance to pain | Treat underlying anxiety |
| Depression | RR 2-4 | Shared serotonergic dysfunction, Central pain amplification | Treat depression (Dual benefit with amitriptyline) |
| Poor Sleep Quality | RR 1.5-2 | Impaired descending pain modulation, Fatigue | Sleep hygiene, Treat sleep disorders |
| Sleep Deprivation | RR 1.5 | Lowered pain threshold | Regular sleep schedule |
| Poor Posture | RR 1.5 | Cervical/shoulder muscle strain, Myofascial dysfunction | Ergonomic correction, Physiotherapy |
| Prolonged Screen Use | RR 1.5-2 | Eye strain, Neck posture, Reduced blinking | Screen breaks, Ergonomics, Blue light filters |
| Physical Inactivity | RR 1.3-1.5 | Reduced endorphins, Muscle weakness | Regular aerobic exercise |
| Caffeine Overuse | Variable | Rebound headache, Central effects | Moderate intake (less than 200mg/day) |
| Caffeine Withdrawal | Common trigger | Adenosine receptor upregulation | Gradual reduction, Consistent intake |
| Medication Overuse | Major risk for chronification | Central sensitisation, MOH | Limit acute analgesics to less than 10-15 days/month |
| Smoking | RR 1.2-1.5 | Vascular effects, Stress association | Smoking cessation |
| Alcohol | Variable | May trigger or relieve | Moderation |
| Dehydration | Common trigger | Unknown mechanism | Adequate hydration |
| Skipping Meals | Common trigger | Hypoglycaemia, Stress response | Regular meals |
Associated Conditions:
| Condition | Association | Clinical Implication |
|---|---|---|
| Migraine | Overlap in 30-40% | Mixed headache types. May coexist. |
| Temporomandibular Disorder (TMD) | Common comorbidity | Shared myofascial dysfunction |
| Fibromyalgia | Increased prevalence in TTH | Central sensitisation overlap |
| Cervicogenic Headache | May mimic or coexist | Careful differential |
| Chronic Fatigue Syndrome | Associated | Central mechanisms |
| Irritable Bowel Syndrome | Increased | Visceral hypersensitivity |
| Generalised Anxiety Disorder | Common | Treat both |
| Major Depression | Common | Treat both |
Overview
The pathophysiology of TTH involves a complex interplay between Peripheral Mechanisms (Pericranial muscle dysfunction, Myofascial trigger points) and Central Mechanisms (Central sensitisation, Impaired pain modulation). The relative contribution shifts from peripheral to central as TTH progresses from episodic to chronic.
Mechanism (Stepwise)
Step 1: Peripheral Nociceptive Activation (Episodic TTH)
The initiating events typically involve activation of peripheral nociceptors in pericranial muscles:
| Component | Details |
|---|---|
| Myofascial Trigger Points | Hyperirritable spots in taut muscle bands. Release nociceptive signals. |
| Muscle Tension | Sustained or inappropriate muscle contraction |
| Muscle Ischaemia | Reduced blood flow during excessive contraction |
| Local Inflammatory Mediators | Substance P, CGRP, Bradykinin, Prostaglandins, Potassium, Hydrogen ions |
| Nociceptor Sensitisation | Lowered threshold for activation |
| Pain Signal Transmission | Via trigeminal (V1, V2, V3) and upper cervical (C1-C3) afferents |
Pericranial Muscles Involved:
| Muscle | Location | Innervation | Role in TTH |
|---|---|---|---|
| Temporalis | Temporal region | Trigeminal (V3) | Often tenderness to palpation |
| Frontalis | Forehead | Facial nerve (VII) | Furrowing with stress |
| Occipitalis | Occiput | Facial/Occipital nerves | Posterior head pain |
| Masseter | Jaw | Trigeminal (V3) | Clenching, TMJ involvement |
| Pterygoids (Medial/Lateral) | Deep jaw | Trigeminal (V3) | Jaw tension |
| Sternocleidomastoid (SCM) | Neck | Accessory nerve (XI) | Neck pain, Postural |
| Trapezius (Upper) | Shoulder/Neck | Accessory nerve (XI) | Shoulder tension, Posture |
| Splenius Capitis | Posterior neck | Cervical nerves | Neck extension strain |
| Suboccipital Muscles | Base of skull | C1 | Fine head movements |
Trigger Points:
- Localised areas of hyperirritability
- Palpable taut bands
- Cause referred pain patterns
- May activate central sensitisation with repeated stimulation
Step 2: Trigeminal Nucleus Caudalis Processing
| Process | Details |
|---|---|
| First-Order Neurons | Transmit from pericranial tissues via V and C1-C3 |
| Synapse | Trigeminal nucleus caudalis (TNC) in brainstem |
| Second-Order Neurons | Relay to thalamus |
| Convergence | Input from multiple sources converges |
| Wind-Up Phenomenon | Repeated stimulation increases neuron excitability |
| Glial Activation | Microglia and astrocytes amplify signalling |
Step 3: Transition to Central Sensitisation (Chronic TTH)
With repeated or persistent peripheral input, central nervous system changes occur:
| Mechanism | Description | Effect |
|---|---|---|
| Reduced Pain Threshold | Less stimulus needed to evoke pain | Hyperalgesia |
| Expanded Receptive Fields | Neurons respond to larger area | Spread of pain |
| Increased Spontaneous Activity | Neurons fire without stimulus | Background pain |
| Impaired Descending Inhibition | Serotonergic/noradrenergic pathways weakened | Pain persists |
| Cortical Reorganisation | Altered pain processing in cortex | Chronic pain state |
| NMDA Receptor Upregulation | Enhanced excitatory neurotransmission | Sensitisation maintains |
Step 4: Impaired Descending Pain Modulation
| Pathway | Neurotransmitters | Status in Chronic TTH |
|---|---|---|
| Periaqueductal Grey (PAG) | Enkephalins, Endorphins | Reduced activity |
| Nucleus Raphe Magnus | Serotonin (5-HT) | Dysfunction |
| Locus Coeruleus | Noradrenaline (NE) | Reduced inhibition |
| Rostral Ventromedial Medulla (RVM) | GABA, 5-HT | Impaired |
This is why tricyclic antidepressants (enhance 5-HT and NE) are effective for chronic TTH.
Step 5: Perpetuating and Modulating Factors
| Factor | Mechanism | Clinical Relevance |
|---|---|---|
| Psychological Stress | Increases muscle tension, HPA axis activation, Affects pain processing | Stress management essential |
| Sleep Disturbance | Impairs descending modulation, Increases pain sensitivity | Sleep hygiene important |
| Mood Disorders | Depression/Anxiety share serotonergic dysfunction, Amplify pain | Treat comorbidity |
| Medication Overuse | Further central sensitisation, MOH development | Limit analgesics |
| Inactivity | Muscle weakness, Reduced endogenous analgesia | Encourage exercise |
| Posture | Sustained muscle activation, Myofascial strain | Ergonomic education |
Step 6: Clinical Implications (Treatment Targets)
| Target | Modality | Examples |
|---|---|---|
| Peripheral (Muscles) | Physiotherapy | Massage, Trigger point release, Stretching, Exercises |
| Peripheral (Inflammation) | NSAIDs | Ibuprofen for acute |
| Central (Serotonin/NE) | Tricyclic antidepressants | Amitriptyline |
| Central (NMDA) | NMDA antagonists | Limited evidence (Ketamine) |
| Psychological | CBT, Relaxation, Biofeedback | Address stress, Catastrophising |
| Lifestyle | Sleep, Exercise, Posture | Holistic management |
Pathophysiology Diagram
Classification (ICHD-3)
Overview:
| Subtype | Frequency Criteria | Duration | Notes |
|---|---|---|---|
| Infrequent Episodic TTH | Less than 1 day/month (Less than 12 days/year) | 30 min - 7 days | Minimal clinical significance. Most population. |
| Frequent Episodic TTH | 1-14 days/month (12-180 days/year) for 3 months or more | 30 min - 7 days | May cause significant disability. Consider prophylaxis. |
| Chronic TTH | 15 days or more per month (180 or more days/year) for more than 3 months | Hours to continuous | Significant impact. Prophylaxis recommended. |
With/Without Pericranial Tenderness: Each subtype further classified by presence or absence of pericranial muscle tenderness on manual palpation.
| Classification | Clinical Significance |
|---|---|
| With Pericranial Tenderness | Suggests peripheral component. May respond to physiotherapy. |
| Without Pericranial Tenderness | Central mechanisms may predominate. |
Symptoms - Detailed Analysis
Core Diagnostic Features (ICHD-3):
| Feature | Description | Frequency | Diagnostic Weight |
|---|---|---|---|
| Bilateral Location | Both sides of head, May be temporal, Frontal, Occipital, Or generalised | ~90% | Essential differentiator from migraine |
| Pressing/Tightening Quality | "Band around the head", "Vice-like", "Cap-like", Non-pulsating | ~90% | Classic description. Non-pulsating key. |
| Mild-Moderate Intensity | VAS 3-6/10. Does NOT significantly impair function. | ~95% | Severe = Question diagnosis |
| Not Aggravated by Activity | Walking, Climbing stairs, Routine activities tolerated | Essential | Key distinction from migraine |
| Duration | 30 minutes to 7 days per episode | Variable | Chronic may be continuous |
Pain Characteristics:
| Characteristic | TTH | Migraine (Comparison) |
|---|---|---|
| Location | Bilateral, Generalised | Often unilateral (60%) |
| Quality | Pressing, Tightening, Dull | Pulsating, Throbbing |
| Intensity | Mild-Moderate | Moderate-Severe |
| Effect of Activity | No worsening | Worsens with activity |
| Duration | 30 min - 7 days | 4-72 hours |
| Aura | Never | Present in 20-30% |
| Nausea/Vomiting | Absent | Often present |
| Photophobia | Absent or mild (1 only) | Present |
| Phonophobia | Absent or mild (1 only) | Present |
Associated Features (Typically ABSENT or Mild):
| Feature | Status in TTH | Notes |
|---|---|---|
| Nausea | Absent in episodic. Mild may occur in chronic. | Vomiting = Not TTH |
| Vomiting | Always absent | Present = Consider migraine |
| Photophobia | Absent OR mild | Max ONE of photo/phonophobia |
| Phonophobia | Absent OR mild | Max ONE of photo/phonophobia |
| Osmophobia | Absent | Smell sensitivity = Migraine |
| Allodynia | Mild in chronic | Cutaneous hypersensitivity |
| Aura | Never | If aura present = Not TTH |
| Autonomic Features | Absent | Tearing, Rhinorrhoea = Trigeminal autonomic cephalalgias |
Symptom Patterns:
| Pattern | Description | Implications |
|---|---|---|
| Morning Onset | May relate to poor sleep, Bruxism | Assess sleep, TMD |
| End-of-Day Worsening | Common in frequent TTH | Work stress, Posture |
| Work-Related | Worse at work, Better on weekends | Occupational factors |
| Stress-Related | Temporally linked to stressful events | Stress management |
| Menstrual Timing | Some women report cyclical pattern | Hormonal component |
| Weekend Headache | May occur with caffeine withdrawal | Caffeine education |
| Waking with Headache | Less common in TTH | If prominent, Exclude sleep apnoea, IIH |
Chronicity Spectrum:
| Type | Frequency | Duration | Associated Features | Impact |
|---|---|---|---|---|
| Infrequent Episodic | Less than 1/month | 30 min - 7 days | Minimal | Low |
| Frequent Episodic | 1-14 days/month | 30 min - 7 days | Mild tenderness | Moderate |
| Chronic | 15+ days/month | Hours-Continuous | Tenderness, Mild nausea | High |
Atypical Presentations:
| Presentation | Frequency | Considerations |
|---|---|---|
| Unilateral TTH | ~10% | May still be TTH if other criteria met. Consider cervicogenic. |
| Severe Intensity | Rare | Question diagnosis. Consider migraine. |
| With Mild Nausea (Chronic) | Allowed in chronic | But vomiting = Not TTH |
| Diffuse/Global | Common | "Whole head" pain |
| Occipital Predominant | Occasional | Check cervicogenic contribution |
| Frontal Predominant | Common | Often stress-related |
Pericranial Tenderness:
| Finding | Description | Clinical Significance |
|---|---|---|
| Present | Tenderness on manual palpation of pericranial muscles | Supports peripheral component. Better response to physiotherapy. |
| Absent | No tenderness on palpation | Central mechanisms may predominate. |
| Severe | Very tender, Patient withdraws | Correlates with chronicity and severity. |
Total Tenderness Score (TTS):
Temporal Pattern
| Pattern | Description | Clinical Relevance |
|---|---|---|
| Episodic Discrete | Clear attacks with pain-free intervals | Easier to manage acutely |
| Episodic Frequent | Multiple attacks per month | Consider prophylaxis |
| Continuous Background | Constant low-grade headache | Suggests chronic TTH |
| Fluctuating Continuous | Background pain with exacerbations | Common in chronic |
| Progressive | Worsening over time | Consider MOH, Secondary causes |
Impact and Disability
| Domain | Impact in Episodic | Impact in Chronic |
|---|---|---|
| Work | Occasional reduced productivity | Significant absenteeism, Presenteeism |
| Social | Minimal | May avoid activities |
| Mood | Transient frustration | Anxiety, Depression common |
| Sleep | Usually unaffected | May be disrupted |
| Quality of Life | Mild reduction | Severely reduced (Comparable to migraine) |
Red Flags (Detailed Analysis)
[!CAUTION] SNOOP Mnemonic for Secondary Headache Red Flags:
- Systemic symptoms (Fever, Weight loss, Malaise) or Systemic disease (Cancer, HIV, Immunocompromise)
- Neurological symptoms or abnormal signs (Papilloedema, Focal deficits, Confusion)
- Onset sudden (Thunderclap - Peak within seconds to 1 minute)
- Older age (New headache after 50 years - Consider GCA)
- Previous headache history change (First, Worst, Different pattern, Progressive)
- Positional component (Worse lying/standing - CSF leak, IIH)
- Precipitated by Valsalva (Cough, Sneeze, Strain - Chiari, Mass)
- Papilloedema or Pregnancy/Postpartum
Red Flag Details:
| Red Flag | Consider | Investigation |
|---|---|---|
| Thunderclap Onset | SAH, RCVS, Dissection, Pituitary apoplexy | CT Brain, LP, CTA/MRA |
| New Onset greater than 50 years | Giant Cell Arteritis, Mass, Subdural | ESR/CRP, MRI, Temporal artery biopsy |
| Neurological Signs | Mass lesion, Stroke, Infection | MRI Brain, LP if infection |
| Papilloedema | IIH, Mass, Cerebral venous thrombosis | MRI/MRV, LP with opening pressure |
| Fever | Meningitis, Encephalitis, Abscess | LP, MRI |
| Weight Loss | Malignancy | CT/MRI, Systemic workup |
| HIV/Immunocompromise | Opportunistic infections, Lymphoma | MRI, LP, HIV test |
| Postural Component | CSF leak (Low pressure), IIH (High pressure) | MRI, LP |
| Pregnancy/Postpartum | Pre-eclampsia, CVST, Pituitary apoplexy | BP, MRV, Endocrine |
| Waking from Sleep | Mass lesion (Raised ICP), Sleep apnoea | MRI, Sleep study |
| Progressive Worsening | Mass, Chronic subdural, MOH | MRI |
| Cancer History | Brain metastases | MRI with contrast |
| Trauma | Subdural, Dissection | CT/MRI, CTA |
| Anticoagulation | Intracranial haemorrhage | CT Brain |
Structured Approach
Order of Examination:
- General observation
- Vital signs
- Head and neck examination
- Pericranial muscle palpation
- Cervical spine examination
- TMJ examination
- Neurological examination
- Fundoscopy
General Observation:
| Finding | Expected in TTH | Red Flag Consideration |
|---|---|---|
| Appearance | Well, Not in acute distress | Unwell, Toxic = Infection, Systemic disease |
| Posture | May have forward head posture | - |
| Distress Level | Minimal to moderate | Severe distress = Consider migraine, Secondary cause |
| Photophobia Behaviour | Not avoiding light | Avoiding light = Consider migraine. Or meningitis with fever. |
| Movement | Moves normally | Moving slowly, Neck stiffness = Red flag |
Vital Signs:
| Parameter | Expected in TTH | Red Flag |
|---|---|---|
| Temperature | Normal | Fever = Infection, GCA |
| Blood Pressure | Normal | Severe hypertension = Secondary cause |
| Heart Rate | Normal | Tachycardia with fever = Concerning |
Neurological Examination (Must Be Normal in TTH):
| Domain | What to Examine | Expected Finding |
|---|---|---|
| Consciousness | GCS, Orientation | Alert, Oriented |
| Speech | Dysphasia, Dysarthria | Normal |
| Cranial Nerves | Pupils, Visual fields, Eye movements, Facial movement, Hearing, Palate, Tongue | All normal |
| Fundoscopy | Optic disc margins, Venous pulsations | No papilloedema |
| Motor | Tone, Power, Drift | Normal |
| Sensory | Light touch, Pinprick | Normal |
| Reflexes | Upper and lower limb reflexes, Plantars | Normal |
| Coordination | Finger-nose, Heel-shin | Normal |
| Gait | Walk, Turn, Tandem | Normal |
ANY NEUROLOGICAL ABNORMALITY = NOT PURE TTH. Investigate.
Head and Neck Specific Examination:
| Area | Technique | Findings in TTH |
|---|---|---|
| Scalp Inspection | Look for lesions, Scars, Erythema | Usually normal |
| Scalp Palpation | Assess for tenderness, Masses | Usually non-tender (Except pericranial muscles) |
| Temporal Arteries | Palpate for tenderness, Nodularity, Absent pulse | Normal. If abnormal consider GCA (Age greater than 50) |
| Sinuses | Palpate frontal and maxillary | Non-tender |
| Cervical Lymph Nodes | Palpate anterior and posterior chains | Non-palpable/Normal |
Pericranial Muscle Palpation (Key Examination)
Technique:
- Use the second and third fingers, Apply firm rotating pressure
- Grade tenderness 0-3 at each site (0 = None, 1 = Mild, 2 = Moderate, 3 = Severe/Withdraws)
- Calculate Total Tenderness Score (TTS) by summing all sites
Muscle Sites to Palpate:
| Muscle | Location | How to Palpate |
|---|---|---|
| Temporalis | Temporal fossa (Side of head) | Palpate anterior and posterior fibres |
| Frontalis | Forehead | Palpate across forehead |
| Occipitalis | Occiput | Palpate nuchal line |
| Masseter | Angle of jaw | Ask patient to clench teeth, Palpate |
| Lateral Pterygoid | Deep to mandible | Difficult. Behind last molar. |
| Sternocleidomastoid (SCM) | Lateral neck | Palpate from mastoid to clavicle |
| Trapezius (Upper) | Upper shoulder/neck | Palpate upper fibres |
| Splenius Capitis | Posterior neck | Deep palpation lateral to spinous processes |
| Suboccipital Muscles | Base of skull | Palpate below occipital ridge |
Total Tenderness Score (TTS):
| Score | Interpretation |
|---|---|
| 0 | No tenderness |
| 1-8 | Mild tenderness (Common in general population) |
| 9-16 | Moderate tenderness (Supports TTH diagnosis) |
| 17+ | Severe tenderness (Correlates with chronic TTH, Poor prognosis) |
Clinical Significance:
- Pericranial tenderness is more common in TTH than controls
- Higher TTS correlates with headache frequency and chronicity
- Patients with tenderness may benefit more from physiotherapy
Cervical Spine Examination
| Test | Technique | Significance |
|---|---|---|
| Range of Motion | Flexion, Extension, Rotation, Lateral flexion | Limitation may suggest cervicogenic component |
| Tenderness | Palpate cervical spinous processes and paraspinals | Upper cervical tenderness common in TTH |
| Spurling's Test | Neck extension + Rotation + Axial compression | Radicular pain = Cervical radiculopathy (Not TTH) |
TMJ Examination
| Finding | Description | Significance |
|---|---|---|
| Tenderness | Pre-auricular palpation | Common comorbidity (TMD) |
| Clicking/Crepitus | Noted on opening/closing | TMJ dysfunction |
| Limited Opening | Less than 40mm | TMD |
| Deviation | Jaw deviates on opening | TMD |
Special Tests
| Test | Technique | Positive Finding | Significance |
|---|---|---|---|
| Total Tenderness Score (TTS) | Systematic palpation of 8 pericranial muscle pairs, Grade 0-3 | Score greater than 8 | Supports TTH diagnosis, Correlates with severity |
| Cervical ROM | Flexion/Extension, Rotation, Lateral flexion | Limited, Painful | Cervicogenic contribution |
| TMJ Assessment | Palpation, Opening, Clicking | Tenderness, Limitation | Comorbid TMJ dysfunction |
| Pull Test (Hair) | Gentle traction on hair | Pain = Allodynia | Present in chronic TTH with central sensitisation |
First-Line (Bedside)
- Clinical Diagnosis: TTH is a clinical diagnosis based on ICHD-3 criteria
- No investigations required if typical presentation and normal examination
- Headache Diary: Essential for classification and treatment monitoring
When to Investigate (Red Flags)
| Investigation | Indication |
|---|---|
| MRI Brain (± Contrast, ± MRV) | Atypical features, Red flags, Neurological signs |
| CT Brain | Acute severe headache, Thunderclap |
| Lumbar Puncture | Suspected SAH (CT-negative), Infection, Idiopathic Intracranial Hypertension |
| ESR/CRP | Age >50 (Giant Cell Arteritis) |
| Blood Tests | Exclude systemic causes if indicated |
ICHD-3 Diagnostic Criteria
Episodic TTH (Infrequent or Frequent):
A. At least 10 episodes fulfilling criteria B-D B. Duration 30 minutes to 7 days C. At least 2 of:
- Bilateral location
- Pressing/tightening (non-pulsating) quality
- Mild or moderate intensity
- Not aggravated by routine physical activity D. Both of:
- No nausea or vomiting
- No more than one of photophobia or phonophobia E. Not better accounted for by another ICHD-3 diagnosis
Chronic TTH: ≥15 days/month for >3 months + above features (Mild nausea permitted).
Management Algorithm
General Principles
| Principle | Details |
|---|---|
| Explanation | Explain diagnosis, Reassure benign, Explain mechanisms |
| Headache Diary | Track frequency, Intensity, Triggers, Medication use before and during treatment |
| Set Expectations | Chronic TTH difficult to cure. Goal is reduction, Not elimination. |
| Multimodal Approach | Combine pharmacological and non-pharmacological |
| Address Comorbidities | Treat depression, Anxiety, Sleep disorders |
| Avoid Medication Overuse | Limit acute analgesics to less than 10-15 days/month |
| Regular Follow-Up | Monitor response, Adjust treatment, Prevent MOH |
Acute Treatment
First-Line Analgesics - Detailed:
| Drug | Dose | Maximum Daily | Onset | Duration | Notes |
|---|---|---|---|---|---|
| Paracetamol (Acetaminophen) | 1000mg PO | 4000mg/day (3000mg in elderly/liver disease) | 30-60 min | 4-6 hours | First choice. Safe. No GI effects. Hepatotoxicity if overdose. |
| Ibuprofen | 400mg PO | 1200-2400mg/day | 30-60 min | 4-6 hours | Effective. GI caution. CI in renal disease, CV risk, Pregnancy. |
| Aspirin | 600-900mg PO | 3600mg/day | 30-60 min | 4-6 hours | Alternative NSAID. Avoid in under 16s (Reye syndrome). |
| Naproxen | 500mg PO | 1000mg/day | 1-2 hours | 8-12 hours | Longer acting. Good for persistent episodes. |
| Diclofenac | 50mg PO | 150mg/day | 30-60 min | 6-8 hours | Alternative NSAID. |
Number Needed to Treat (NNT) for Pain-Free at 2 Hours:
| Drug | Dose | NNT vs Placebo |
|---|---|---|
| Ibuprofen | 400mg | ~4-5 |
| Paracetamol | 1000mg | ~5-6 |
| Aspirin | 1000mg | ~4-5 |
Combination Analgesics:
| Combination | Evidence | Notes |
|---|---|---|
| Paracetamol + Caffeine (65-130mg) | Slightly more effective than paracetamol alone | NNT ~4 |
| Aspirin + Caffeine | Slightly more effective | Available OTC |
| Paracetamol + Codeine | Not recommended | Risk of MOH, Dependence |
| Compound analgesics with multiple agents | Not recommended | Higher MOH risk |
Acute Treatment Principles:
| Principle | Details |
|---|---|
| Treat Early | Take medication at first sign of headache |
| Adequate Dose | Subtherapeutic doses are ineffective |
| Limit Frequency | Maximum 2 days/week to prevent MOH |
| Avoid Opioids | High MOH risk. NOT indicated for TTH. |
| Avoid Triptans | Not effective for pure TTH (No evidence of efficacy) |
| Track Usage | Headache diary to monitor medication days |
Side Effects of Acute Treatments:
| Drug Class | Side Effects | Cautions/Contraindications |
|---|---|---|
| Paracetamol | Hepatotoxicity (overdose). Generally safe. | Liver disease. Alcohol abuse. Max 4g/day. |
| NSAIDs | GI ulceration, Bleeding, Renal impairment, CV events, Fluid retention | Renal disease, GI ulcer history, CV disease, Pregnancy, Aspirin-sensitive asthma |
| Caffeine | Insomnia, Anxiety, Palpitations, Rebound headache | Anxiety disorders. Evening dosing. |
Prophylactic Treatment
Indications for Prophylaxis:
| Indication | Details |
|---|---|
| Frequency | 2 or more headache days/week (8 or more days/month) |
| Chronic TTH | 15 or more days/month |
| Significant Disability | Impact on work, Social life, Quality of life |
| Medication Overuse Risk | Using acute treatments 10 or more days/month or approaching this |
| Poor Acute Response | Inadequate relief from analgesics |
| Patient Preference | Prefers preventive approach |
First-Line Prophylaxis - Amitriptyline:
| Parameter | Details |
|---|---|
| Drug | Amitriptyline (Tricyclic antidepressant) |
| Starting Dose | 10-25mg nocte |
| Titration | Increase by 10-25mg every 1-2 weeks |
| Target Dose | 30-75mg nocte (Some patients need 100mg) |
| Time to Efficacy | 4-6 weeks at adequate dose |
| Mechanism | Enhances serotonin and noradrenaline, Modulates descending pain pathways |
Amitriptyline Side Effects:
| Side Effect | Frequency | Management |
|---|---|---|
| Sedation/Drowsiness | Common | Take at night. Dose-related. May reduce over time. |
| Dry Mouth | Common | Sugar-free gum/sweets. Adequate hydration. |
| Weight Gain | Common | Dietary advice. Exercise. Consider nortriptyline. |
| Constipation | Common | Fibre, Fluids, Laxatives. |
| Urinary Retention | Occasional | Caution in prostate disease. |
| Blurred Vision | Occasional | Usually transient. |
| Cognitive Slowing | Occasional | Start low. May limit use in elderly. |
| Cardiac Effects | Rare | ECG if cardiac history. QT prolongation. |
| Overdose Toxicity | Serious | Prescribe limited quantities. |
Contraindications to Amitriptyline:
| Contraindication | Alternative |
|---|---|
| Recent MI | Venlafaxine, Non-pharmacological |
| Arrhythmia | Avoid tricyclics |
| Narrow-angle Glaucoma | Consider venlafaxine |
| Urinary Retention/Prostate | Use with caution or avoid |
| Pregnancy | Avoid or discuss with obstetrics |
| Elderly with Falls Risk | Low dose or alternative |
Second-Line Prophylaxis:
| Drug | Dose | Mechanism | Notes |
|---|---|---|---|
| Nortriptyline | 10-75mg nocte | Tricyclic (NE greater than 5-HT) | Less sedating than amitriptyline. Less anticholinergic. |
| Mirtazapine | 15-30mg nocte | Noradrenergic and specific serotonergic (NaSSA) | Sedating. Weight gain. Good if depression comorbid. |
| Venlafaxine | 75-150mg OD | SNRI | Less sedating. GI side effects. Withdrawal syndrome. |
| Duloxetine | 30-60mg OD | SNRI | Alternative to venlafaxine. |
Third-Line/Specialist:
| Drug | Dose | Notes |
|---|---|---|
| Topiramate | 50-100mg BD | Weight loss. Cognitive effects. Limited evidence in TTH. |
| Gabapentin | 300-600mg TDS | May help some patients. |
| Botulinum Toxin A | Injections | Not approved for TTH. Limited evidence. |
| Muscle Relaxants (Tizanidine) | 2-8mg nocte | Some evidence. Sedating. |
Prophylaxis Trial and Duration:
| Phase | Details |
|---|---|
| Adequate Trial | 4-6 weeks at target dose (Not just starting dose) |
| If Ineffective | Switch to alternative class |
| If Effective | Continue for 6-12 months |
| Withdrawal | Taper slowly. Monitor for recurrence. |
| Reassess | If headaches return, Consider reinstitution. |
Non-Pharmacological Management (Essential)
Importance:
- Must be part of management for ALL patients with frequent/chronic TTH
- May be as effective as medication in some patients
- Reduces medication dependence
- Addresses underlying mechanisms
Stress Management:
| Intervention | Details |
|---|---|
| Identify Stressors | Work, Family, Financial. Diary can help. |
| Lifestyle Modification | Reduce overcommitment. Time management. |
| Work-Life Balance | Boundaries. Holidays. |
| Social Support | Friends, Family, Support groups. |
Relaxation Techniques:
| Technique | Description | Evidence |
|---|---|---|
| Progressive Muscle Relaxation (PMR) | Sequential tensing and relaxing of muscle groups | Strong |
| Diaphragmatic Breathing | Slow, Deep abdominal breathing | Strong |
| Guided Imagery | Visualisation of relaxing scenes | Moderate |
| Mindfulness Meditation | Present-moment awareness. Non-judgemental. | Growing |
| Yoga | Combines physical postures, Breathing, Relaxation | Moderate |
Cognitive Behavioural Therapy (CBT):
| Aspect | Details |
|---|---|
| Targets | Negative thought patterns, Pain catastrophising, Avoidance behaviours |
| Components | Cognitive restructuring, Behavioural activation, Relaxation training |
| Delivery | Individual or group. 6-10 sessions typically. |
| Evidence | Strong for chronic TTH. Equal to amitriptyline in some studies. |
| Access | IAPT (NHS), Private, Online programmes (e.g., Headspace, apps) |
Biofeedback:
| Type | Description | Mechanism |
|---|---|---|
| EMG Biofeedback | Measures muscle tension (e.g., Frontalis). Visual/audio feedback. | Patient learns to reduce muscle tension. |
| Thermal Biofeedback | Measures skin temperature (peripheral blood flow) | Promotes relaxation response. |
| Evidence | Strong for TTH. Often combined with relaxation. | |
| Availability | Limited. Specialist centres. |
Physiotherapy:
| Intervention | Details |
|---|---|
| Postural Assessment | Identify forward head posture, Rounded shoulders |
| Postural Correction | Exercises, Ergonomic advice, Strengthening |
| Manual Therapy | Massage, Mobilisation of cervical spine, Trigger point release |
| Stretching | Neck, Shoulder, Upper back stretches |
| Strengthening | Deep neck flexors, Scapular stabilisers |
| Evidence | Moderate. May reduce headache frequency. |
Exercise:
| Details | Recommendation |
|---|---|
| Type | Aerobic (Walking, Swimming, Cycling) |
| Frequency | 3-5 times/week |
| Duration | 30-45 minutes |
| Intensity | Moderate |
| Mechanism | Endorphin release, Stress reduction, Improved sleep |
| Evidence | Moderate for headache prevention |
Acupuncture:
| Details | Description |
|---|---|
| Traditional Chinese | Needling of specific points |
| Mechanism Proposed | Endorphin release, Central modulation |
| Evidence (Cochrane) | Moderate. As effective as sham in some studies. May be helpful. |
| Recommendation | Can consider if available and patient interested |
Sleep Hygiene:
| Recommendation | Details |
|---|---|
| Regular Schedule | Same bedtime and wake time |
| Environment | Dark, Quiet, Cool bedroom |
| Avoid Screens | 1 hour before bed |
| No Caffeine | After 2pm |
| No Alcohol | As sleep aid (Disrupts sleep architecture) |
| Treat Sleep Disorders | Sleep apnoea, Insomnia |
Ergonomic Assessment:
| Area | Intervention |
|---|---|
| Desk Setup | Monitor at eye level, Keyboard at elbow height, Chair support |
| Screen Breaks | 20-20-20 rule (Every 20 min, Look 20 feet away, 20 seconds) |
| Driving | Adjust seat and mirrors, Take breaks on long journeys |
| Reading/Phone | Avoid prolonged neck flexion |
Medication Overuse Headache (MOH)
[!WARNING] Suspect MOH if:
- Headache occurs 15 or more days/month
- Regular use of acute medication for 3 months or more
- Threshold: Simple analgesics 15 or more days/month OR Triptans/Opioids/Ergots/Combinations 10 or more days/month
MOH Management Protocol:
| Step | Details |
|---|---|
| 1. Recognise and Diagnose | History of escalating medication use. Headache worsening. |
| 2. Educate Patient | Explain concept. Medication is perpetuating, Not helping. |
| 3. Set Expectations | Withdrawal will cause temporary worsening (1-4 weeks). Improvement expected after. |
| 4. Plan Withdrawal | Abrupt (Preferred for simple analgesics) OR Gradual (Opioids, Barbiturates). |
| 5. Bridge Therapy | Start prophylactic medication (Amitriptyline). Consider short course of bridge analgesic (Naproxen 500mg BD for 2 weeks). |
| 6. Support | Regular follow-up. Manage withdrawal symptoms (Nausea, Anxiety, Insomnia). |
| 7. Post-Withdrawal | Maintain headache diary. Limit acute use to less than 10 days/month. |
Withdrawal Symptoms:
| Symptom | Duration |
|---|---|
| Worsening Headache | Peak 2-7 days. Improves 2-4 weeks. |
| Nausea/Vomiting | 1-2 weeks |
| Anxiety | Variable |
| Sleep Disturbance | 1-2 weeks |
| Tachycardia, Sweating | If opioids |
Referral Criteria
| Indication | Referral Target |
|---|---|
| Diagnostic Uncertainty | Neurology/Headache Specialist |
| Red Flags / Need Investigation | Neurology, Emergency if acute |
| Treatment Failure | Headache Specialist. After 2-3 medication trials. |
| Chronic TTH | Consider specialist for multidisciplinary approach |
| Medication Overuse Headache | Specialist, Headache clinic |
| Significant Psychiatric Comorbidity | Liaison Psychiatry, Psychology |
| Workplace Disability | Occupational Health |
| Physiotherapy Needs | Musculoskeletal Physiotherapy |
Overview
| Complication Type | Timeframe | Key Concerns |
|---|---|---|
| Immediate | During attack | Functional impairment, Medication side effects |
| Short-term | Days-Weeks | Medication overuse, Acute treatment side effects |
| Long-term | Months-Years | Chronification, Psychiatric comorbidity, Quality of life |
Immediate Complications
| Complication | Description | Management |
|---|---|---|
| Functional Impairment | Reduced concentration, Productivity loss despite continuing activities | Acute treatment, Rest if needed |
| Work/School Impact | Reduced performance, Presenteeism | Treat attack, Modify activities |
| Mood Effects | Irritability, Frustration during attacks | Reassurance, Resolve headache |
| Analgesic Side Effects (Acute) | GI upset (NSAIDs), Drowsiness (Some combinations) | Use appropriate medications |
Short-Term Complications (Days-Weeks)
| Complication | Incidence | Description | Prevention/Management |
|---|---|---|---|
| Medication Overuse Headache (MOH) | 1-2% of population | Paradoxical worsening with frequent analgesic use. Threshold: Simple analgesics 15+ days/month, Triptans/Opioids 10+ days/month. | Limit acute medications to less than 10-15 days/month. Educate. Withdraw if established. |
| NSAID-Related GI Complications | Variable | Gastritis, Peptic ulcer, GI bleeding with frequent use | Use lowest effective dose. Short courses. PPI if recurrent NSAID needed. |
| Paracetamol Hepatotoxicity | Rare if dosed correctly | Risk with overdose or chronic excess (greater than 4g/day) | Dose correctly. Avoid in liver disease. |
| NSAID Renal Effects | Rare with episodic use | Reduced GFR, Salt/water retention with chronic use | Avoid in renal impairment. Monitor if chronic use. |
| Prophylactic Medication Side Effects | Variable | Amitriptyline: Dry mouth, Sedation, Weight gain, Constipation | Start low, Titrate slowly, Manage side effects. |
Long-Term Complications (Months-Years)
| Complication | Description | Risk Factors | Prevention/Management |
|---|---|---|---|
| Chronification | Transition from Episodic TTH to Chronic TTH (15+ days/month) | Frequent episodes, Medication overuse, Stress, Psychiatric comorbidity, Poor sleep | Early prophylaxis, Avoid MOH, Stress management, Treat comorbidites |
| Medication Overuse Headache | Chronic daily/near-daily headache perpetuated by frequent acute medication use | Frequent analgesic use, Pre-existing high frequency | Patient education, Limit acute use, Monitor headache diary |
| Depression | Significantly elevated risk in chronic TTH | Chronic pain, Disability, Central sensitisation overlap | Screen routinely (PHQ-9). Treat if present. Amitriptyline has dual benefit. |
| Anxiety | Common comorbidity | Chronic pain, Worry about headaches, Anticipatory anxiety | Screen (GAD-7). CBT. Treat if indicated. |
| Reduced Quality of Life | TTH underestimated. Chronic TTH can be as disabling as migraine. | Chronic disease, Psychiatric comorbidity | Comprehensive management, Psychological support |
| Social Isolation | May avoid activities due to headaches | Chronic, Severe | Encourage activity, Psychological support |
| Occupational Disability | Lost workdays, Reduced career progression | Chronic, frequent TTH | Occupational health input, Workplace modifications |
| Healthcare Overutilisation | Repeated consultations, Investigations, Referrals | Diagnostic uncertainty, Treatment failure | Clear diagnosis, Management plan, Follow-up |
| Polypharmacy | Multiple failed medications | Treatment-resistant chronic TTH | Rationalise. Specialist input. |
Medication Overuse Headache - Detailed
| Aspect | Details |
|---|---|
| Definition | Headache 15+ days/month in patient with pre-existing headache, with regular overuse of acute medication for greater than 3 months |
| Thresholds | Simple analgesics: 15+ days/month. Triptans, Opioids, Ergots, Combinations: 10+ days/month. |
| Mechanism | Central sensitisation, Reduced descending inhibition, Receptor changes |
| Recognition | Escalating medication use, Worsening headache despite treatment, Daily/near-daily headache |
| Prognosis | Most improve after withdrawal. 40-50% relapse at 1 year. |
| Prevention | Patient education. Headache diary. Limit acute use. Early prophylaxis. |
Natural History
| Subtype | Natural History | Notes |
|---|---|---|
| Infrequent Episodic TTH | Self-limiting. Many never seek medical attention. | Excellent prognosis. |
| Frequent Episodic TTH | May persist. Risk of chronification if risk factors present. | May require prophylaxis. |
| Chronic TTH | Persistent in many. May fluctuate. Spontaneous remission possible but uncommon. | Challenging to treat. |
Outcomes with Treatment
| Intervention | Outcome | Notes |
|---|---|---|
| Acute Treatment (Paracetamol/NSAIDs) | Pain relief in 60-70% | NNT ~4-6 for pain-free at 2 hours |
| Amitriptyline Prophylaxis | 40-50% achieve 50% or greater reduction in headache days | Considered successful response |
| Non-Pharmacological (CBT, Relaxation) | Comparable to medication in some studies | Particularly effective in chronic TTH |
| Combined Approach | May be more effective than single modality | Recommended for chronic TTH |
Long-Term Outcomes
| Outcome | Timeframe | Details |
|---|---|---|
| Remission (Chronic TTH) | 3 years | ~15-20% achieve remission |
| Improvement | 1-3 years | Many improve with treatment, Even if not remission |
| Fluctuation | Variable | Chronic may become episodic and vice versa |
| MOH Resolution | 2-4 weeks | Improvement expected after withdrawal period |
Disability Impact
| Condition | Disability Level | Comparison |
|---|---|---|
| Infrequent Episodic TTH | Minimal | - |
| Frequent Episodic TTH | Mild-Moderate | Intermittent productivity loss |
| Chronic TTH | Significant | Comparable to chronic migraine |
Prognostic Factors
Factors Associated with Good Prognosis:
| Factor | Reason |
|---|---|
| Infrequent Episodes | Low risk of progression |
| Short Duration of Chronic TTH | Earlier intervention |
| No Medication Overuse | Avoids MOH complication |
| Good Response to Acute Treatment | Disease control achievable |
| No Psychiatric Comorbidity | Fewer perpetuating factors |
| Identifiable Modifiable Triggers | Can address directly |
| Engagement with Non-Pharmacological Treatment | Addresses underlying mechanisms |
| Good Social Support | Resources for coping |
Factors Associated with Poor Prognosis:
| Factor | Reason | Intervention |
|---|---|---|
| Chronic TTH | Established central sensitisation | Comprehensive, Long-term management |
| Medication Overuse | Perpetuates headache | Withdraw, Educate |
| Depression/Anxiety | Amplifies pain, Reduces coping | Treat aggressively |
| Poor Sleep | Affects pain modulation | Sleep hygiene, Treat disorders |
| High Pericranial Tenderness | Marker of severity, Peripheral input | Physiotherapy |
| Multiple Failed Treatments | Treatment-resistant | Specialist referral |
| High Baseline Frequency | Harder to reduce | Intensive management |
| Low Socioeconomic Status | Limited access to care | Address barriers |
Mortality
TTH is a benign condition with no direct mortality. However:
- Chronic pain syndromes are associated with reduced life expectancy due to comorbidities (Depression, Reduced activity)
- Medication complications (NSAID-related events) can rarely be serious
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| ICHD-3 Classification | International Headache Society (2018) | Diagnostic criteria for TTH subtypes |
| EFNS Guideline | European Federation of Neurological Societies | Paracetamol/NSAIDs acute; Amitriptyline prophylaxis |
| NICE Headache Guideline | NICE CG150 (2012, Updated 2021) | Diagnosis, Acute treatment, Prophylaxis, MOH management |
Landmark Trials/Evidence
Amitriptyline for Chronic TTH (Bendtsen et al., 1996)
- RCT, n=40, Chronic TTH
- Amitriptyline vs Placebo
- Result: Significant reduction in headache area-under-curve and analgesic use
- Impact: Established amitriptyline as first-line prophylaxis
- PMID: 8641250
NSAIDs for Episodic TTH (Cochrane Review, 2017)
- Meta-analysis of RCTs
- Result: Ibuprofen 400mg, Aspirin 1000mg superior to placebo
- NNT ~4-5 for pain-free at 2 hours
- PMID: 28111748
Non-Pharmacological Therapies (Cochrane, 2016)
- Acupuncture, Relaxation, Biofeedback, Physiotherapy
- Result: Modest benefit, Useful adjuncts
- PMID: 27045188
Evidence Strength
| Intervention | Level | Key Evidence |
|---|---|---|
| Simple Analgesics (Acute) | 1a | Multiple RCTs, Cochrane review |
| Amitriptyline (Prophylaxis) | 1b | RCTs (Bendtsen et al.) |
| Physiotherapy | 2a | Multiple RCTs |
| CBT/Relaxation | 2a | Multiple RCTs |
What is Tension-Type Headache?
Tension-type headache is the most common type of headache – most people will experience it at some point. It feels like a tight band or pressure around your head, like wearing a hat that's too tight.
Key Features:
- Pain is usually on both sides of your head
- It feels like pressing or tightening (not throbbing)
- The pain is mild to moderate – annoying but doesn't usually stop you doing things
- Unlike migraine, walking around or activity doesn't make it worse
- You don't usually feel sick or need to lie in a dark room
Why Does It Happen?
The exact cause isn't fully understood, but it involves several factors:
| Factor | Explanation |
|---|---|
| Muscle Tension | Tight muscles in the head, Neck, And shoulders can trigger pain |
| Stress | Mental stress and tension contribute to muscle tightness and pain sensitivity |
| Central Sensitisation | In chronic cases, The brain's pain system becomes more sensitive |
| Poor Sleep | Lack of sleep or poor quality sleep can trigger headaches |
| Posture | Poor posture (e.g., At a desk, Looking at screens) strains muscles |
| Anxiety and Depression | These can make headaches worse and more difficult to treat |
| Dehydration and Skipped Meals | Common triggers for some people |
| Eye Strain | Prolonged screen use without breaks |
Types of Tension-Type Headache
| Type | How Often | What It Means |
|---|---|---|
| Infrequent Episodic | Less than once a month | Very common. Usually no treatment needed. |
| Frequent Episodic | 1-14 days per month | May need treatment to prevent headaches |
| Chronic | 15 or more days per month | Needs preventive treatment. See a doctor. |
How is it Different from Migraine?
| Feature | Tension-Type Headache | Migraine |
|---|---|---|
| Location | Both sides of head | Often one side |
| How it Feels | Pressing, Tightening | Throbbing, Pulsating |
| Intensity | Mild-Moderate | Moderate-Severe |
| Activity | Doesn't make it worse | Makes it worse |
| Nausea | No (Maybe mild in chronic) | Often present |
| Light/Sound Sensitivity | Usually none | Common |
| Aura (Visual symptoms) | Never | Sometimes before migraine |
Many people have both migraine and tension headaches at different times.
How is it Treated?
For Occasional Headaches (Less Than 2 Days Per Week):
| Medication | How to Use | Important Points |
|---|---|---|
| Paracetamol | 1000mg (2 x 500mg tablets) | Safe for most people. Can take every 4-6 hours. Max 8 tablets (4g) in 24 hours. |
| Ibuprofen | 400mg (2 x 200mg tablets) | Take with food. Avoid if you have stomach problems, Kidney disease, Or heart disease. |
| Aspirin | 600-900mg | Alternative to ibuprofen. Not for under 16s. |
Tips for Taking Painkillers:
- Take them early – They work better at the start of a headache
- Take the full dose – Half a dose often doesn't work
- Don't use too often – Using painkillers more than 10-15 days per month can make headaches worse (Medication Overuse Headache)
For Frequent Headaches (More Than 2 Days Per Week):
If you're having headaches this often, You should see your doctor. They may recommend:
| Treatment | What It Is | What to Expect |
|---|---|---|
| Amitriptyline | A low-dose tablet taken at night | Takes 4-6 weeks to work. May cause drowsiness, Dry mouth. Not an antidepressant at this dose. |
| Other Preventive Medications | Alternatives if amitriptyline doesn't work | Your doctor will discuss options |
Self-Help Strategies
Stress Management:
- Identify what's causing stress in your life
- Take regular breaks during work
- Make time for activities you enjoy
- Consider apps like Headspace or Calm for relaxation
Relaxation Techniques:
- Breathing exercises – Slow, Deep breaths from your belly
- Progressive muscle relaxation – Tense then relax each muscle group
- Meditation – Even 10 minutes a day can help
- Yoga – Combines relaxation with gentle exercise
Sleep:
- Aim for 7-8 hours per night
- Keep a regular sleep schedule
- Avoid screens for 1 hour before bed
- Make your bedroom dark, Quiet, And cool
Exercise:
- Regular moderate exercise (Walking, Swimming, Cycling) helps prevent headaches
- Aim for 30 minutes, 3-5 times per week
- Exercise releases natural painkillers (endorphins)
Posture and Ergonomics:
- If you work at a desk, Make sure your screen is at eye level
- Take breaks every 30 minutes – Look away from the screen
- Check your posture – Shoulders back, Head not jutting forward
Hydration and Meals:
- Drink plenty of water throughout the day
- Don't skip meals
- Limit caffeine (Coffee, Tea, Cola) – Too much can cause rebound headaches
Medication Overuse Headache – Important Warning
[!WARNING] Using Painkillers Too Often Can Make Headaches WORSE
If you're taking painkillers for headaches more than 10-15 days per month for 3 months or more, You may develop Medication Overuse Headache. This is a frustrating cycle where the painkillers that were helping now make the headaches come back more often.
Signs of Medication Overuse Headache:
- Headaches are more frequent than before
- Painkillers don't work as well as they used to
- You feel you need painkillers every day
What to Do:
- See your doctor – They can help you stop the cycle
- Stopping the overused painkillers is the treatment (This is hard, But headaches improve after 2-4 weeks)
When to See a Doctor
See Your GP if:
- Headaches are getting more frequent or severe
- You're using painkillers more than 2 days per week
- Headaches are affecting your work or daily life
- Treatment isn't working
Seek Urgent Medical Attention if:
- Sudden severe headache – The worst headache of your life (Call 999)
- New headache after age 50
- Fever with headache
- Vision changes, Weakness, Numbness, Confusion, or Difficulty speaking
- Headache after head injury
- Headache with stiff neck (Unable to touch chin to chest)
Frequently Asked Questions
Q: Is tension-type headache caused by actual tension or stress? A: The name is a bit misleading. While stress can trigger them, The "tension" refers to tight muscles in the head and neck. Central brain mechanisms are also involved, Especially in chronic cases.
Q: Can I become addicted to painkillers? A: Simple painkillers like paracetamol and ibuprofen are not addictive in the classic sense. However, Using them too often can cause Medication Overuse Headache, Where your body becomes dependent on them and headaches get worse.
Q: Is amitriptyline an antidepressant? Am I depressed? A: No, You're not being treated for depression. Amitriptyline is also used at low doses for pain prevention. The doses used for headaches are much lower than those for depression.
Q: How long will I need to take preventive medication? A: Usually 6-12 months. After that, Your doctor may suggest slowly stopping to see if headaches stay improved.
Q: Will I have these headaches forever? A: Many people's headaches improve over time, Especially with good management. Chronic TTH is more persistent, But treatments can reduce how often you get headaches.
Q: Are there any tests to diagnose tension-type headache? A: No, It's diagnosed based on your symptoms. Tests (Brain scans) are only needed if there are warning signs of something else.
Support Resources
| Resource | Details |
|---|---|
| NHS Website | www.nhs.uk – Search "Tension headache" for information |
| Migraine Trust | www.migrainetrust.org – Also covers tension headache information |
| Headache UK | www.headache.org.uk – Patient resources |
| Your GP | First point of contact for persistent headaches |
Primary Guidelines
-
Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1-211. PMID: 29368949
-
Bendtsen L, et al. EFNS guideline on the treatment of tension-type headache. Eur J Neurol. 2010;17(11):1318-25. PMID: 20482606
-
National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management (CG150). NICE. 2012, Updated 2021. Link
Landmark Trials
-
Bendtsen L, Jensen R. Amitriptyline reduces myofascial tenderness in patients with chronic tension-type headache. Cephalalgia. 2000;20(6):603-10. PMID: 11075846
-
Derry S, et al. Ibuprofen for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev. 2015;7:CD011474. PMID: 26230487
-
Linde K, et al. Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2016;4:CD007587. PMID: 27045188
Systematic Reviews
-
Verhagen AP, et al. Treatment of tension-type headache: a systematic review. Cephalalgia. 2010;30(12):1-16.
-
Jackson JL, et al. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ. 2010;341:c5222. PMID: 20961988
Additional References
-
Stovner LJ, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27(3):193-210. PMID: 17381554
-
Jensen R. Pathophysiological mechanisms of tension-type headache. Cephalalgia. 2001;21(7):786-9. PMID: 11595012
-
Ashina S, et al. Tension-type headache. Nat Rev Dis Primers. 2021;7(1):24. PMID: 33790276
-
Silberstein SD. Tension-type headache: classification and management. Continuum (Minneap Minn). 2015;21(4):968-981. PMID: 26252584
-
Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. 2008;7(1):70-83. PMID: 18093564
-
Bendtsen L, et al. Guidelines for controlled trials of drugs in tension-type headache. Cephalalgia. 2010;30(1):1-16. PMID: 19614702
-
Crystal SC, Robbins MS. Epidemiology of tension-type headache. Curr Pain Headache Rep. 2010;14(6):449-454. PMID: 20865353
Common Exam Questions
-
MRCP/MRCGP: "A 35-year-old office worker presents with bilateral, pressing headaches for 3 months, occurring 10 days/month. No nausea. Not worsened by activity. What is the most likely diagnosis and first-line prophylaxis?"
- Answer: Frequent Episodic Tension-Type Headache. First-line prophylaxis: Amitriptyline.
-
Clinical Exam: "How do you differentiate tension-type headache from migraine?"
- Answer: TTH: Bilateral, Pressing/non-pulsating, Mild-moderate, Not worsened by activity, No nausea/vomiting. Migraine: Often unilateral, Pulsating, Moderate-severe, Worsened by activity, Nausea/vomiting, Photo/phonophobia.
-
Short Answer: "What clinical sign supports a diagnosis of TTH on examination?"
- Answer: Pericranial muscle tenderness on palpation.
-
Therapeutics: "What medication would you use for prophylaxis of chronic tension-type headache?"
- Answer: Amitriptyline 10-75mg nocte.
-
Clinical Scenario: "A patient with frequent headaches has been taking paracetamol daily for 6 months. What diagnosis and management?"
- Answer: Medication Overuse Headache. Educate, Withdraw analgesics, Bridge with preventive, Support through withdrawal.
Viva Points
Opening Statement:
"Tension-type headache is the most common primary headache disorder, characterised by bilateral, non-pulsating, pressing headache of mild-moderate intensity that is not aggravated by physical activity. It is classified by ICHD-3 as infrequent episodic, frequent episodic, or chronic based on frequency."
Key Facts to Mention:
- Lifetime prevalence ~80%
- Bilateral, pressing, mild-moderate, not worsened by activity
- No nausea/vomiting (Max 1 of photo/phonophobia)
- Paracetamol/NSAIDs for acute
- Amitriptyline for prophylaxis
Classification to Quote:
- "ICHD-3 classifies TTH into Infrequent Episodic (less than 1 day/month), Frequent Episodic (1-14 days/month), and Chronic (≥15 days/month)"
Evidence to Cite:
- "The EFNS guideline recommends amitriptyline as first-line prophylaxis"
- "Cochrane reviews support NSAIDs for acute treatment"
Common Mistakes
What fails candidates:
- ❌ Confusing TTH with migraine (Especially regarding nausea/activity)
- ❌ Not knowing ICHD-3 diagnostic criteria
- ❌ Forgetting to mention amitriptyline for prophylaxis
- ❌ Ignoring medication overuse headache in frequent analgesic users
- ❌ Ordering unnecessary investigations for typical TTH
Dangerous Errors:
- ⚠️ Missing red flags for secondary headache
- ⚠️ Prescribing opioids or codeine (Risk of MOH)
Outdated Practices:
- Describing TTH as purely "muscular" – Central sensitisation is key in chronic
- Using "tension" to mean stress – Pericranial muscle mechanisms are peripheral component
Examiner Follow-Up Questions
-
"What would you do if amitriptyline fails?"
- Answer: Try nortriptyline, mirtazapine, or venlafaxine. Combine with non-pharmacological therapies.
-
"What is the evidence for physiotherapy?"
- Answer: Moderate evidence from RCTs. Manual therapy and exercise beneficial as adjuncts.
-
"How long would you trial prophylaxis before deeming it ineffective?"
- Answer: 4-6 weeks at adequate dose.
-
"When would you image this patient?"
- Answer: Red flags (Thunderclap, >50yo new onset, Neurological signs, Systemic symptoms).
Last Reviewed: 2025-12-25 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and current guidelines.