Overview
A tension-type headache (TTH) is a very common primary headache. A primary headache is a headache that is not associated with another underlying condition. It may be overdiagnosed and may even be misdiagnosed when the patient has a migraine.
TTH can be episodic or chronic:
- Episodic – occurs on <15 days each month
- Chronic – occurs on >15 days each month
May be medication–induced or associated with comorbidity e.g. depression
Epidemiology
- Most common primary headache disorder
- Onset is usually between 20–30 years
- Affects women more than men
Risk Factors
- Stress and other psychosocial tensions
- Missing meals
- Fatigue
- Female sex
- Analgesia overuse
Presentation
The classic presentation of TTH is a generalised bilateral headache that feels like a “tight band” is around the head or pressure is being applied:
- The pain is usually:
- Dull and non-pulsatile (not throbbing)
- Generalised but can be frontal or occipital
- No associated abnormal neurological findings
- No associated nausea or vomiting
- Usually no associated photophobia or phonophobia but these may be present
- Pericranial tenderness may be present
Differential Diagnoses
Migraine
- The pain is usually unilateral and pulsatile/throbbing
- There is usually associated nausea
- The pain is usually worse with activity and severe
- Patients often feel like they need to rest in dark and quiet rooms and try to sleep off the headache
Medicine overuse headache
- Patient usually taking excess analgesia with headaches becoming worse when stopping them – usually opiates/barbiturates
Management
All patients
- 1st-line: simple analgesia with paracetamol/NSAIDs
- Do not offer opioids – if these are needed, reconsider the diagnosis
- If chronic TTH, consider 5-8 weeks acupuncture
- Consider amitriptyline prophylaxis – discontinue if no response and discuss with neurology
Monitoring and Patient Advice
Monitoring
- Patients can be encouraged to keep headache diaries which can help monitor progress and response to treatment
Patient Advice
- Patients should be advised on the risk of medication overuse headaches
- Patients should keep headache diaries recording the frequency, severity, characteristics, and duration of the headaches, along with the effectiveness of medications – this can help if the diagnosis needs to be reconsidered
Complications
- Reduced quality of life
- Psychosocial complications – e.g. depression
Prognosis
- Infrequent episodic TTH is usually self-limiting and simple analgesia alone is usually effective
- Chronic TTH can arise as a result of TTH and can lead to a decreased quality of life
