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

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