Tension-Type Headache
Commonest primary headache disorder. Bilateral, pressing/tightening, mild-moderate intensity headache without significant nausea, photophobia, or phonophobia. Affects up to 80% of the population. Divided into episodic and chronic forms.
Key Facts
Commonest primary headache: lifetime prevalence up to 80%; accounts for ~90% of all headaches Bilateral, pressing/tightening ('band-like') quality; mild-moderate intensity; NOT aggravated by routine physical activity No nausea/vomiting (may have mild photophobia OR phonophobia but not both — distinguishes from migraine) Duration: 30 minutes to 7 days per episode Episodic (<15 days/month) and chronic (≥15 days/month for >3 months) forms Treatment: simple analgesia (paracetamol 1g, ibuprofen 400mg) for acute episodes; amitriptyline 10-75mg ON for chronic TTH prophylaxis (NICE CG150)
Overview
Key Facts
TTH is the most prevalent headache disorder globally. It is often underdiagnosed as patients may not seek medical attention. Chronic TTH can be significantly disabling and may overlap with medication overuse headache.
Epidemiology
Lifetime prevalence 30-80%. More common in women (F:M 1.5:1). Peak prevalence in 30s-40s. Chronic TTH affects ~3% of the population.
Aetiology
- Multifactorial: stress, poor posture, anxiety, depression, sleep disruption, jaw clenching, eye strain
- Chronic TTH: central sensitisation plays a key role
- Genetic factors contribute (~40% concordance in twin studies)
Pathophysiology
Episodic TTH: peripheral mechanisms predominate — increased pericranial myofascial tenderness, nociceptive input from pericranial muscles. Chronic TTH: central sensitisation of second-order neurones in the trigeminal nucleus caudalis → enhanced pain perception; reduced descending inhibition. Peripheral and central mechanisms operate on a continuum from episodic to chronic TTH.
Clinical Presentation
Typical Features (ICHD-3)
- Bilateral, pressing/tightening (non-pulsating) quality
- Mild-moderate intensity (does NOT prevent activity — patients can continue work)
- NOT aggravated by routine physical activity
- Duration 30 minutes to 7 days
- No nausea/vomiting (mild nausea allowed in chronic TTH)
- Photophobia OR phonophobia (not both) or neither
Subtypes
- Infrequent episodic: <1 day/month
- Frequent episodic: 1-14 days/month for ≥3 months
- Chronic: ≥15 days/month for >3 months
Associated Features
- Pericranial muscle tenderness on palpation
- Stress, anxiety, depression frequently coexist
Red Flags (Same SNOOP Criteria as Migraine)
- Thunderclap onset, fever, focal neurological signs, papilloedema, new onset >50 years, progressive worsening
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Migraine | Unilateral, pulsating, moderate-severe, nausea, photo+phonophobia | Clinical (ICHD-3) |
| Medication overuse headache | Daily/near-daily, analgesic use ≥15 days/month | Medication diary |
| Cervicogenic headache | Unilateral, triggered by neck movement, occipital origin | Clinical, MRI cervical spine |
| Idiopathic intracranial hypertension | Papilloedema, visual obscurations, pulsatile tinnitus, obese female | LP (opening pressure), MRI/MRV |
| Giant cell arteritis | Age >50, temporal tenderness, jaw claudication, raised ESR | ESR, CRP, temporal biopsy |
| Depression/anxiety | Persistent headache with mood disturbance | Psychiatric assessment |
Diagnosis / Investigation
Clinical Diagnosis
- TTH is a clinical diagnosis — no investigations needed for typical presentation
- Headache diary: useful to classify frequency and identify medication overuse
When to Investigate
- Red flag features: CT/MRI brain
- New onset >50 years: ESR, CRP (exclude GCA)
- Chronic daily headache: consider MRI to exclude secondary causes
- Papilloedema: urgent CT then LP
Management
Acute Treatment
- Paracetamol 1g or ibuprofen 400mg (or aspirin 600-900mg) — simple analgesia
- Avoid codeine/opioid combinations (risk of medication overuse headache)
- Limit acute treatment to <15 days/month (simple analgesics) or <10 days/month (triptans/opioids)
Prophylaxis (Chronic TTH)
- Amitriptyline 10-75mg ON: first-line prophylactic; start at 10mg, titrate slowly; NICE CG150
- Mirtazapine 15-30mg ON: alternative if amitriptyline not tolerated
- Acupuncture: NICE CG150 recommends as option for chronic TTH prophylaxis
Non-Pharmacological
- Stress management, relaxation techniques
- CBT: effective for chronic TTH
- Physiotherapy: cervical spine, posture correction
- Regular exercise, adequate sleep hygiene
- Reduce caffeine intake
Medication Overuse Headache
- Withdraw overused medication (may need abrupt or gradual depending on agent)
- Bridge with alternative if needed
Referral Criteria
- Headache clinic: chronic TTH refractory to treatment, diagnostic uncertainty, medication overuse headache
Prognosis
Episodic TTH: generally benign, self-limiting. ~3% of episodic TTH progresses to chronic TTH per year. Chronic TTH: can be significantly disabling; ~40% remit to episodic over 2 years with treatment. Medication overuse is the most common factor perpetuating chronic TTH. Amitriptyline reduces headache frequency by ~50% in chronic TTH.
Other Relevant Information
Migraine vs Tension-Type Headache
| Feature | Migraine | TTH |
|---|---|---|
| Location | Unilateral (60%) | Bilateral |
| Quality | Pulsating | Pressing/tightening |
| Intensity | Moderate-severe | Mild-moderate |
| Physical activity | Aggravated | Not aggravated |
| Nausea/vomiting | Yes | No |
| Photophobia + phonophobia | Both | Neither or one only |
| Duration | 4-72 hours | 30 min-7 days |
| Aura | ± | No |