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Tension-Type headache

Tension-type headache ( TTH ) is the most common primary headache disorder across all age groups worldwide.

Ill-defined heterogeneous syndrome – often diagnosed based on 
absence of features found in other headache types Term coined by International Headache Society to describe a new heading that underlies the uncertain pathogenesis but, nevertheless indicates that some form of mental or muscular tension may play a role Lifetime prevalence may vary from 30-78 % TTHA leads to considerable disability , decreased effectiveness from
 work , ↑↑ absenteeism and ↓↓ social engagement Features may overlap with a migraine ( may co-exist with other headache disorders) Females are affected slightly more Patients less likely to seek medical attention, in comparison to migraine

Exact cause – not known Psychological stress Peripheral pain mechanisms ( Episodic TTH ) Central pain mechanisms and Generalized increased pain sensitivity
( Chronic ) Possibly multifactorial ( factors involving CNS, PNS and environmental factors ) Genetic factors

episodic tension type headache

Infrequent episodic ,frequent episodic, chronic Duration 30 min to 7 days
 At least two of

♦ b/l location 
♦ pressing or tightening ( non-pulsatile ) quality
♦ mild or moderate intensity
♦ not aggravated by routine physical activity such as walking or climbing stairs
 No nausea or vomiting and no more than one of photophobia or phonophobia
 Not better accounted by any other cause

Presentation-B/L head pain of mild- moderate intensity with a pressing, tightening, squeezing quality ” Band round the head ” – constriction band Does not worsen with routine physical activity Commonly spreads into or arises from the neck Not associated with any significant autonomic symptoms Headache worsens as the day progresses Frontal and occipital region most commonly affected Headache not exacerbated by physical activity unlike migraine No nausea or vomiting 
( mild nausea may happen in chronic TTH ) Rarely incapacitating Pericranial tenderness Patients with chronic TTH are ↑↑ likely than those with an episodic type to seek help

Check- General history Neurological examination , mental 
Fundoscopy BP , temp , head injury ( elderly ) Temporal tenderness Manual palpation of pericranial muscles
Commonly tender muscles include
SCMastoid , trapezius, temporalis , lateral pterygoid and massater Neurological examination should be normal Lab tests should be unremarkable ( not helpful )
 CT of sinuses
MRI of brain
Lumbar puncture

Differential-Migraine – particular mild migraine without aura Giant cell arteritis Temperomandibular joint dysfunction Trigeminal autonomic cephalgias eg
○ cluster headache
○ paroxysmal hemicranias Significant cervical pathology Tumours (Pituitary, brain ) Medication overuse in chronic headaches Sinusitis Chronic subdural haematoma Idiopathic intracranial hypertension

Red flags-Thunderclap headache- sudden onset “worse headache of my life” 
( max intensity within 5 minutes ) New onset headache in a person over 50 ( r/o temporal arteritis ) Progressive or persistent headache that has changed dramatically Associated symptoms as
○ fever , impaired consciousness , seizure , neck pain/ stiffness or photophobia
○ papilloedema
○ new onset neurological deficit
○ atypical aura
○ dizziness
○ visual disturbance
○ vomiting Recent ( within 3 months ) head injury Headache triggered by cough , Valsalva or sneeze Headache that worsens on standing ( CSF leak ) Headache that worsens on lying down (SOL , CVS thrombosis ) Visual disturbance ( glaucoma ) Vomiting Contacts with similar symptoms ( eg carbon monoxide poisoning ) Immunosuppression Current or past malignancy

 Biofeedback Physical measures eg
Physiotherapy , acupuncture
spinal manipulation Myofascial trigger point focused massage CBT Lifestyle Exercise Relaxation training

Amitriptyline ( 10-75 mg ) Consider other tricyclics if one not effective SSRIs ( limited evidence ) Venlafaxine ,Mirtazepine 
small studies have suggest may be of some value Botulinium toxin not recommended ( SIGN ) 

Further study-research needed (10 )


Patient information

Tension Headache from Harvard Health Publishing – a well written balanced article for patients

Patient UK has produced a useful section on TTH

The Migraine Trust has a useful section on TTH which educates the patient on differences between TTH and migraine

A headache diary can be downloaded via

A large word file from NHS Grampian on TTH

Information for clinicians

British Association for Study of Headaches ( BASH )– guidelines on headache

Canadian Family Physician – guideline for primary care management of headache in adults

A 57-minute video on TTH by National Headache Foundation

NICE guideline Headaches in over 12s : diagnosis and management 2012

An article on management of Chronic Tension Type Headache BMJ Clin Evid 2016 ( open access )

International Headache Society TTH

European Academy of Neurology -EFNS guideline on the treatment of tension-type headache – Report of an EFNS task force

Management of Chronic Headache RACGP



  1. KE Waldie, J Buckley, PN Bull, R Poulton – J Headache Pain, 2015
  2. Tension-Type headache : current research and clinical management Amaud Fumal, Jean Schoenen Lancet Neurology , The, 2008-01-01, Volume 7,, Issue 1, Pages 70-83
  3. Primary Headache Disorders- Part 2 : Tension-type headache and medication overuse headache Gary w et al Disease-a-month, 2017-12-01 , Volume 63 , Issue 12, Pages 342-367
  4. Headache- tension type CKS NHS Last revised November 2017
  5. EFNS guideline on the treatment of tension-type-headache- Report of an EFNS task force  2010 Nov;17(11):1318-25. doi: 10.1111/j.1468-1331.2010.03070.x.
  6. Tension Headache  BMJ Best Practice
  7. Tension-type headache Tension-type headache BMJ 2008 336 ;88
  8. Minor Emergencies Philip Buttaravoli et al Mosby Lack of benefit for prophylactic drugs of tension-type headache in adults
  9. DynaMed Plus Tension Type headache
  10. Diagnosis and management of headache in adults A national clinical guideline SIGN Nov 2008
  11. Guidelines for All Healthcare Professionals in the
    Diagnosis and Management of Migraine Tension-Type Headache Cluster Headache Medication-Overuse Headache 3rd edition (1st revision) 2010 These guidelines are available at



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