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 state 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 )
LINKS AND RESOURCES
Patient information
Tension Headache from Harvard Health Publishing – a well written balanced article for patients https://www.health.harvard.edu/a_to_z/tension-headache-a-to-z
Patient UK has produced a useful section on TTH https://patient.info/brain-nerves/headache-leaflet/tension-headache
The Migraine Trust has a useful section on TTH which educates the patient on differences between TTH and migraine https://www.migrainetrust.org/about-migraine/types-of-migraine/other-headache-disorders/tension-type-headache/
A headache diary can be downloaded via https://headaches.org/wp-content/uploads/2018/08/HEADACHE-DIARY.pdf
A large word file from NHS Grampian on TTH https://www.nhsgrampian.org/neurology/files/Tension_Headache.doc
Information for clinicians
British Association for Study of Headaches ( BASH )– guidelines on headache https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf
Canadian Family Physician – guideline for primary care management of headache in adults https://www.cfp.ca/content/cfp/61/8/670.full.pdf
A 57-minute video on TTH by National Headache Foundation https://headaches.org/resources/tension-type-headache/
NICE guideline Headaches in over 12s : diagnosis and management 2012 https://www.nice.org.uk/guidance/cg150/ifp/chapter/Treatments-for-tensiontype-headache
An article on management of Chronic Tension Type Headache BMJ Clin Evid 2016 ( open access ) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4747324/
International Headache Society TTH https://ichd-3.org/2-tension-type-headache/
European Academy of Neurology -EFNS guideline on the treatment of tension-type headache – Report of an EFNS task force https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-1331.2010.03070.x
Management of Chronic Headache RACGP https://www.racgp.org.au/afp/2014/march/chronic-headache/
References
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KE Waldie, J Buckley, PN Bull, R Poulton – J Headache Pain, 2015
- 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
- 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
- Headache- tension type CKS NHS Last revised November 2017 https://cks.nice.org.uk/headache-tension-type
- EFNS guideline on the treatment of tension-type-headache- Report of an EFNS task force Eur J Neurol. 2010 Nov;17(11):1318-25. doi: 10.1111/j.1468-1331.2010.03070.x.
- Tension Headache BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/12
- Tension-type headache Tension-type headache BMJ 2008 336 ;88
- Minor Emergencies Philip Buttaravoli et al Mosby Lack of benefit for prophylactic drugs of tension-type headache in adults
- DynaMed Plus Tension Type headache
- Diagnosis and management of headache in adults A national clinical guideline SIGN Nov 2008
- 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 https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf