Tension Type Headache 

Definition

Tension-type headache (TTH) is the most common primary headache disorder, characterized by:

• Bilateral, non-pulsatile, pressing/tightening pain
• Mild to moderate intensity
• No aggravation by routine physical activity
• Minimal or no associated symptoms (no prominent nausea/vomiting)

Epidemiology

• Lifetime prevalence: ~70–80%
• More common in females
• Peak: 20–40 years
• Major cause of disability + reduced productivity

 Pathophysiology 

1. Peripheral Mechanism (episodic TTH)

• Increased pericranial muscle tenderness
• Myofascial nociceptor activation

2. Central Mechanism (chronic TTH)

• Central sensitization:
• Increased excitability of pain pathways
• Reduced descending inhibitory control
• Altered neurotransmitters:
• ↓ serotonin
• ↑ glutamate

👉 Chronic TTH behaves more like a central pain disorder

Classification (International Classification of Headache Disorders)

1. Infrequent Episodic

• <1 day/month

2. Frequent Episodic

• 1–14 days/month

3. Chronic TTH

• ≥15 days/month for >3 months

Diagnostic Criteria (ICHD-3)

At least 10 episodes fulfilling:

Headache characteristics (≥2):

• Bilateral location
• Pressing/tightening (non-pulsating)
• Mild–moderate intensity
• Not worsened by routine activity

Associated features:

• No nausea/vomiting
• Either:
• Photophobia OR
• Phonophobia (not both)

Clinical Features

 Pain description

• “Band-like”, “tight helmet”, “vice-like”
• Typically frontal, temporal, occipital

 Associated features

• Mild photophobia or phonophobia
• No aura
• No autonomic symptoms (distinguishes from cluster headache)

 Examination

• Usually normal
• May show:
• Pericranial muscle tenderness
• Neck stiffness

 Red Flags (Always rule out secondary headache)

Use SNOOP:

• Systemic symptoms (fever, cancer)
• Neurological deficit
• Onset sudden (thunderclap)
• Older age (>50)
• Pattern change

 Differentiation 

 Key: No nausea + non-pulsatile = TTH

 Investigations

• Clinical diagnosis
• No imaging unless red flags

 Management (NICE + ICHD)

 Acute Treatment

• Simple analgesics:
• Paracetamol
• NSAIDs (e.g., ibuprofen)

 Avoid:

• Opioids
• Combination analgesics → risk of Medication Overuse Headache

Prophylaxis (Frequent/Chronic TTH)

First-line:

• Amitriptyline

Alternatives:

• Nortriptyline
• Mirtazapine

 Non-Pharmacological 

• Stress management
• Cognitive behavioral therapy (CBT)
• Biofeedback
• Sleep hygiene
• Regular exercise

 Medication Overuse Headache 

• Headache ≥15 days/month
• Due to frequent analgesic use
• Management:
• Withdraw offending drug
• Start prophylaxis

 Chronic TTH 

• Central sensitization dominates
• Often associated with:
• Anxiety
• Depression
• Sleep disorders

 Pearls

• Most common headache → TTH
• No nausea/vomiting → excludes migraine
• Bilateral + pressing + mild → TTH
• First-line prophylaxis → Amitriptyline
• Imaging not required unless red flags
• Chronic TTH → think central sensitization + MOH