Tension Headache
✨ Epidemiology & Demographics
- Female predominance less marked than in migraine.
- Commonly begins in young adulthood or later.
- 50% lifetime prevalence; often coexists with migraine.
✨ Clinical Features
| Feature | Tension-Type Headache | Migraine |
|---|---|---|
| Nature of Pain | Dull, pressing, tight (“band-like”); non-pulsatile | Throbbing, pulsatile |
| Severity | Mild to moderate | Moderate to severe |
| Laterality | Bilateral (90%) | Unilateral (typically temporal or retro-orbital) |
| Location | Frontal, occipital, bitemporal, generalised | Unilateral, frontotemporal or occipital |
| Systemic/Neurological Symptoms | Absent | Common (photophobia, phonophobia, nausea) |
| Aura | Absent | Often present (e.g., visual disturbances) |
| Exacerbated by physical activity | No | Yes |
| Associated Symptoms | May include photophobia, phonophobia (not both), rare nausea (no vomiting) | Often includes nausea, vomiting, photophobia, phonophobia, osmophobia |
| Duration | 30 minutes to 7 days | 4–72 hours |
| Course | Spectrum: infrequent to chronic daily | Episodic or chronic |
✨ Precipitating & Aggravating Factors
| Tension-Type Headache | Migraine |
|---|---|
| – Stress (esp. at end of day) – Sleep deprivation or oversleeping – Sedentary lifestyle – Poor posture | – Stress (onset or relief) – Hormonal changes (e.g., menstruation) – Bright light, strong odours – Skipping meals – Weather changes |
✨Pathophysiology Overview
- Thought to involve peripheral myofascial nociception (episodic) and central sensitisation (chronic).
- Lack of overt vascular or neurological features.
✨ Treatment Overview
🟦 Acute Management – Infrequent TTH
- First-line non-opioid analgesics (taken at onset):
| Medication | Dose | Max in 24h |
|---|---|---|
| Aspirin | 600–900 mg PO, q4–6h | 2 g |
| Diclofenac potassium | 50 mg PO, q4–6h | 150 mg |
| Ibuprofen | 400 mg PO, q4–6h | 2.4 g |
| Naproxen | 500–750 mg PO, q6h | 1250 mg |
| Paracetamol | 1000 mg PO, q4–6h | 4 g |
💡 Avoid opioids due to risk of dependence and rebound headache.
🟦 General & Lifestyle Measures
- Stress reduction (CBT, relaxation therapy)
- Regular exercise, aerobic activity
- Postural correction, ergonomic assessment
- Avoidance of excessive alcohol and analgesic overuse
- Address contributing factors: depression, anxiety, sleep hygiene
- Tobacco cessation
🟦 Non-Pharmacological Therapies
- Cognitive behavioural therapy – effective for frequent TTH
- Acupuncture – ≥6 sessions may benefit
- Physiotherapy – especially with neck stretching/endurance program
- Massage or mobilisation of cervical/paraspinal musculature
✨ Preventive Pharmacotherapy (for frequent or chronic TTH)
First-line Preventives
- Amitriptyline 10–75 mg nocte (max up to 200–250 mg in refractory cases)
- Nortriptyline 10–75 mg nocte (fewer anticholinergic effects)
Trial for 8 weeks, then review. Continue for 6 months if effective, followed by tapering.
Alternatives
- Mirtazapine 15–30 mg nocte, review at 8–12 weeks
- Venlafaxine XR 75–150 mg in the morning with food
✨ Refractory Headache Strategy
- Short trial (3-week) of naproxen 250–500 mg BD to break the analgesic dependency cycle
- ⚠️ Do not repeat if ineffective
🟫 Interventional Treatments (selected cases)
- Trigger point injections (occiput, trapezius)
- Myofascial release techniques
- C1–C2 lateral joint injection (specialist referral only)
🔄 Coexisting Migraine Consideration
- TTH and migraine can coexist; distinguish overlapping features
- Mixed-type headache sufferers may benefit from dual-pathway approaches (e.g., TCAs ± triptans PRN for migraine episodes)
📌 Key Points
Consider specialist referral if non-responsive to multiple prophylactic strategies or for interventional options.
Tension-type headache is non-pulsatile, bilateral, and typically not aggravated by exertion.
Management relies on lifestyle modification, non-opioid analgesia, and prophylaxis for chronic forms.
Avoid medication overuse; address comorbid depression/anxiety.