Tension-type headache

What is a tension-type headache?

Headaches are a major cause of morbidity. Tension-type headache (TTH) is a significant cause of sickness absence and impaired ability at work. TTH (previously just called tension headache) is classified as a primary headache according to the International Classification of Headache Disorders.¹

TTH is a very common form of headache and is divided into:²

• Infrequent episodic: less than 1 day of headache per month.

• Frequent episodic: at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months.

• Chronic: 15 days or more of headache per month, for more than 3 months, in the absence of medication overuse.

This separation seems slightly arbitrary but it has practical importance because the chronic type is more likely to be associated with comorbidity such as depression, which also needs to be treated if the condition is to be managed successfully.¹

TTH is probably overdiagnosed: often what is diagnosed as TTH is in fact migraine. Always consider migraine if the headache had migrainous components.

As with many headache disorders, a good history (see box below) is essential to make the diagnosis. There are both physical and psychological aetiological factors. With the correct diagnosis, effective treatment and advice can be offered.

How common are tension-type headaches? (Epidemiology)²

• The British Association for the Study of Headache (BASH) guideline states it has a mean global lifetime prevalence of 42%, and chronic tension-type headache has a global prevalence of 0.5–4.8%.¹

• It is slightly more common in women than in men.

• The average age of headache onset is 25–30 years, with prevalence peaking at 30–39 years, and then declining slightly.

Symptoms of tension-type headaches (Presentation)¹

• TTH is a featureless, often generalised, headache.

• It is mild to moderate in severity.

• Typically, TTH is described as pressure or tightness, like a vice or tight band around the head.²³

• There is often a relationship to the neck, with pain into or from the neck.

• TTH can be disabling for a few hours but lacks the specific features and associated symptoms of migraine.

• Although photophobia and exacerbation by movement are common to many headaches, photophobia, phonophobia and visual/sensorimotor disturbance are not present.

• Mild nausea may occur, especially if there is medication-induced headache, but profound nausea and vomiting do not occur.

When compared to migraine, TTH is:

• More gradual in onset.

• More variable in duration (usually shorter).

• More constant in quality.

• Less severe.

• Usually responsive to 'over-the-counter' medication (in the episodic variety).

Diagnosis of TTH is suggested by two of the following in at least ten previous headaches:

• Bilateral or generalised, and of mild-to-moderate intensity (interfering with but not preventing activities).

• Frontal-occipital.

• Non-pulsatile in quality (pressing or tightening).

• Not aggravated by routine physical activity.

History

Taking a headache history

A guide to important questions according to the British Association for the Study of Headache (BASH) guidelines and the National Institute for Health and Care Excellence (NICE).²

TTH is suggested by the following history:

Time questions

• 10 or more previous headache episodes.

• Often present at, or soon after, getting up in the morning.

• Chronicity: a duration of more than five years is described by 75% of patients with the chronic variety.

• Duration ranging from 30 minutes to seven days.

Character questions

• Pain is mild-to-moderate in intensity.

• Pain is described as:

  • 'Fullness'.

  • 'Tightness'.

  • 'Squeezing'.

  • 'Pressure'.

  • 'Like a skullcap'.

  • 'Band or vice-like'.

• Pain is bilateral and occipito-nuchal or bi-frontal.

• Associated symptoms:

  • Muscular tightness or stiffness in the neck, occipital or frontal regions.

  • Difficulty concentrating.

  • Symptoms of stress and anxiety.

  • Insomnia.

  • Usually no photophobia or phonophobia (may be one or both of these symptoms).

  • No nausea or vomiting.

  • No prodrome.

Cause questions

• Anxiety.

• Depression.

• Poor posture.

• Poor sleep.

• Stress.

• Muscular tightness (as above).

• Usually relieved by simple analgesics.

Response questions

• Patients can usually manage their normal activities.

• Simple analgesics will have been tried, and are usually effective.

State between attacks

• Well between attacks.

• May be anxious about the headaches.

Examination¹

This will be normal in TTH and is performed to exclude other causes and to reassure the patient. There may be some tenderness in the scalp or neck (especially the upper cervical muscles, with occipital headache). Examination should include:

• Head and neck.

• Blood pressure.

• Optic fundi.

Differential diagnosis

The following alternatives should be considered and can usually be excluded by history and examination:

• Migraine.

• Headache from medication overuse.

• Giant cell arteritis (temporal arteritis).

• Trigeminal neuralgia.

• Temporomandibular joint dysfunction.

• Subarachnoid haemorrhage.

• Sinusitis.

• Encephalitis.

• Cervical spondylosis.

• Carbon monoxide poisoning.

Diagnosing tension-type headaches (investigations)¹

These do not generally contribute anything to the diagnosis of TTH. They may be required if history or examination suggests the headache is secondary to another condition. Cervical spine X-rays and eye tests are unlikely to contribute to the diagnosis.

Management of tension-type headaches^{1 3}

Non-pharmaceutical management

• Reassurance through a positive diagnosis, based on the features of the headache.

• Appropriate explanation and discussion. Reassurance that the condition is self-limiting and not serious. Neuro-imaging should NOT be used to reassure patients.³

• Attention to any stress, anxiety or depression.⁴

• Appropriate advice on exercise and posture. TTH is more common in sedentary people and regular exercise is potentially beneficial.

• Physiotherapy may be helpful for mobilisation, and correction of contributing postural factors may be helpful. It can also help where there has been neck trauma such as whiplash injury but is less likely to be helpful where degenerative disease of the neck is a contributing factor.

• Advice on use of any medication: opioids including codeine should be avoided because of the risk of medication-induced headache.

• Lifestyle changes and cognitive therapy to help reduce stress may also be helpful.

• There is some evidence for acupuncture in the management of episodic and chronic TTH.⁵

• There is also some evidence for osteopathy in the management of chronic TTH.⁶ .=

Pharmaceutical management

• Simple analgesics:¹

  • Symptomatic or acute treatment is not usually beneficial, although it can be appropriate for episodic TTH occurring on fewer than two days a week.

  • Over-the-counter medication with ibuprofen 400 mg is the first choice.

  • Other non-steroidal anti-inflammatory drugs (NSAIDs) - naproxen 250 mg-500 mg, ketoprofen 25 mg-50 mg - are sometimes indicated. Paracetamol 500 mg-1000 mg is recommended for those intolerant of NSAIDs but appears less effective.

  • Advise to avoid the frequent and excessive use of acute analgesia due to the risk of developing medication overuse headache. As the frequency of headaches increases, so does the risk of medication-induced headache.

• Tricyclic antidepressants:¹

  • Drug prophylaxis with amitriptyline 10 mg nocte, increasing in dose increments of 10–25 mg every 1–2 weeks, up to a maximum dose of 150 mg ('off-label' indication).

  • Drug prophylaxis should be used instead of acute treatment for attacks.

  • Suggest a trial of treatment for at least 2–3 months before stopping if it is ineffective. If there is a good response to treatment for at least 6 months, consider gradually reducing and stopping amitriptyline.

Other analgesics are not indicated: codeine and dihydrocodeine should be actively avoided in chronic TTH.

Prognosis²

• Infrequent episodic tension-type headache is usually self-limiting, and over-the-counter simple analgesia is usually effective.

• Chronic tension-type headache can evolve from frequent episodic tension-type headache, with daily or very frequent episodes.

• Symptoms of primary headache disorders tend to improve with increasing age.

Prevention of tension-type headaches

It is important to beware of creating cases of medication-induced headache. Those at risk are patients using analgesics (or triptans) for more than 17 days a month.

Dr Mary Lowth is an author or the original author of this leaflet.