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.
TTH is a very common form of headache and is divided into:
- Episodic TTH. This occurs on fewer than 15 days each month. It can evolve into the chronic variety.
- Chronic TTH. This occurs on more than 15 days each month and has all the features of the episodic TTH.
This separation seems slightly arbitrary but it has practical importance because:
- The chronic type is more likely to be medication-induced.
- 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.
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.
- TTH is the most common type of chronic recurring head pain.
- It is one of the most common conditions for which patients seek medical advice.
- It is more common in women than in men (ratio 1.4:1).
- It is most common in young adults.
- Episodic TTH is widely experienced.
- Estimated lifetime prevalence of episodic TTH has not been clearly measured. Figures of 30% to 78% are widely quoted but there are no published studies which support these numbers.
- First onset over the age of 50 years is unusual.
- Care should be taken when diagnosing TTH in the elderly, as more secondary headache disorders occur in the elderly.
- 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.[3, 5]
- 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).
- Non-pulsatile in quality (pressing or tightening).
- Not aggravated by routine physical activity.
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).
Consider advising the patient to keep a headache diary in order to distinguish infrequent episodic TTH (less than one episode per month), frequent episodic TTH (more than one episode per month) and chronic TTH.
Establish how many different types of headache the patient experiences:
- If the patient has more than one type of headache, take separate histories for each type of headache.
- Why consulting now?
- How recent in onset?
- How sudden in onset?
- How frequent and what temporal pattern? (Distinguishes episodic, daily and unremitting.)
- Intensity of pain?
- Nature and quality of pain?
- Site and spread of pain?
- Associated symptoms?
- Predisposing or trigger factors:
- Co-existing depression or stress?
- Lifestyle factors such as poor sleep patterns or lack of physical exercise?
- Aggravating or relieving factors?
- Family history of any similar headaches?
- What do you do during a headache?
- How much are your activities limited?
- What medication has been used?
- How has the medication been used?
- Completely well between attacks?
- Any residual or persistent symptoms between attacks?
- Any fears or concerns about recurrent headaches?
- Any fears or concerns about the cause of headache?
TTH is suggested by the following history:
- 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.
- Pain is mild-to-moderate in intensity.
- Pain is described as:
- '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.
- Usually no photophobia or phonophobia (may be one or both of these symptoms).
- No nausea or vomiting.
- No prodrome.
- Poor posture.
- Poor sleep.
- Muscular tightness (as above).
- Usually relieved by simple analgesics.
- 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.
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
The following alternatives should be considered and can usually be excluded by history and examination:
- Giant cell arteritis (temporal arteritis).
- Trigeminal neuralgia.
- Temporomandibular joint dysfunction.
- Subarachnoid haemorrhage.
- Cervical spondylosis.
- Carbon monoxide poisoning.
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.
This has the features described above. Headaches occur on fewer than 15 days each month.
Management should incorporate:
- 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.
- Attention to any stress, anxiety or depression.[6, 7]
- 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 chronic TTH.[8, 9]
- There is also some evidence for osteopathy in the management of chronic TTH.
- Simple analgesics:
- 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.
- Aspirin 600 mg-900 mg can also be used in those over 16 years of age.
- As the frequency of headaches increases, so does the risk of medication-induced headache. Therefore, these treatments are not indicated in chronic TTH.
- Despite this, a single 'rescue' course of naproxen 250 mg-500 mg bd for three weeks may break the cycle of recurrence. If it is not successful it should not be repeated.
- Tricyclic antidepressants:
- Amitriptyline is the treatment of choice for frequently recurring episodic TTH or chronic TTH
- Warn of side-effects (dry mouth for example).
- Evidence from clinical trials has not established a specific dose.
- Start at 10-15 mg at night.
- Increments of 10 mg-25 mg are suggested every 1-2 weeks, as side-effects permit.
- Stop when effective - this may be as high as 150 mg at night. Usually the condition responds to 20 mg-30 mg. (If higher doses are required, this may suggest an alternative diagnosis such as depression).
- Withdrawal may begin once improvement is maintained for between four and six months.
- Reduce gradually, but be prepared to hold the reduction if headaches recur.
- Other tricyclic antidepressants such as nortriptyline have been used due to better tolerance, but evidence is limited.
- There is no evidence that selective serotonin reuptake inhibitors (SSRIs) reduce headache in chronic TTH.
- Anxiolytics may be effective where specifically indicated:
- Beta-blockers are probably, on balance, not recommended as they may have a depressant effect.
- Benzodiazepines should be avoided due to their addictive qualities.
Other analgesics are not indicated: codeine and dihydrocodeine should be actively avoided in chronic TTH.
TTH in the episodic form is particularly common and causes minimal disability or discomfort. However, if it evolves into the chronic TTH then the morbidity escalates dramatically. It seems to improve over the age of 60 years. However, for those who have TTH, the condition is likely to be a recurrent problem.
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.
Further reading and references
Loder E, Rizzoli P; Tension-type headache. BMJ. 2008 Jan 12336(7635):88-92.
Jensen R; Diagnosis, epidemiology, and impact of tension-type headache. Curr Pain Headache Rep. 2003 Dec7(6):455-9.
Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache; British Association for the Study of Headache (BASH) Guidelines, (2010 - reviewed 2014)
Headaches in over 12s: diagnosis and management; NICE Clinical Guideline (September 2012)
Kaniecki RG; Tension-type Headache in the Elderly. Curr Treat Options Neurol. 2007 Jan9(1):31-7.
Headache - tension-type; NICE CKS, November 2012 (UK access only)
Holroyd KA, Stensland M, Lipchik GL, et al; Psychosocial correlates and impact of chronic tension-type headaches. Headache. 2000 Jan40(1):3-16.
Baskin SM, Lipchik GL, Smitherman TA; Mood and anxiety disorders in chronic headache. Headache. 2006 Oct46 Suppl 3:S76-87.
Wang K, Svensson P, Arendt-Nielsen L; Effect of Acupuncture-like Electrical Stimulation on Chronic Tension-type Headache: A Randomized, Double-blinded, Placebo-controlled Trial. Clin J Pain. 2007 May23(4):316-322.
Melchart D, Streng A, Hoppe A, et al; Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ. 2005 Aug 13331(7513):376-82. Epub 2005 Jul 29.
Anderson RE, Seniscal C; A comparison of selected osteopathic treatment and relaxation for tension-type headaches. Headache. 2006 Sep46(8):1273-80.
Couch JR; The long-term prognosis of tension-type headache. Curr Pain Headache Rep. 2005 Dec9(6):436-41.
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