Tension type headache

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Tension-Type Headache (TTH)

Definition

Tension-type headache is defined as a mild-to-moderate, typically bilateral headache without nausea or vomiting. Patients may have photophobia or phonophobia, but not both. The headache does not worsen with routine physical activity.

The term "type" was deliberately added ("tension-type") to move away from implying that actual muscle tension is the primary mechanism. — Bradley and Daroff's Neurology in Clinical Practice

Epidemiology

The most common variety of headache overall
1-year prevalence: 14–93 per 100,000 for episodic TTH; 8.1 per 100,000 for chronic TTH
Prevalence in general population: 30–78%
More common in women than men, across age, race, and educational level
More prevalent in Western countries and in Caucasian individuals
Unlike migraine, TTH infrequently begins in childhood — more likely arises in middle age, coinciding with anxiety, fatigue, and depression

— Goldman-Cecil Medicine; Bradley and Daroff's Neurology; Adams and Victor's Principles of Neurology

Clinical Features

Feature	Description
Location	Bilateral; occipitonuchal, temporal, frontal, or diffuse ("band-like")
Quality	Dull, aching, pressure/tightening — non-pulsating
Severity	Mild to moderate
Duration	30 minutes to 7 days (episodic); hours to continuous (chronic)
Physical activity	NOT aggravated by routine activity
Nausea/vomiting	Absent
Photophobia/phonophobia	At most one of the two
Onset	Gradual (vs. migraine's more abrupt onset)

Patients often describe it as a feeling that the head is in a vise or tight band, or that it is swollen and about to burst. In contrast to migraine, there is no persistent throbbing quality, no clear lateralization, and daily activities are generally not seriously impaired.

Chronic TTH is unique in being present throughout the day, day after day, for weeks to years — no other primary headache does this. — Adams and Victor's Principles of Neurology

ICHD-3 Diagnostic Criteria

Frequent Episodic TTH

A. ≥10 episodes occurring ≥1 but <15 days/month for ≥3 months
B. Duration 30 minutes to 7 days
C. At least 2 of:
1. Bilateral location
2. Pressing/tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity
D. Both:
1. No nausea or vomiting
2. No more than one of photophobia or phonophobia
E. Not attributed to another disorder

Chronic TTH

A. Headache ≥15 days/month for >3 months (≥180 days/year)
B. Lasts hours, may be continuous
C. Same as above (≥2 characteristics)
D. No more than one of photophobia, phonophobia, or mild nausea; no moderate/severe nausea or vomiting

— Kaplan & Sadock's Comprehensive Textbook of Psychiatry (ICHD-3)

Pathophysiology

Not fully understood. The old concept of excessive craniocervical muscle contraction causing headache has been largely abandoned — EMG recordings show most patients' muscles are quite relaxed.

Current understanding favors a central sensitization mechanism:

Interaction between peripheral myofascial input and sensitization of second-order nociceptive neurons in the trigeminal nucleus and spinal dorsal horn
Lower pain tolerance threshold demonstrated even at distal sites (fingers), suggesting widespread allodynia and hyperalgesia
Nitric oxide has been implicated in genesis
Genetic factors are uncertain
Myofascial tenderness is increased, especially in chronic TTH

TTH and migraine may represent two ends of a continuum rather than entirely distinct entities. — Bradley and Daroff's Neurology; Adams and Victor; Goldman-Cecil

Associations

Anxiety and depression are present in the majority of patients with protracted headaches
Adolescents with ≥2 psychiatric factors (e.g., depression + anxiety) have worse prognosis
Obstructive sleep apnea increases the likelihood of developing TTH; screening recommended in frequent/chronic cases
Medication overuse is a major complication — analgesics used >3 days/week can worsen headaches and lead to medication-overuse headache

Physical Examination

Acute TTH: generally unrevealing
Chronic TTH: may show craniocervical muscle tenderness
In elderly: check ESR to exclude giant-cell arteritis
New or worsening headache: consider CT/MRI to rule out structural disease
Cervical spine imaging if secondary causes suspected

Treatment

Acute / Episodic

Drug	Dose
Acetaminophen	650–1000 mg
Aspirin	250–1000 mg
Ibuprofen	200–800 mg
Naproxen	250–500 mg
Ketoprofen	12.5–75 mg

Note: Triptans are not effective in pure TTH (though they work in apparent TTH when migraine coexists). — Harrison's Principles of Internal Medicine

Combination analgesics with codeine, butalbital, or caffeine should be avoided due to risk of medication-overuse headache.

Prophylaxis (Chronic TTH)

Amitriptyline — the most effective and best-evidenced drug; start 10 mg at bedtime, titrate to 50–150 mg; >50% improvement in >65% of patients
Nortriptyline (25–100 mg/night), doxepin, maprotiline, fluoxetine
Tricyclics are generally more efficacious than SSRIs
Muscle relaxants, physical therapy, biofeedback/relaxation training
Botulinum toxin: placebo-controlled trials in chronic TTH were negative (Harrison's); some sources report benefit
Acupuncture: no evidence per Harrison's
Localized nerve blocks (occipital, supraorbital)
Screen and treat OSA if present

Prognosis

Variable. Most patients with episodic TTH respond well to OTC analgesics and lifestyle modification. Adolescents with ≥2 psychiatric comorbidities (depression, anxiety) have a worse prognosis. Chronic TTH is difficult to manage and often has underlying psychiatric comorbidity.

Sources: Adams and Victor's Principles of Neurology 12e | Goldman-Cecil Medicine | Bradley and Daroff's Neurology in Clinical Practice | Harrison's Principles of Internal Medicine 22e | Kaplan & Sadock's Comprehensive Textbook of Psychiatry

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