Makindo Medical Notes

💡 Tension-Type Headache (TTH) is the most common primary headache worldwide. Often described as a "tight band" around the head 🤕, it is usually mild–moderate and not associated with vomiting or major neurological deficits. 🌍 Affects up to 40% of adults at some point in life.

📌 About

• Most common headache type, much more frequent than migraine or cluster headache.
• Unlike migraine, it is rarely disabling and patients can usually continue daily activities.
• Pathophysiology: due to increased pericranial muscle tension, stress, and central pain sensitisation 🧠.
• Triggers include: stress, fatigue, poor posture, dehydration, and prolonged screen time 📱.

⚡ Characteristics

• Duration: 30 minutes – 7 days per episode.
• Quality: pressing/tightening (non-pulsatile), “band-like” pressure around forehead or occiput.
• Intensity: mild–moderate (patients often carry on with tasks).
• Associated symptoms: May have either photophobia or phonophobia (never both, unlike migraine).
• Not aggravated by walking, climbing stairs, or physical activity 🚶.

🧾 Diagnostic Criteria (≥2 Required)

• Bilateral location 🤕.
• Pressing/tightening quality.
• Mild to moderate intensity.
• Not worsened by routine activity.

🩺 Clinical Features

• Episodic TTH: <15 days/month.
• Chronic TTH: ≥15 days/month for >3 months.
• Often linked with: anxiety, stress, poor sleep, eye strain 👓, and musculoskeletal tension in neck/shoulders.
• No vomiting, aura, or severe light/noise sensitivity (helps distinguish from migraine ⚡).

🔍 Investigations

• Diagnosis is clinical → no routine imaging required.
• Red flag symptoms: consider CT/MRI to exclude secondary headache (tumour, SAH, raised ICP).
• ESR/CRP: in patients >50 yrs with new headache → exclude temporal arteritis ⏳.

💊 Management

• Acute: – Paracetamol 1 g QDS PRN. – NSAIDs (e.g. ibuprofen 400 mg TDS) if no contraindications. ⚠️ Avoid frequent analgesic use → risk of medication-overuse headache.
• Non-pharmacological: Stress reduction, relaxation training 🧘, regular sleep, hydration 💧, and screen breaks.
• Physical therapy: Neck/shoulder massage, stretching, ergonomic corrections at work 💻.
• Preventive (chronic TTH): Amitriptyline 10–30 mg nocte is first-line; other options: mirtazapine, venlafaxine.
• Patient reassurance: TTH is benign, unlike migraine or secondary causes — reassurance itself often reduces anxiety-driven exacerbation ✅.

🚩 Red Flags (Suggest Secondary Headache)

• “Thunderclap” headache (sudden, maximal at onset) → suspect SAH ⚡.
• New headache after age 50 👵.
• Progressive worsening over weeks/months 📈.
• Neurological deficit, seizure, confusion 🧠.
• Systemic illness: fever 🤒, weight loss, immunosuppression.
• Headache waking patient at night 🌙.

📝 Exam & OSCE Pearls

• TTH = “band-like” headache, bilateral, mild–moderate, not disabling.
• Distinguish from migraine (pulsatile, unilateral, photophobia + phonophobia, vomiting, aura).
• Management = lifestyle + simple analgesia → amitriptyline if chronic.
• Always mention medication-overuse headache as a differential in frequent attenders 💊.

📚 References

• NICE CKS: Headache Assessment
• ICHD-3 Classification: Tension-Type Headache