Tension Headache
Related Subjects:Migraine
|Basilar Migraine
|Takayasu arteritis (pulseless disease)
|Fibromuscular Dysplasia
💡 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
