Tension headache

Definition/diagnostic criteria Tension headache, also known as tension-type headache (TTH), is a common primary headache disorder characterised by bilateral, pressing or tightening pain without specific features such as aura, photophobia or phonophobia, nausea or vomiting. TTH lasts from 30 minutes to seven days and is of mild to moderate intensity and not aggravated by routine physical activity.

Epidemiology TTH is one of the most prevalent headache disorders in the UK. It affects individuals of all ages, with a higher prevalence in females than males. It often starts during adolescence and tends to peak in midlife.

Diagnosis
Clinical features: TTH is primarily diagnosed based on clinical features. Patients typically report a bilateral, dull, and squeezing headache that feels like a tight band around the head. The pain is usually mild to moderate in intensity and is not exacerbated by routine physical activity. Patients may experience episodic or chronic tension headache, with the latter involving headaches occurring for 15 or more days per month for at least three months.

Investigations: In most cases, TTH diagnosis does not require additional investigations, as it is primarily a clinical diagnosis. However, investigations may be warranted if patients present with atypical features or if secondary causes of headache are suspected.

Treatment
Acute management:

• Over-the-counter analgesics: Patients can initially use OTC analgesics like paracetamol, aspirin or an NSAID as soon as possible during the acute attack as first-line treatment.
• Avoid overuse: It’s essential to educate patients about the risk of medication overuse headache and recommend limiting the use of acute medications to fewer than 15 days per month.

Prophylactic measures:

• Behavioural and physical therapies: Cognitive-behavioural therapy (CBT), relaxation techniques, acupuncture and physiotherapy may be beneficial for chronic tension headache management.
• Medications: Daily low-dose amitriptyline can be offered as drug prophylaxis for chronic TTH.

Prognosis Most patients can effectively manage their symptoms with lifestyle modifications, OTC medications or prophylactic treatments. The condition often improves over time and remission can occur. However, some patients may experience chronic tension headache, which can be more challenging to manage.