Tension-type headache

Background/Epidemiology

  • Most common type of chronic/recurring head pain (lifetime prevalence of between 30 and 80%)
  • Can be
    • Episodic (most common)- occuring <15 days/month
    • Chronic (affects ~3% of the population)- occuring >15 days/month (accompanied by classical symptoms/signs)

Presentation

  • Pain characterised as ‘dull’, ‘tight’ or ‘pressure’
    • often described as a band around the top of the head, often radiating forward from the occipital region
    • can last prolonged periods (sometimes days/weeks) although severity may vary (usually less severe if the patient is occupied or during the morning and becomes worse as the day goes on, particularly in the evenings when the patient is trying to relax)
      • NB patient often wakes up with a mild headache (suggestive of TTH)
  • Often associated with anxiety, depression, poor sleep, stress

Differential Diagnosis and Suggestive features

  • Compared to migraine:
    • TTH is more gradual in onset; more variable in duration (usually shorter, but can remain persistent for longer durations than migraine); more constant in quality; less severe; can be responsive to analgesia e.g. paracetamol (NB codeine and overuse of certain medications can perpetuate headache syndromes); no photophobia, aura or nausea; activities are usually not impaired due to headache
  • Suggestive features include
    • Bilateral/generalised headache of mild/moderate intensity (frontal-occipital); non-pulsatile; not aggravated by routine physical activity

Management

  • Often patients require no investigations but they can be reassuring to the patient (which can often help symptom control- although they should always be informed of the most likely outcome i.e. normal investigations)
  • Simple analgesia e.g. ibuprofen (first line) and paracetamol
    • STOP any opiates
  • Amitryptiline may be useful for chronic sufferers
  • Also physio-/psycho-therapy e.g. relaxation etc can be beneficial

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