Epidemiology

• TTH is the most common type of chronic recurring head pain.
• It is one of the most common conditions for which patients seek medical advice.
• It is more common in women than in men (ratio 1.4:1).
• It is most common in young adults with about 60% occurring in people over 20 years of age. Onset over the age of 50 years is unusual.
• Lifetime prevalence of episodic TTH is between 30% and 78%.
• Care should be taken when diagnosed in the elderly because more secondary headache disorders occur in the elderly.^[4]

Presentation

Typically, TTH is described as pressure or tightness, like a vice or tight band around the head.^[3] There is often a relationship to the neck, with pain into or from the neck. TTH can be disabling for a few hours but lacks the specific features and associated symptoms of migraine (although photophobia and exacerbation by movement are common to many headaches).^[2] When compared to migraine, TTH is:

• More gradual in onset.
• More variable in duration (usually shorter).
• More constant in quality.
• Less severe.
• Usually responsive to 'over-the-counter' medication (in the episodic variety).

Diagnosis of TTH is suggested by two of the following in at least ten previous headaches:

• Bilateral or generalised, and of mild-to-moderate intensity (interfering with but not preventing activities).
• Frontal-occipital.
• Non-pulsatile in quality (pressing or tightening).
• Not aggravated by routine physical activity.

History

TTH is suggested by the following history (see box above):

• Time questions:
  • 10 or more previous headache episodes help to confirm the diagnosis.
  • 'Infrequent' is considered to mean fewer than 180 days per year with headache.
  • Often present at, or soon after, getting up in the morning.
  • It may be chronic with a duration of more than five years in 75% of patients with the chronic variety.
  • Duration will range from 30 minutes to seven days.
• Character questions:
  • Pain is mild-to-moderate in intensity.
  • The pain is described as:
    • 'Fullness'
    • 'Tightness'
    • 'Squeezing'
    • 'Pressure'
    • 'Like a skullcap'
    • 'Band or vice-like'
  • Pain is bilateral and occipito-nuchal or bifrontal.
  • Associated symptoms:
    • Muscular tightness or stiffness in the neck, occipital or frontal regions.
    • Difficulty concentrating.
    • Symptoms of stress and anxiety.
    • Insomnia.
    • Usually no photophobia or phonophobia (may be one or both of these symptoms).
    • No nausea or vomiting.
    • No prodrome.
• Cause questions:
  • Anxiety.^[5]
  • Depression.^[5]
  • Poor posture.
  • Poor sleep.
  • Stress.
  • Muscular tightness (as above).
  • Usually relieved by simple analgesics.
• Response questions:
  • Patients can usually do normal activities.
  • Simple analgesics will have been tried usually with good effect.
• State between attacks:
  • Well between attacks.
  • May be anxious about the headaches.

Examination^[2]

This will be normal in TTH and is performed to exclude other causes and to reassure the patient. There may be some tenderness in the scalp or neck (especially the upper cervical muscles, with occipital headache). Examination should include:

• Head and neck
• Blood pressure
• Optic fundi

Differential diagnosis

The following may be worthy of consideration:

• Migraine
• Temporal arteritis
• Trigeminal neuralgia
• Temporomandibular joint dysfunction
• Subarachnoid haemorrhage
• Sinusitis
• Encephalitis
• Cervical spondylosis
• Carbon monoxide poisoning

Investigations^[2]

These do not generally contribute anything to the diagnosis of TTH. They may be required if history or examination suggests the headache is secondary to another condition. Cervical spine X-rays and eye tests are unlikely to contribute to the diagnosis.

Management^[2][3] 

Episodic tension-type headache

This has the features described above. Headaches occur on fewer than 15 days each month.

Management should incorporate:

• The patient receiving a positive diagnosis, based on the features of the headache. An explanation and discussion of the diagnosis should follow.
• Reassurance that the condition is self-limiting and not serious. Neuro-imaging should NOT be used to reassure patients.^[3] 
• Attention to any stress, anxiety or depression.^[5][6]
• Appropriate advice on exercise and posture.
• Advice on medication: opioids including codeine should be avoided because of the risk of medication-overuse headache. Recommended drug treatment is:
  • Ibuprofen:
    • This is the first choice.
    • From the age of 16 years the dose is from 400 mg to 800 mg three times daily with food.
  • Diclofenac:
    • This is an alternative to ibuprofen but has an intermediate risk of gastrointestinal (GI) side-effects.
    • From the age of 16 years the dose is 25 mg to 50 mg three times daily.
  • Naproxen:
    • This is another alternative to ibuprofen but also with intermediate risk of GI side-effects.
    • From the age of 16 years the dose is 250 mg to 500 mg twice daily.
  • Paracetamol:
    • This is recommended for those intolerant of non-steroidal anti-inflammatory drugs (NSAIDS).
    • Dosage is 500 mg, two tablets every 4 to 6 hours.

Chronic tension-type headache

What is the potential for treatments other than medication? It can be difficult to access the different modalities of treatment on offer. Reports on efficacy are mixed. Some patients may be driven to use ineffective and expensive treatments.^[7] However, some of the treatments on offer are attractive to patients and promising in some clinical trials. The following might be broadly considered:

• Relaxation therapies
• Physical treatments
• Psychological therapies

Specific therapies may incorporate elements of all three - for example, yoga, therapeutic massage, acupuncture,^[8][9] and osteopathy.^[10] There are a number of studies evaluating spinal manipulation for episodic TTH.^[11] However, the evidence as yet is inconclusive.

Medication:

• Amitriptyline is the treatment of choice.
• Warn of side-effects (dry mouth for example).
• Start at 10-15 mg at night, increased up to as much as 150 mg at night. Usually requires no more than 20-30 mg. If higher doses are required, this may suggest an alternative diagnosis (for example, depression).
• Reduce once improvement is maintained for between 4 and 6 months.
• Reduce gradually, but be prepared to hold the reduction if headaches recur.

Prognosis

TTH in the episodic form is particularly common and causes minimal disability or discomfort. However, if it evolves into the chronic TTH, then the morbidity escalates dramatically. It seems to improve over the age of 60 years but appears to remain a problem for most sufferers throughout their lives.^[12]

Prevention

It is important to beware of creating cases of medication-overuse headache. Those at risk are patients using analgesics (or triptans) for more than 17 days a month.