Tension Type Headache

General features

The female : male ratio is 5:4 where women are only slightly more affected than men.

Average age of onset: 25 – 30 years, peaks between 30 – 39 years, & decreases slightly with age.

Common triggers:

• Stress – mental or physical
• Irregular or inappropriate meals
• High intake or withdrawal of coffee & other caffeine containing drinks
• Dehydration
• Sleep disorders
• Psycho-behavioral problem
• Reduced exercise
• Variations during the female menstrual cycle & hormonal substitution

Proposed pathophysiology

• Activation of hyperexcitable peripheral afferent neurons from head & neck muscles.
• Muscle tenderness & psychological tension
• Abnormalities in central pain processing & generalized increased pain sensitivity
• Genetic factors

Diagnosis

Tension type headache (TTH) can be diagnosed using The International Classification of Headache Disorders (ICHD-3) criteria as follow:

TTH can be further categorized into subtypes – Episodic (infrequent, frequent) & Chronic

Peripheral mechanisms are probably more important in episodic TTH, whereas central pain mechanisms are pivotal in chronic TTH.

Clinical features of TTH

1. Bilateral 
2. Non throbbing (pressing/tightening) 
3. Absence of :  

• Nausea/vomiting
• Photophobia, phonophobia and osmophobia
• Movement exacerbation.

4. Pericranial tenderness – if present, is the most pronounced & abnormal finding in TTH

• Can be detected by manual palpation.
• Local tenderness may be determined by using small rotating movement with the 2nd and 3rd fingers over the frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius & trapezius muscles. 

Possible co-morbid conditions with TTH

• Sleep apnea 
• TMJ disorders 
• Fibromyalgia 
• Anxiety & depression 
• Back pain 
• Neck pain 
• Irritable bowel syndrome

Management

Consist of pharmacological & non-pharmacological treatment

Pharmacological treatment

Can be divided into:

1. Acute therapy – for infrequent or low-frequency episodic TTH
2. Prophylactic therapy – for chronic or high-frequency episodic TTH 

Both acute & prophylactic therapy can be used together

Acute therapy

Preferred 1st choice – simple analgesics e.g.

• Paracetamol (PCM)
• NSAIDs – Aspirin, Ibuprofen, Ketoprofen, Naproxen, Diclofenac
  (There are no clinical trials to support the use of COX-2 inhibitors)

2nd choice – combination analgesics containing caffeine

• More effective than simple analgesics or NSAIDs alone, but more likely to induce medication overuse headache. 

Not recommended/No role: Triptans, Muscle relaxants, Opioids

In general, medication for acute treatment should be used not more than 2 – 3 days/week, to minimize chance of overuse or “rebound” headache.

Prophylactic therapy

Indication: For chronic TTH or very frequent episodic TTH.

🥇First line – Amitriptyline (Tricyclic Antidepressant)

• Mechanism: Pain-modulating effect independent of antidepressant action.
• Dose:
  – Start low: 10 – 25 mg/day
  – Titrate: increase by 10 – 25 mg weekly
  – Maintenance: usually 30 – 75 mg/day, better taken 1 – 2 hours before bedtime to avoid the sedative adverse effects.
• Common side effects: Dry mouth, drowsiness, dizziness, constipation, weight gain.
• Evaluation: If no response after 4 weeks on maintenance dose, consider switching therapy

🥈Second line

Treatment notes

• Efficacy of preventive therapy is modest; benefits must outweigh side effects.
• Continue successful therapy for ~6 months, then taper while monitoring headache frequency.
• Resume treatment if headaches recur.
• Avoid medication overuse to prevent chronic daily headache.

Non-pharmacological treatment

General recommendation: Non-pharmacological approaches should be considered for all TTH patients, even though scientific evidence supporting their efficacy is limited.

These include:

1. Education & Lifestyle Changes

• Patient counseling – provide information, reassurance and help identifying headache triggers
• Routine optimization – Encourage regular sleep, exercise and meal schedule

2. Pyscho-Behavioral Therapies

Tailored use:

• CBT – Best for patients with psychological or emotional contributors.
• Biofeedback/relaxation – Preferable for patients with high physical tension.

3. Physical modalities

• Physical therapy and Acupuncture may be helpful, though robust evidence is lacking.

When to refer?

1. When the headache diagnosis is unclear
2. Patient not responding to treatment
3. Headache complicated by medication overuse
4. Presence of red flags (SNOOP mnemonic)

Reference

1. Bendtsen, L., Evers, S., Linde, M., Mitsikostas, D.D., Sandrini, G. and Schoenen, J. (2010), EFNS guideline on the treatment of tension-type headache – Report of an EFNS task force. European Journal of Neurology, 17: 1318-1325. https://doi.org/10.1111/j.1468-1331.2010.03070.x
2. Loder, E., & Rizzoli, P. (2008). Tension-type headache. BMJ (Clinical research ed.), 336(7635), 88–92. https://doi.org/10.1136/bmj.39412.705868.AD
3. Merican, J. S., Goh, K. J., Wan Sulaiman, W. A., Chan, P. H., Puvanarajah, S. D., Tai, M. L., & Chee, K. Y. (2021). Consensus guidelines on the management of headache 2021 [PDF]. Malaysian Society of Neurosciences.