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BASICS

Description

  • Bilateral mild to moderate, nonthrobbing head pain or pressure
  • Formerly known as muscle contraction headache, stress headache, idiopathic headache
  • Types:
  • Episodic TTH: ≥10 episodes lasting 30 min to 7 days
  • Chronic TTH: ≥15 days/month for >3 months

Epidemiology

  • Most common primary headache worldwide; second-most prevalent disorder overall
  • Peak prevalence in 4th decade
  • Episodic TTH decreases with age; chronic TTH increases

Etiology and Pathophysiology

  • Multifactorial; peripheral nociceptor activation causes myofascial pain in episodic TTH
  • Central sensitization leads to chronic TTH
  • Nitric oxide implicated

Risk Factors

  • Stress (mental/physical)
  • Sleep changes
  • Skipping meals, dehydration
  • Dietary triggers (caffeine, alcohol, chocolate)
  • Environmental factors (sun glare, odors, noise)
  • Female hormonal changes
  • Medications (nitrates, SSRIs, antihypertensives)
  • Overuse of abortive medications

General Prevention

  • Avoid triggers
  • Exercise regularly
  • Maintain sleep hygiene
  • Limit caffeine and alcohol
  • Stay hydrated

Commonly Associated Conditions

  • Frequently coexists with migraine (83%)
  • Anxiety and depression common comorbidities

DIAGNOSIS

History

  • Thorough pain history: onset, location, quality, severity, associated symptoms, medications, trauma
  • Pain described as dull, band-like, or pressure
  • Diagnostic criteria (ICHD-3):
  • Episodic TTH: ≥10 episodes lasting 30 min–7 days
  • Chronic TTH: ≥15 days/month for >3 months, lasting hours to days or unremitting
  • Rule out red flags for secondary headache

Physical Exam

  • Usually normal
  • Palpate pericranial muscles for tenderness
  • Neurologic exam to exclude other causes

Differential Diagnosis

  • Migraine, cluster headache
  • Cerebrovascular disease, temporal arteritis
  • Intracranial neoplasm, infection
  • Medication overuse, caffeine dependency
  • Temporomandibular joint syndrome, cervical spondylosis

Diagnostic Tests

  • Labs and imaging not routinely required
  • Consider MRI/CT if red flags or atypical presentation
  • Headache diary helpful for tracking

TREATMENT

General Measures

  • Relaxation techniques, rest in quiet/dark room
  • Hot baths, neck and temple massage

Medications

First-Line

  • NSAIDs (ibuprofen, naproxen), aspirin, acetaminophen for episodic TTH

Prophylaxis

  • Amitriptyline first-line for chronic TTH (10 mg up to 100 mg QHS)
  • Consider if depression, anxiety, insomnia present

Second-Line

  • Caffeine combinations for episodic TTH
  • Ketorolac IM for severe attacks
  • Avoid opioids, butalbital-containing meds

Additional Therapies

  • Stress management + amitriptyline best for chronic TTH
  • Topiramate (limited evidence)
  • Alternative TCAs (nortriptyline, protriptyline)
  • Trigger point lidocaine injections; Botox evidence conflicting

Complementary & Alternative Medicine

  • Topical tiger balm, peppermint oil
  • Cognitive-behavioral therapy
  • EMG biofeedback, relaxation
  • Physical therapy, exercise
  • Acupuncture (some evidence)

ONGOING CARE

Diet

  • Identify and avoid dietary triggers
  • Maintain regular meals

Patient Education

  • National Headache Foundation and family doctor websites as resources

Prognosis

  • Most cases intermittent and improve with age

Complications

  • Medication-overuse headache
  • NSAID-induced GI bleeding
  • Dependence on narcotics

Clinical Pearls

  • Typical tension headache is bilateral, mild/moderate, nonthrobbing without other symptoms
  • NSAIDs are first-line abortive therapy; TCAs useful for prophylaxis though not FDA-approved
  • Consider further evaluation if atypical features or treatment failure
  • Avoid opioids or butalbital for recurrent headaches due to risk of MOH

References

  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
  2. Becker WJ, Findlay T, Moga C, et al. Guideline for primary care management of headache in adults. Can Fam Physician. 2015;61(8):670-679.
  3. Jackson JL, Mancuso JM, Nickoloff S, et al. Tricyclic and tetracyclic antidepressants for prevention of tension-type headaches: a systematic review and meta-analysis. J Gen Intern Med. 2017;32(12):1351-1358.
  4. Sun-Edelstein C, Mauskop A. Complementary and alternative approaches to tension-type headache treatment. Curr Pain Headache Rep. 2012;16(6):539-544.
  5. Varangot-Reille C, Suso-Martí L, Dubuis V, et al. Exercise and manual therapy for primary headache treatment: an umbrella and mapping review. Phys Ther. 2022;102(3):pzab308.
  6. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for prevention of tension-type headache. Cochrane Database Syst Rev. 2016;4(4):CD007587.