Chronic Tension-Type Headache

Chronic tension type headache is headache on 15 or more days per month for over 3 months, bilateral, pressing and of mild to moderate intensity. It is disabling, frequently complicated by medication overuse and mood disorder.

• Central sensitisation and impaired descending pain inhibition are central features.
• Common comorbidities: depression, generalised anxiety, insomnia, sleep apnoea, bruxism, neck pathology.
• Acute analgesic use over 10 to 15 days per month sustains the disorder.

Daily or near daily dull pressing headache, bilateral, lasting hours to continuous.

• Pericranial muscle tenderness; reduced sleep, poor concentration, fatigue.
• Mild photophobia or phonophobia or mild nausea (not more than one) may occur.
• Normal neurological examination.
• Differential diagnosis: medication overuse headache, chronic migraine, new daily persistent headache, cervicogenic headache, hemicrania continua, raised or low intracranial pressure, chronic sinus disease, temporomandibular disorder, depression, cerebral venous thrombosis, hypertension, intracranial space occupying lesion.
• Complications: medication overuse headache, depression, anxiety, disability, opioid dependence, gastric and renal injury from analgesics.

Clinical, supported by headache diary over 4 weeks and analgesic use calendar.

• Blood pressure, fundoscopy, neurological, neck and jaw examination.
• Full blood count, ESR, renal function, glucose; HIV serology and sleep assessment as indicated.
• MRI or CT if red flags, change in pattern, or poor response to adequate treatment.
• Screen for depression and anxiety using a short validated questionnaire.

Prophylaxis, withdrawal of overused analgesics and behavioural therapy.

• Supportive: structured sleep, regular exercise, relaxation training, cognitive behavioural therapy, biofeedback, stress management, posture correction.
• Pharmacological: amitriptyline 10 mg at night, increased by 10 mg every 1 to 2 weeks to 50 to 75 mg, continued for at least 3 months at effect. Alternatives: mirtazapine 15 to 30 mg at night; venlafaxine modified release 75 to 150 mg daily. For medication overuse: stop the overused analgesic abruptly, bridge with naproxen 500 mg twice daily for 2 weeks, expect worsening for 1 to 2 weeks. Avoid opioids and ergotamine.
• Procedures: physiotherapy, manual therapy, acupuncture where available, greater occipital nerve block with lidocaine 1 percent for short term relief.
• Special groups: pregnancy, avoid prophylactic drugs where possible and use non drug measures with paracetamol; elderly, start amitriptyline at 5 to 10 mg and watch for urinary retention, glaucoma and arrhythmia; children, behavioural therapy first.
• Red flags: change from usual pattern, new neurological signs, papilloedema, progressive course, systemic illness, immunosuppression, cognitive change.
• Follow-up: review at 4 weeks then every 2 to 3 months; taper prophylaxis after 6 months of control.