Tension-Type Headache

Tension type headache is the commonest primary headache, a bilateral, pressing, non pulsating headache of mild to moderate severity without significant nausea. The episodic form occurs on fewer than 15 days per month.

• Lifetime prevalence is high and peaks in the fourth decade.
• Contributors: stress, sleep deprivation, poor posture, eye strain, neck and jaw muscle tension, skipped meals.
• Peripheral sensitisation of pericranial muscles and central sensitisation are likely mechanisms.

Band like pressure or tightness, bilateral, lasting 30 minutes to 7 days, not worsened by routine activity.

• No nausea or vomiting; photophobia or phonophobia may be present but not both.
• Pericranial tenderness on palpation.
• Normal neurological examination.
• Differential diagnosis: migraine, cluster headache, cervicogenic headache, temporomandibular disorder, sinusitis, medication overuse headache, hypertension, raised intracranial pressure, refractive error, sleep apnoea, depression.
• Complications: progression to chronic tension type headache, medication overuse headache, work absence, anxiety and depression.

Clinical; at least 10 episodes meeting the pattern with a normal examination.

• Blood pressure, fundoscopy, neck and jaw examination, visual acuity.
• Investigations only when features are atypical: full blood count, ESR, glucose, HIV serology; CT or MRI for red flags.

Reassure, treat early with simple analgesia and limit use to avoid overuse headache.

• Supportive: regular sleep, hydration, regular meals, exercise, relaxation, heat or massage to neck, correction of posture and eyeglasses.
• Pharmacological: paracetamol 1 g, ibuprofen 400 mg, or aspirin 900 mg at onset; naproxen 500 mg alternative. Limit simple analgesics to under 15 days per month. For frequent episodic attacks: amitriptyline 10 mg at night, increased by 10 mg weekly to 30 to 50 mg. Avoid opioids and combination analgesics containing butalbital or codeine.
• Procedures: physiotherapy for neck; acupuncture where available; trigger point injection with lidocaine 1 percent for focal tender points.
• Special groups: pregnancy, paracetamol 1 g up to four times daily, non drug measures; children, paracetamol 15 mg/kg or ibuprofen 10 mg/kg; elderly, avoid NSAIDs in renal impairment, peptic ulcer or anticoagulation.
• Red flags: new headache over 50 years, thunderclap onset, fever or neck stiffness, papilloedema, focal deficit, progressive worsening, head injury, HIV with new headache.
• Follow-up: review in 4 to 6 weeks with headache diary; escalate if attacks reach 15 days per month.