Tension Type Headache for Clinicians

Epidemiology

Tension-Type Headache (TTH) is the most common primary headache disorder with a mean global lifetime prevalence of 42% (Range 19-83%). Chronic tension-type headache affects 0.5 – 4.8 % of the worldwide population.

Clinical Features

TTH is characterised by mild-moderate and not severe, headache. It is bilateral and often described as pressing or tightening like a vice or tight band.

It typically lacks the specific features that characterise migraine such as nausea, light and noise sensitivity.

The headache is not aggravated by routine physical activity and this is a key criterion for diagnosis.

Duration of pain can be variable with a range from half an hour to several days. TTH on 15 or more days per month for at least 3 months is termed chronic TTH.

Disabling TTH is rare.  Most patients diagnosed with disabling TTH have migraine, and respond to triptans.

Management

Reassurance may suffice in the majority of patients.

Individual attacks can be treated with simple analgesics (see table).

ANALGESIC	SINGLE DOSE	MAXIMUM DAILY DOSE
Paracetamol	1000 mg	4000 mg
Aspirin	500-1000 mg (UK doses are 300-900 mg)	4000 mg (for oral dosing)

Preventive treatment is rarely necessary, though can be considered if symptoms are causing significant disability (see table).

Recommended preventive treatment in tension-type headache

DRUG	STARTING DOSE	TITRATION	MAXIMUM DOSE
Amitriptyline	10 mg	10-25 mg	150 mg

All acute treatments in tension-type headache

TREATMENT	SINGLE DOSE	MAX DAILY DOSE
Aspirin	500-1000 mg (UK doses are 300-900 mg)	4000 mg (for oral dosing)
Diclofenac	25-75 mg	150 mg
Ibuprofen	400 mg	2400 mg
Ketoprofen	50 mg	300 mg
Naproxen	250-500 mg	1000 mg
Paracetamol	1000 mg	4000 mg

All preventive treatments in tension-type headache

TREATMENT	STARTING DOSE	TITRATION	MAXIMUM DAILY DOSE
Acupuncture	6 treatment sessions
Amitriptyline	10 mg	10-25 mg	150 mg