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Tension type headache

Tension type headache

  • April 22, 2021

Tension-type headache (TTH) is the most prevalent form of primary headache in the general population but paradoxically it is the least studied of headaches.


The lifelong prevalence of headache is 96%, with a female are predominantly affected. The global active prevalence of tension-type headache is approximately 40% and migraine 10%. Studies from the western world have shown that absenteeism resulting from Tension-type headaches is considerable and can be as high as three times more than that seen in migraines.

Indirect cost of managing tension type headache is more than migraine!!!


  1. Tension-type headaches are more common in women than in men.
  2. The onset is more gradual than that of migraine, and the headache, once established, may persist with only mild fluctuations for days, weeks, months, or even years.
  3. Likely to occur in middle age and to coincide with anxiety, fatigue, and depression.
  4. Usually bilateral, with occipitonuchal, temporal, or frontal predominance, or diffuse extension over the top of the cranium.
  5. The pain is usually described as dull and aching, but questioning often uncovers other sensations, such as fullness, tightness, or pressure (as though the head were surrounded by a band or clamped in a vise) or a feeling that the head is swollen and may burst.
  6. Absence of the persistent throbbing quality, nausea, intolerance to light (photophobia), intolerance to sound (phonophobia), and clear lateralization as seen in migraine.
  7. Usually doesn’t seriously interfere with daily activities.
  8. Sleep is usually undisturbed, but the headache develops soon after awakening.

How Tension type headache occurs?

The exact mechanism for causation of tension-type headache is unknown. For a long time, it was postulated that it occurs as a result of excessive contraction of craniocervical muscles and an associated constriction of the scalp arteries. But it’s not scientifically proven yet.

The role of nitric oxide specifically by creating a central sensitization to sensory stimulation from cranial structures has been implicated in the genesis of tension-type headaches.

Treatment of Tension Headache

Making the correct diagnosis is the most important thing for patients to get benefitted. Emotional support and assurance by a specialist help these patients to allay concerns. They should be told that the control of their headache is possible and they should not lose hope.

A) Pharmacological therapy:

For patients with frequent episodic tension-type headaches, simple analgesics and NSAIDs are the mainstays in acute therapy. Aspirin (500 mg and 1000 mg), acetaminophen (1000 mg) are effective in acute therapy for TTH.

For recurrent attacks, Amitriptyline should be started on a low dose (10 mg to 25 mg per day) and titrated by 10-25 mg weekly till the therapeutic effect or the side effects appear. Significant clinical effect of Amitriptyline is usually seen by the end of one week and should be apparent by 3-4 weeks. If the patient does not show an improvement by 4 weeks of treatment, serious consideration should be given for alternatives. The common side effects of the drug are dry mouth and drowsiness. Most of the time patient avoid taking Amitriptyline thinking its antidepressant drug but concern physician should emphasize it that drug is given for pain relief to improve the compliance.

Usually, amitriptyline is continued for 6 months following which withdrawal is attempted. After withdrawal of drug, some patients continue to remain headache free while others start to have headaches again. These patients often require long term treatment.

Few  drugs like citalopram, sertraline, mianserine, fluvoxamine, paroxetine, velnaflaxine (extended-release), and a D2 antagonist sulpiride, but there are no robust data for recommending these agents yet

B) Non-pharmacologic management:

includes physical therapy and psychological treatment. Ideally, these should be tried in all patients as adjuncts to pharmacotherapy. These may however be more attractive to patients reluctant to use drugs.

  • Physical therapy: It is the most commonly used non-pharmacologic treatment of TTH. Its components include improvement of posture, relaxation, exercise programs, hot and cold packs, ultrasound, and electrical stimulation.
  • Psychologic therapy: This includes relaxation training, EMG biofeedback, and cognitive-behavioral therapy.

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