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Tension headache - diagnosis and treatment

In the fourth of our headache series, consultant neurologist Dr Nicholas Silver discusses tension headache

In the fourth of our headache series, consultant neurologist Dr Nicholas Silver discusses tension headache

Tension-type headache (TTH) is a frequently diagnosed yet poorly understood condition. It is generally regarded as a ‘featureless', bilateral headache that is never severe and does not limit physical activity.

The use of the term ‘tension' does not imply that the patient is suffering from mental tension or stress.

In clinical practice, the main aims are to:

• exclude underlying potentially serious pathology

• identify features that allow an alternative diagnosis of migraine to be made.

Clinical features

Characteristically, TTH:

• has at least three of the following pain characteristics

– bilateral location

– pressing or tightening (non-pulsatile) quality

– mild or moderate intensity

• is not aggravated by routine activity such as walking or climbing stairs

• is not associated with nausea

• is not attributed to another disorder.

In general, the pain of TTH:

• is a dull, aching and non-pulsatile feeling of tightness, pressure or constriction that may be band-like or patchy

• commonly spreads to the occiput and down into the neck, but location varies between individuals and it can affect any part of the cranium

• may or may not be associated with a degree of pericranial or neck muscle tenderness

• may feature pain that may last for hours or even days, and is usually bearable

• is different from migraine in that TTH lacks features of sensory sensitivity of any description, so absolutely no nausea and no sensitivity to light, sound or smell should be ‘allowed'

• never throbs and is not aggravated by routine physical activity

• has low impact when episodic and is usually managed satisfactorily by the patient

• when chronic, can have a significant impact on quality of life and socioeconomic cost.

41218432Features raising the possibility of, or indicating, an alternative diagnosis of migraine should be pursued (see box right).

Differential diagnosis

The important differential diagnosis is secondary headache due to underlying pathology. In particular:

• tumour

• giant cell arteritis

• high- and low-pressure syndromes.

One condition that is often misdiagnosed as chronic TTH is new daily persistent headache, characteristically:

• featureless bilateral pressure or constricting headaches

• patient will typically recall the actual day of onset of a headache that arrived out of the blue and persisted on a daily basis.

Tension-type headache and migraine

TTH may be part of a migraine spectrum.

• Factor analysis studies fail to find clinical features that distinguish the two conditions.

• Most migraine sufferers also have TTH.

• About 25% of TTH patients have migraine.

• Migraine may also cause pericranial muscle and neck tenderness.

• Routine physical activity exacerbates TTH in those patients who also have migraine.

• Photophobia, phonophobia, and nausea can be present in TTH where there is comorbid migraine.

• Migraine sufferers may experience TTH triggered by alcohol, cheese, chocolate and exertion.

• The early phase of migraine may resemble TTH, and patient reporting may be distorted by use of acute attack medication.

• Triptans abort TTH in patients with frequent migraine.


• Underlying mechanisms not understood.

• May run in families but is not clearly associated with any specific genotype.

• Previously considered to be related to sustained muscle contraction or secondary to emotion or mental stress, but now considered unlikely.

• Current consensus is peripheral pain mechanisms play some role in infrequent and frequent TTH, with central pain mechanisms including central sensitisation being more important in chronic TTH.

• It is not clear whether episodic and chronic TTH are part of the same disorder or separate entities. Amitriptyline is only effective for chronic and not episodic TTH.


Once a diagnosis of TTH has been established and other more sinister causes of headache excluded, reassurance is all that may be required. Treatment trials are limited by diagnostic difficulties.

Pharmacological treatment

41218431• Episodic TTH:

– Simple analgesics usually suffice. These include paracetamol and NSAIDs.

– Stronger opioid analgesics are not recommended.

– If the headaches escalate in frequency, it is advisable to change from acute attack to preventive strategies.

• Frequent or chronic TTH:

– Be alert for medication overuse headache.

– Eliminate concurrent medication prior to starting a preventive drug.

– As a general rule, preventive drugs should be introduced and increased slowly over a number of weeks to minimise adverse effects (see box).

Non-pharmacological therapies

In general the evidence base is poor.

• There is limited evidence that cognitive behaviour therapy (CBT) may help patients who are also facing stress, especially where previous response with pharmacological treatment has been poor.

• Regular exercise may be helpful.

• The evidence for physical therapy including oromandibular treatment is poor.

• There is little evidence to recommend other therapies such as acupuncture, EMG biofeedback, chiropractic, osteopathy or physiotherapy

Dr Nicholas Silver is a consultant neurologist at the Walton Centre for Neurology and Neurosurgery, Liverpool

This is an extract from Headache: a Practical Manual by Dr David Kernick and Dr Peter Goadsby, published by Oxford University Press, ISBN 978-0-19-923259-8. It is a handbook aimed at all healthcare professionals dealing with patients with headache. Available from bookshops or from

Drugs Migraine Tension headache

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