Tension Headache

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Tension headache is the most common type of primary headache, characterised by a bilateral, dull, pressing, or tightening pain, often described as a ‘band-like’ sensation around the head.

Aetiology

The exact cause is unknown, but tension headaches are believed to be linked to muscle tension and stress.

Pathophysiology

  • Involves increased sensitivity of pain pathways in the brainstem.
  • Chronic tension in pericranial muscles may contribute.
  • Emotional stress and poor posture may exacerbate symptoms.

Risk factors

  • Emotional stress (workplace, family, financial stress).
  • Poor posture leading to neck and scalp muscle tension.
  • Sleep deprivation.
  • Excessive screen time (computer, phone usage).
  • Dehydration.

Signs and symptoms

Tension headaches present with mild to moderate pain without significant disability.

Key Features:

  • Quality of pain: dull, pressing, tightening (non throbbing).
  • Location: bilateral (often in the forehead, temples, or back of the head).
  • Intensity: mild to moderate.
  • Duration: 30 minutes to several days.
  • No aggravation by physical activity: unlike migraines.
  • No nausea, vomiting, or significant photophobia/phonophobia: helps differentiate from migraines.

Investigations

  • Clinical diagnosis: based on history and symptom pattern.
  • Neuroimaging (CT/MRI): only indicated if red flags suggest secondary headache (e.g., sudden onset, neurological deficits, change in pattern).

Management

1. Acute Symptom Relief:

  • Paracetamol: 1g every 4–6 hours as needed.
  • NSAIDs (e.g., ibuprofen 400 mg): consider if paracetamol is ineffective.
  • Avoid opioid analgesia: to prevent medication-overuse headache.

2. Preventative Treatment:

  • Amitriptyline (low dose, 10–75 mg at night): considered for chronic tension type headache.

3. Lifestyle Modifications:

  • Regular sleep: maintain a consistent sleep schedule.
  • Stress management: cognitive behavioural therapy (CBT), relaxation techniques.
  • Exercise: regular aerobic activity can reduce headache frequency.
  • Posture correction: avoid prolonged desk work without breaks.
  • Hydration: prevents dehydration related headaches.

4. Referral to Specialist:

  • Consider if headaches are frequent and disabling despite treatment.
  • Neuroimaging if atypical features are present.
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