Tension Headache

Definition

Tension headache, also known as tension-type headache (TTH), is a common type of headache characterised by a dull, aching pain that is often described as a tight band around the head. It is usually bilateral and can vary in intensity and duration.

Aetiology

The exact cause of tension headaches is not well understood. They are believed to be related to muscle tension, stress, and possibly changes in brain chemicals. Factors such as poor posture, eye strain, fatigue, and emotional stress can contribute to the development of tension headaches.

Pathophysiology

Tension headaches are thought to result from a combination of peripheral and central mechanisms. Muscle contraction in the head, neck, and scalp regions due to stress and tension may contribute to the pain. Additionally, central sensitisation within the nervous system may play a role, leading to an increased perception of pain.

Risk factors

• Stress and anxiety
• Poor posture
• Fatigue
• Eye strain
• Depression
• Lack of sleep
• Dehydration

Signs and Symptoms

• Dull, aching head pain
• Sensation of tightness or pressure across the forehead or on the sides and back of the head
• Tenderness in the scalp, neck, and shoulder muscles
• Often bilateral (on both sides of the head)
• Not aggravated by physical activity
• No associated nausea or vomiting

Red Flags

• Sudden, severe headache (thunderclap headache)
• Headache with fever, stiff neck, or rash
• Headache after a head injury
• New headache in individuals over 50
• Headache with neurological symptoms (e.g., weakness, vision changes)
• Headache that is progressively worsening over time

Investigations

• Clinical history and physical examination, focusing on the characteristics of the headache
• Neurological examination to rule out other conditions
• Neuroimaging (MRI or CT scan) if there are red flags or atypical symptoms
• Blood tests to exclude metabolic or infectious causes

Management

Primary Care Management:

• Over-the-counter pain relief (e.g., paracetamol 1000 mg or ibuprofen 400 mg)
• Tricyclic antidepressants (e.g., amitriptyline 10-25 mg at night) for chronic tension headaches
• Stress management techniques, including relaxation exercises, yoga, and biofeedback
• Physical therapy to address posture and muscle tension
• Cognitive-behavioural therapy (CBT) for stress and anxiety management
• Education on maintaining proper hydration, regular sleep patterns, and ergonomics

Example Management for Tension Headache:

A patient presenting with tension headaches may be advised to take paracetamol 1000 mg as needed, up to four times a day, for pain relief. If headaches are frequent or chronic, amitriptyline may be prescribed, starting at 10 mg at night and gradually increasing the dose based on response. Stress management techniques, such as relaxation exercises and physical therapy, can also be beneficial. Patients should be educated on maintaining good posture, staying hydrated, and ensuring adequate sleep.

References:

1. NICE. (2023). Headaches: Diagnosis and Management. Retrieved from https://www.nice.org.uk/guidance/cg150
2. NHS. (2023). Tension Headache. Retrieved from https://www.nhs.uk/conditions/tension-headache/
3. National Institute of Neurological Disorders and Stroke (NINDS). (2023). Tension Headache Information Page. Retrieved from https://www.ninds.nih.gov/Disorders/All-Disorders/Tension-Headache-Information-Page
4. O'Sullivan, S. B., & Schmitz, T. J. (2016). Physical Rehabilitation. 6th ed. F.A. Davis Company.
5. Ropper, A. H., & Samuels, M. A. (2019). Adams and Victor's Principles of Neurology. 11th ed. McGraw-Hill Education.