Tension-type headache is the most prevalent primary headache disorder worldwide (lifetime prevalence 30–78%), characterized by bilateral, pressing/tightening, mild-to-moderate intensity pain that is not aggravated by routine physical activity. [1-3] Despite its high prevalence, TTH is frequently overdiagnosed in the ED — one study found only 5 of 211 patients discharged with a TTH diagnosis actually fulfilled ICHD-3 criteria, with 6.1% ultimately having a life-threatening disorder. [4]
1. History
- Quality: Bilateral, pressing or tightening ("band-like"), non-pulsating
- Intensity: Mild to moderate (not severe)
- Duration: 30 minutes to 7 days per episode
- Aggravating factors: Not worsened by routine physical activity (walking, climbing stairs) — this is a key distinguishing feature from migraine [5]
- Associated symptoms: No nausea or vomiting; may have photophobia OR phonophobia but not both [5-6]
- Frequency classification:
- Infrequent episodic: <1 day/month (<12 days/year)
- Frequent episodic: 1–14 days/month for >3 months
- Chronic: ≥15 days/month for >3 months [5]
- Key HPI questions: Onset timing, prior similar episodes, recent stressors, sleep changes, medication use (frequency of OTC analgesics), caffeine intake, trauma history
- Important negatives: No thunderclap onset, no fever, no focal neurologic symptoms, no visual changes, no neck stiffness, no weight loss
2. Alarm Features
Red flags warranting urgent workup (use the SNNOOP10 mnemonic): [7]
- Thunderclap onset (peak intensity in seconds) → SAH
- Fever + meningismus → meningitis/encephalitis
- Focal neurologic deficits → stroke, mass lesion, vascular malformation
- Papilledema → intracranial hypertension, mass lesion
- New headache in age >50 → giant cell arteritis, neoplasm
- Progressive or changing pattern → mass lesion, medication overuse headache
- Positional component → intracranial hypo-/hypertension
- Immunosuppression → opportunistic infection
- Impaired consciousness or seizure
- First or worst headache of life
- A single or first-time headache should always prompt evaluation for secondary causes [6]
3. Medications
Acute treatment:
- Ibuprofen 400 mg or acetaminophen 1,000 mg — first-line for acute episodes. Lower doses of acetaminophen are not effective. [3][6][8]
- Aspirin and combination analgesics with caffeine are also effective [3]
- Triptans are NOT effective for TTH unless the patient also has migraine [3]
Preventive treatment (for frequent episodic or chronic TTH):
- Amitriptyline 10–25 mg nightly — first-line preventive; benefits seen after 3 months [3][8]
- Mirtazapine 15–30 mg at bedtime — second-line [2-3]
- Venlafaxine up to 150 mg daily — third-line [2-3]
- OnabotulinumtoxinA is NOT effective for TTH (unlike chronic migraine) [8]
Medication cautions:
- Limit OTC analgesic use to ≤2 days per week (or ≤10 days/month) to prevent medication overuse headache (MOH) [6][9]
- NSAIDs: monitor for GI, renal, and cardiac risks with chronic use [6]
- Chronic TTH is associated with acute medication overuse [3]
4. Diet
- No specific dietary triggers are well-established for TTH (unlike migraine)
- Regular meals — skipping meals may contribute to headache [9]
- Adequate hydration — dehydration is a common headache precipitant
- Caffeine: moderate intake may help acutely (included in some combination analgesics), but excessive use or withdrawal can trigger headache
- Alcohol is a recognized precipitant in some patients [10]
5. Review of Systems
- Neurologic: Visual changes, focal weakness, numbness, speech difficulty, gait disturbance (to rule out secondary causes)
- Psychiatric: Anxiety, depression, sleep disturbance — strongly associated with chronic TTH [3][11-12]
- Musculoskeletal: Neck pain, jaw clenching, TMJ symptoms
- Ophthalmologic: Vision changes, eye pain (rule out glaucoma, refractive error)
- Constitutional: Fever, weight loss, night sweats (rule out infection, malignancy)
- ENT: Sinus pressure, nasal congestion (rule out sinusitis)
6. Collateral History and Family History
- Prior headache diagnoses and treatments tried
- Family history of migraine (TTH and migraine frequently coexist; migraine has a stronger genetic component) [5]
- Occupational and psychosocial stressors — stress and mental tension are the most common precipitating factors [10][12]
- Screen for domestic violence, substance use, and workplace ergonomics
- Medication history from pharmacy records (to assess for MOH)
7. Risk Factors
- Stress and mental tension — most conspicuous precipitating factor [10][12-13]
- Poor sleep quality/insomnia — particularly associated with chronic TTH [14-16]
- Anxiety and depression — strongly comorbid with chronic TTH [3][11-12]
- Sedentary lifestyle — higher prevalence of TTH in men with exclusively sedentary activity [10]
- Medication overuse — risk factor for chronification [3][5]
- Age 30–39 years — peak prevalence [3]
- Sex: TTH is slightly more common in men than women (unlike migraine) [3]
8. Differential Diagnosis
Cannot-miss diagnoses:
- Subarachnoid hemorrhage — thunderclap onset, worst headache of life
- Meningitis/encephalitis — fever, neck stiffness, altered mental status
- Intracranial mass/neoplasm — 23.5% of patients with intracranial malignancy present with TTH-like symptoms [3]
- Cerebral venous thrombosis — progressive headache, especially postpartum or with hypercoagulable state
- Cervical artery dissection — neck pain, Horner syndrome, focal deficits
- Giant cell arteritis (age >50) — jaw claudication, visual symptoms, elevated ESR/CRP [7]
- Idiopathic intracranial hypertension — obesity, visual obscurations, papilledema [3]
Common mimics:
- Migraine without aura — the most common diagnostic difficulty; distinguished by pulsating quality, moderate-severe intensity, aggravation by activity, nausea/vomiting, and both photophobia AND phonophobia [5]
- Medication overuse headache — headache ≥15 days/month with regular overuse of acute headache medications for >3 months [5]
- Cervicogenic headache — unilateral, associated with neck movement
- Sinusitis — facial pressure, purulent discharge, fever
- TMJ dysfunction — jaw pain, clicking, tenderness over TMJ
- Refractive error/eye strain
9. Past Medical History
- Prior headache types and frequency (headache diary is valuable) [5][9]
- History of head/neck trauma
- Depression, anxiety, or other psychiatric conditions
- Sleep disorders (insomnia, OSA)
- Fibromyalgia (shares pathophysiological features with chronic TTH) [12]
- Prior neuroimaging results
- Medication list with focus on analgesic frequency
10. Physical Exam
- Vital signs: Blood pressure (hypertensive emergency can cause headache), temperature (fever → secondary cause)
- Neurologic exam: Must be normal in TTH — cranial nerves, motor, sensory, reflexes, coordination, gait. Any focal deficit mandates further workup [3][7]
- Fundoscopy: Assess for papilledema (intracranial hypertension) [3]
- Pericranial tenderness: The most significant abnormal finding in TTH — palpate frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius, and trapezius muscles bilaterally using small rotating movements with firm pressure. Score 0–3 per muscle to generate a total tenderness score. Tenderness increases with headache frequency and intensity. [5][12]
- Cervical spine: Range of motion, paraspinal tenderness
- TMJ: Palpation, range of motion, clicking
- Temporal arteries: Tenderness, reduced pulsation (if age >50)
11. Lab Studies
- No routine labs are needed for typical TTH with normal neurologic exam [7]
- If red flags present:
- ESR and CRP — if age >50 (giant cell arteritis) [7]
- CBC — infection, anemia
- BMP — metabolic derangement
- Blood cultures — if febrile
- Coagulation studies — if hemorrhage suspected
- Pregnancy test — reproductive-age women (changes differential and treatment)
- TSH — if chronic/atypical headache
- LP with opening pressure — if SAH suspected after negative CT, or if meningitis/IIH suspected [7][17]
12. Imaging
- Primary headache disorders without red flags or abnormal exam findings do NOT need neuroimaging [7]
- When indicated:
- Non-contrast CT head — first-line for emergent evaluation (thunderclap headache, suspected hemorrhage, mass effect) [7][17]
- MRI brain with/without contrast — preferred for less urgent concerning features (progressive headache, new neurologic symptoms, suspected neoplasm, infection, IIH) [3][7]
- CTA or MRA — if vascular pathology suspected (dissection, aneurysm, CVT)
- Consider MRI in patients >50 with new-onset TTH-like headache given risk of intracranial malignancy mimicking TTH [3]
The following figure outlines a systematic approach to headache evaluation:
13. Special Tests
- SNNOOP10 mnemonic — systematic screening tool for secondary headache red flags [7]
- ID Migraine screener — 3-question validated tool to distinguish migraine from TTH (disability, nausea, photophobia) [7]
- Total Tenderness Score (TTS) — manual palpation of pericranial muscles; recommended by ICHD-3 for subclassifying TTH [5][18]
- Headache diary — essential for tracking frequency, severity, medication use, and triggers; helps distinguish TTH from migraine and identify MOH [5][9]
14. ECG
- ECG is not routinely indicated for tension-type headache
- Consider ECG if:
- Hypertensive emergency with headache
- Syncope or presyncope associated with headache
- Concern for cardiac etiology (e.g., exertional headache with chest pain)
- Pre-treatment screening if starting medications with cardiac effects (e.g., amitriptyline — QT prolongation risk)
15. Assessment
- TTH is a clinical diagnosis based on ICHD-3 criteria — requires ≥10 episodes with characteristic features and absence of migraine-defining symptoms [5-6]
- The primary clinical challenge is distinguishing TTH from mild migraine without aura, as these frequently coexist [5]
- Chronic TTH (≥15 days/month) causes significant disability — average 27 missed workdays per year [3]
- Peripheral mechanisms (myofascial pain, trigger points) likely drive episodic TTH, while central sensitization contributes to chronification [2][11]
- Always consider secondary causes when headache is new-onset, changing in pattern, or accompanied by any red flag features [3-4]
16. Treatment Plan
Acute management:
- Ibuprofen 400 mg PO or acetaminophen 1,000 mg PO [6][8]
- Combination analgesics with caffeine are an alternative [3]
- Limit acute medication use to ≤2 days/week to prevent MOH [6]
Non-pharmacologic (all patients):
- Stress management, regular sleep hygiene, regular meals, regular physical activity [9][19]
- Manual therapy/physical therapy — modestly reduces TTH frequency [8]
- CBT, biofeedback, relaxation therapy — evidence-based adjuncts, especially for chronic TTH [3][9][19]
- Acupuncture — may be helpful [3]
Preventive pharmacotherapy (initiate when ≥10 attacks/month, significant disability, or chronic TTH):
- Amitriptyline 10–25 mg nightly (titrate as tolerated) — first-line; expect benefit after ~3 months [3][8]
- Mirtazapine 15–30 mg at bedtime — second-line [3]
- Venlafaxine up to 150 mg daily — third-line [3]
17. Disposition
Discharge criteria (vast majority of TTH patients):
- Normal neurologic exam
- No red flag features
- Pain adequately controlled
- Able to tolerate PO
Admission/observation criteria:
- Abnormal neurologic exam or red flag features requiring workup
- Intractable headache not responding to ED treatment
- Concern for secondary headache disorder pending imaging/LP results
- New neurologic findings
Specialist consultation triggers:
- Chronic daily headache refractory to first-line preventive therapy
- Diagnostic uncertainty (TTH vs. migraine vs. secondary cause)
- Medication overuse headache requiring structured withdrawal
- Abnormal neuroimaging findings → neurology or neurosurgery
18. Follow Up / Return Precautions
Follow-up timing:
- Episodic TTH managed with OTC analgesics: follow up with PCP if headaches increase in frequency or severity
- Chronic TTH started on preventive therapy: follow up in 4–6 weeks to assess tolerability, then at 3 months to evaluate efficacy [8]
- Headache diary should be maintained between visits [5][9]
Return precautions — instruct patients to return immediately for:
- Sudden severe "worst headache of life"
- Fever with stiff neck
- New weakness, numbness, vision changes, speech difficulty, or confusion
- Headache after head trauma
- Headache that is progressively worsening despite treatment
- Seizure
Expected recovery:
- Episodic TTH is self-limiting; most episodes resolve within hours with simple analgesics [20]
- Chronic TTH may require months of multimodal therapy before significant improvement [8][19]
- Educate patients that overuse of acute medications can paradoxically worsen headache frequency [6][9]
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