Medically Fit For Exams
Medically Fit For Exams

Tension-type headache


  • Common headache type associated with muscular tension and stress
  • Can present as episodic or chronic (>15 days per month)


Risk factors

  • Stress and anxiety
  • Depression
  • Neck and shoulder pain/musculoskeletal problems
  • Poor posture
  • Weak neck extension muscles


Differential diagnoses

  • Migraine
  • Medication overuse headache
  • Raised ICP/tumour
  • Temporal arteritis



  • Episodic TTH reported by up to 70% of people
  • Chronic TTH affects 1-3%
  • More common in women, 3:2 ratio



  • Pain is likely a result of contraction of scalp muscles in response to over-use during times of stress, or as a result of musculoskeletal problems


Clinical features

  • ‘Pressing’ or ‘tightness’ pain, that may be throbbing, but generally nonpulsatile
  • Often slower onset than migraine – over several hours
  • Bilateral
  • Fronto-occipital
  • Not aggravated by physical activity
  • No prodrome
  • No nausea/vomiting
  • May have phonophobia and photophobia
  • Insomnia
  • Neck and shoulder pain may be present
  • Duration 30 minutes to 7 days
  • Varying intensity



  • Muscular and psychogenic mechanisms, although the specifics not known



  • Clinical diagnosis
  • Neurological examination
  • Further investigations only if other pathology suspected



  • Lifestyle change: increase physical activity and reduce stress
  • Physiotherapy
  • Cognitive therapy and relaxation therapy
  • Over the counter drug therapies are usually effective
    • Aspirin and ibuprofen are more effective than paracetamol
  • Prescribed NSAIDS such as naproxen and ketoprofen may help
  • Amitriptyline for recurrent or chronic TTH
  • Codeine, dihydrocodeine and other opidates are not considered helpful



  • Chronic TTH can be disabling
  • Side effects of medication are likely to cause more harm than the TTH itself
  • 4x risk of epilepsy

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