Tension-type headache is the most common type of primary headache. It is a pain or discomfort in the head, scalp or neck and is often associated with muscle tightness in these areas.
For most of the population, the first onset of TTH is before the second decade of life. The peak prevalence appears to be between 30- 39 years of age. The lifetime prevalence ranges between 30%- 78%. It is seen in both sexes with female preponderance. The studies show that there is slight decrease in the occurrence with advancing age.
|Number of days of headache||TTH type|
|<1 / month||Infrequent episodic|
|1-14 / month||Frequent episodic|
Diagnosis of TTH is confirmed if there are 10 episodes of any of the above headaches fulfilling the following criteria:
Pericranial tenderness by manual palpation.
Electromyogram and pressure algometry have limited clinical diagnostic value.
Rarely evidence based. Physical therapy is the most common form which includes relaxation and exercise programs, improvement of posture, hot and cold packs, ultrasound and electrical stimulation. Spinal manipulation is also extensively used. Patients with frequent attacks of TTH are often referred for acupuncture.
Cognitive behaviour therapy significantly improves the patients on measures of headaches, depression, anxiety and quality of life.
Oromandibular treatment with occlusal splints is an attractive option but lacks scientific data.
Biofeedback and relaxation training can be done to reduce the emotional and physiologic arousal that can trigger and exacerbate headache. Isometric strength training of the neck flexors correlates with decrease in pressure pain scores in patients with CTTH.
Simple analgesics like aspirin, acetaminophen are used.
Sometimes combination analgesics including caffeine can be more effective, but with frequent use side effects such as rebound headache may emerge.
Acute treatments to be limited to no more than twice per week as they can produce medication overuse headache and undesirable effects on liver, kidneys, GIT and other organs.
Tricyclic antidepressant amitriptyline is the mainstay in treatment of patients with CTTH.
Mirtazapine a tetracyclic antidepressant is reported to be effective in chronic TTH.
Centrally acting muscle relaxant tizanidine.
Botulinum type A toxin is sometimes used in patients with CTTH.
Calcitonin Gene Related Peptide receptor antagonism.
Antagonism of substance P and nitric oxide pathways.
TTH is the most prevalent primary headache type worldwide and is associated with significant disability.
Although the current diagnosis is primarily clinical and based on negative associations and by exclusion, a majority of individuals with TTH do not seek medical attention. Thus identifying the factors that characterize TTH as a specific entity has proven difficult.
The interactions between sleep quality, depression and headache and pain sensitivity provide an opportunity for multimodal therapeutic intervention.
For acute treatment, the most common interventions involve the use of simple analgesics. For preventive treatment, the best studied medicine is amitriptyline, but nortriptyline, mirtazapine, tizanidine, and other medications may be used. Future therapies should encompass the new status of knowledge in the pathophysiology of this disorder and may include CGRP receptor antagonism, as well as substance P and the nitric oxide pathways.
Author: Dr Priyadharshini V C Moorthy