Tension-Type Headache (TTH) ปวดศรีษะจากความเครียด

• ICD-10:
  • G44.2 – Tension-type headache
• ICD-11:
  • 8A81 – Tension-type headache
  • 8A81.0 – Infrequent episodic tension-type headache
  • 8A81.1 – Frequent episodic tension-type headache
  • 8A81.2 – Chronic tension-type headache

Overview

Tension-type headache (TTH) is a primary headache disorder characterised by dull, non-pulsating, bilateral pain often described as a “tight band” or “pressure” around the head. It represents the most prevalent type of headache worldwide and is a leading cause of decreased productivity and quality of life. TTH may occur episodically or become chronic when symptoms persist for more than 15 days per month over three months. The pain is typically mild to moderate in intensity and not aggravated by routine physical activity such as walking or climbing stairs.

Unlike migraine, TTH is usually not associated with nausea, vomiting, or sensitivity to light and sound. The disorder is thought to involve both peripheral and central mechanisms, including myofascial nociception from pericranial muscles and altered pain modulation within the central nervous system. Although benign, chronic TTH can lead to significant psychosocial burden, especially when associated with anxiety or depressive disorders. Diagnosis is clinical, based on ICHD-3 criteria, and neuroimaging is generally unnecessary unless atypical features are present.

Epidemiology

Tension-type headache affects approximately 40–70% of the global population at some point in their lives, making it the most common headache disorder. Lifetime prevalence ranges from 30% to 80%, with the highest prevalence between ages 20 and 50 years. Both sexes are affected, though women report a slightly higher prevalence than men, particularly for chronic forms.

Episodic TTH is much more frequent than chronic TTH. The Global Burden of Disease (GBD 2019) study ranked TTH as the second most prevalent neurological disorder after migraine, contributing substantially to years lived with disability (YLDs) worldwide. Risk factors include emotional stress, poor ergonomics, prolonged computer work, anxiety, depression, irregular sleep, and dehydration. Chronic TTH is often linked to psychological comorbidity and overuse of analgesics.

Pathophysiology

Clinical Presentation

Tension-Type Headache (TTH) presents as a bilateral, non-pulsating, pressing or tightening pain of mild to moderate intensity. Patients often describe the pain as a “band-like pressure” or “tightness” around the head, forehead, or occipital region. It may last from 30 minutes to several days. Unlike migraine, it is not aggravated by physical activity and is rarely associated with nausea or vomiting. Mild photophobia or phonophobia may occur, but not both. Muscle tenderness over pericranial regions is frequently found on palpation, especially in chronic cases.

Sign & Symptom	Pathogenesis	Frequency	Specificity
Bilateral dull, pressing, or tightening headache (“band-like” sensation)	Peripheral myofascial nociceptor activation and muscle tension	++++	+++
Mild to moderate pain, not aggravated by routine activity	Normal cerebral blood flow; absence of vasodilation seen in migraine	++++	+++
No nausea or vomiting	Lack of trigeminal–autonomic activation	+++	++++
Pericranial muscle tenderness on palpation	Myofascial hyperalgesia due to peripheral sensitisation	++++	++++
Mild photophobia or phonophobia (not both)	Central sensitisation affecting sensory processing	++	++
Sleep disturbance, fatigue, or stress-related worsening	Dysregulation of HPA axis and sympathetic overactivity	+++	++

Investigation

TTH is a clinical diagnosis. Investigations are mainly used to exclude secondary causes of headache when atypical features are present.

• Neuroimaging (CT/MRI): Indicated if red-flag symptoms (sudden onset, neurological deficits, seizures, systemic signs) are present.
• Laboratory tests: CBC, ESR, TSH may be performed if systemic or metabolic causes are suspected.
• Psychological assessment: Screening for anxiety, depression, or stress-related disorders is recommended in chronic cases.

Diagnosis Criteria (Dx)

Diagnosis is based on the International Classification of Headache Disorders (ICHD-3) criteria:

• At least 10 episodes occurring on <1 day per month (infrequent) or 1–14 days per month (frequent) for ≥3 months.
• Headache lasting from 30 minutes to 7 days.
• At least two of the following features:
  • Bilateral location
  • Pressing/tightening (non-pulsating) quality
  • Mild or moderate intensity
  • Not aggravated by routine physical activity
• Both of the following:
  • No nausea or vomiting
  • No more than one of photophobia or phonophobia
• Not better accounted for by another diagnosis.

Differential Diagnosis (DDx)

Disease	Distinguishing Features	Diagnostic Clues
Migraine	Unilateral, throbbing pain with nausea, photophobia, phonophobia; aggravated by activity	Responds to triptans; may have aura
Cluster headache	Severe unilateral orbital pain with autonomic symptoms (lacrimation, nasal congestion)	Short attacks (15–180 min), male predominance
Cervicogenic headache	Unilateral pain originating from neck; worsens with neck movement	Reduced cervical mobility; relief with occipital nerve block
Medication Overuse Headache (MOH)	Daily or near-daily headache in patients using analgesics excessively	History of chronic analgesic use; improves after withdrawal
Temporal arteritis	Throbbing temporal pain in elderly; scalp tenderness; jaw claudication	Elevated ESR/CRP; abnormal temporal artery biopsy

Treatment Overview

The management of Tension-Type Headache (TTH) focuses on symptom relief, prevention of chronicity, and improving quality of life. As the most common primary headache, TTH requires a multimodal approach that combines pharmacologic and non-pharmacologic therapy. Acute episodes are typically managed with simple analgesics, while chronic or frequent headaches necessitate preventive medications and behavioural modification.

For acute pain relief, NSAIDs (e.g. Ibuprofen, Naproxen) and Paracetamol remain first-line therapies. Caffeine combinations may enhance efficacy but should be used cautiously to avoid medication overuse headache (MOH). Opioids and barbiturate-containing agents are contraindicated due to dependency risk. If stress or muscle tension contributes significantly, muscle relaxants or anxiolytics may be considered short-term.

For chronic TTH, pharmacologic prevention using amitriptyline (a tricyclic antidepressant) is most effective. Other agents such as venlafaxine or mirtazapine may be used if intolerance occurs. Non-drug approaches — including cognitive behavioural therapy (CBT), relaxation training, physiotherapy, and ergonomic correction — play essential roles in reducing muscle tension and stress-related triggers. Education, sleep hygiene, and lifestyle modification remain integral to long-term success.

Pharmacology

Pharmacologic treatment in Tension-Type Headache (TTH) is divided into two main strategies: acute symptomatic therapy for relieving pain during attacks and preventive therapy to reduce frequency and severity of headaches. Appropriate use and limitation of medication are crucial to prevent rebound or medication overuse headache.

Drug Class	Example	Mechanism of Action	Dosage	Comments
Analgesic / Antipyretic	Paracetamol (Acetaminophen)	Inhibits central prostaglandin synthesis, modulating pain signals in CNS	500–1000 mg PO q6h prn (max 4 g/day)	First-line for mild TTH; minimal GI irritation
NSAIDs	Ibuprofen, Naproxen, Diclofenac	Inhibits COX enzymes → reduces prostaglandin-mediated inflammation	Ibuprofen 400 mg q6h or Naproxen 500 mg q12h	Preferred for moderate pain; caution in gastritis or renal disease
Muscle Relaxant	Tizanidine, Cyclobenzaprine	α2-adrenergic agonist reducing muscle tone and nociceptive input	Tizanidine 2–4 mg TID	Short-term adjunct in muscle-related TTH; may cause sedation
Antidepressant (TCA)	Amitriptyline	Inhibits serotonin and norepinephrine reuptake → enhances descending pain inhibition	10–75 mg HS (start low, titrate)	Most effective prophylactic for chronic TTH
SNRI / NaSSA	Venlafaxine, Mirtazapine	Enhances serotonergic and noradrenergic tone in CNS	Venlafaxine 75–150 mg/day	Alternative to TCA; better tolerability in some patients
Anxiolytic (short-term)	Diazepam, Clonazepam	Enhances GABA-mediated inhibition	Diazepam 2–5 mg HS	Used briefly in high-stress-induced TTH; avoid long-term use

Combination analgesics (e.g. paracetamol + caffeine) can be used for refractory acute attacks but must be limited to prevent dependence. Preventive therapy with antidepressants is indicated for chronic cases. The therapeutic effect may take 4–6 weeks, requiring patient education and adherence. For chronic refractory TTH, botulinum toxin A injections have shown modest benefit in selected patients.

Treatment Guideline

Evidence-based management of Tension-Type Headache (TTH) follows a stepwise approach recommended by the European Federation of Neurological Societies (EFNS) and Thai Neurological Society (2024).

1. Step 1: Acute (Abortive) Management
   
   • Use simple analgesics (Paracetamol or NSAIDs) at headache onset.
   • Avoid opioid or barbiturate-containing combinations.
   • Restrict medication use to <10 days/month to prevent medication overuse headache (MOH).
2. Step 2: Preventive (Prophylactic) Treatment
   
   • Indicated in patients with ≥10 headache days per month or chronic TTH (>15 days/month for >3 months).
   • First-line: Amitriptyline 10–75 mg at bedtime; titrate gradually to tolerance.
   • Alternatives: Venlafaxine or Mirtazapine if TCA not tolerated.
3. Step 3: Non-Pharmacologic Interventions
   
   • Stress management, relaxation therapy, and cognitive behavioural therapy (CBT).
   • Physiotherapy and posture correction to relieve myofascial tension.
   • Sleep hygiene and regular exercise improve long-term outcomes.
4. Step 4: Chronic / Refractory Cases
   
   • Consider OnabotulinumtoxinA injection (155 units, every 12 weeks).
   • Assess for psychiatric comorbidity and treat underlying anxiety or depression.

Follow-up every 2–3 months is recommended to assess response, adherence, and medication overuse. Headache diaries should be maintained to monitor frequency and triggers.

Example Doctor’s Orders

Prognosis

The prognosis of Tension-Type Headache is generally favourable. Most patients with episodic TTH respond well to simple analgesics and stress reduction. However, around 2–3% of the population may develop chronic TTH, characterised by daily or near-daily headaches lasting over three months.

Factors associated with poor prognosis include chronic stress, psychiatric comorbidity, poor sleep, and medication overuse. Early recognition and management with preventive therapy and lifestyle modification can significantly improve long-term outcomes. Regular follow-up and behavioural support reduce relapse and improve quality of life.

Prevention

• Maintain regular sleep and meal schedules.
• Perform neck and shoulder stretching exercises daily.
• Limit caffeine and avoid analgesic overuse (<10 days/month).
• Practice relaxation or mindfulness techniques.
• Ensure proper workstation ergonomics and avoid prolonged computer use.

Conclusion

Quiz (USMLE OSCE)

FAQ (Frequently Asked Questions)

Can stress alone cause Tension-Type Headache?

Yes. Emotional stress activates the hypothalamic–pituitary–adrenal axis, leading to muscle tension and pain sensitisation. Managing stress through relaxation, yoga, or meditation is crucial.

What is the difference between episodic and chronic TTH?

Episodic TTH occurs less than 15 days per month, whereas chronic TTH occurs ≥15 days/month for more than 3 months.

Is imaging necessary for diagnosis?

No. Diagnosis is clinical. Imaging (CT/MRI) is only indicated for red-flag symptoms such as sudden severe headache or neurological deficits.

Can caffeine help or worsen TTH?

In small doses, caffeine can enhance analgesic efficacy, but frequent use increases the risk of rebound headaches.

How long should preventive therapy be continued?

Prophylactic treatment (e.g. amitriptyline) should be continued for at least 6 months after symptom control, then tapered gradually under medical supervision.