Tension-Type Headache (TTH)

🔍 When to Suspect

Bilateral, non-pulsating headache of mild to moderate intensity, described as a dull pressure or a feeling of a tight band around the head

From the full topic in The Ocean Library: Tension-Type Headache (TTH)

🧭 When to suspect

Tension-type headache (TTH) is the most common primary headache and one of the most frequent presentations in general practice. It is a positive clinical diagnosis, not a diagnosis of exclusion.

Suspect it in a patient describing a headache that is:

• Bilateral

• Pressing or tightening (“band-like”)

• Mild to moderate in intensity

• Not aggravated by routine physical activity

• With no significant associated features

There is no diagnostic test – the diagnosis rests on the history, a normal examination, and the absence of red flags.

Classically the pain is featureless: no throbbing, no vomiting, and no aura.

• Mild sensitivity to light or sound (but not both) is permissible.

• Mild nausea may accompany chronic TTH.

Anything more should move migraine up your differential:

• Moderate or severe nausea

• Vomiting

• Photophobia and phonophobia together

• Throbbing pain made worse by activity

Two things matter most in primary care:

• Make the diagnosis positively so you can reassure with confidence.

• Decide whether the pattern is episodic or chronic – because that determines whether prophylaxis and a search for medication overuse are needed.

Pattern	Frequency (days of headache)	What it means in practice
Infrequent episodic TTH	< 1 day/month (< 12 days/year)	Usually self-managed with occasional simple analgesia.
Frequent episodic TTH	1–14 days/month for > 3 months	• Focus on triggers and lifestyle • Warn about medication overuse
Chronic TTH	≥ 15 days/month for > 3 months	Consider prophylaxis and actively screen for medication overuse headache.

Source: NICE CG150 · International Classification of Headache Disorders (ICHD-3)

🧠 Clinical pearl – if there are any migrainous features, it is not tension-type headache • NICE is explicit: where chronic migraine and chronic TTH overlap, the presence of any migraine feature (throbbing quality, aggravation by activity, nausea, or photophobia and phonophobia together) means you diagnose migraine, not TTH. • The distinction is not academic – it changes the whole treatment pathway (triptans for acute attacks and propranolol, amitriptyline or topiramate as prophylaxis for migraine, versus acupuncture for chronic TTH).

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