Tension Type Headache (TTH) is NOT Migraine

Tension type headache (TTH) is one of the most prevalent headache among population. Typical presentation of tension type headache (TTH) is bilateral, non throbbing headache without other symptoms of migraine. So it is important to differentiate TTH from migraine. Like migraine headache, tension type headache is also popular among women.

Classification of Tension Type Headache (TTH)

There are 3 main subtypes of TTH;

Infrequent episodic TTH – patients experience headache episodes less than one day per month.

Frequent episodic TTH – patients experience headache episodes 1 to 14 days a month.

Chronic TTH – having headache episodes 15 or more days a month.

Pathophysiology

Exact mechanism for tension type headache is unknown. There are environmental influences for episodic types. Usually genetic factors play a major role for developing the chronic TTH. But those genetic factors has low profile of involvement when compared to migraine.

Activation of myofascial nociceptors is the most likely cause for TTH. It causes activation of pain pathways in central nervous system and develop typical headache.

Clinical Features

Usual presentation is mild to moderate intensive, bilateral non throbbing headache without other typical symptoms of migraine. Many patients describe this headache: ‘dull’, ‘band like’, or ‘heavy weight on their head and shoulders ‘.

So you may feel pain in both sides of your head. And without throbbing or pulsatile type. But rarely it may be unilateral and throbbing.

Most important symptom of tension type headache (TTH) is increased pericranial muscle tenderness. Pericranial muscles are attached to your face, head and neck. You may feel severe pain when you touch those muscles. It is very important to diagnose TTH.

Pericranial Muscle Tenderness

There is tenderness in head, neck or shoulders. That means when you touch those areas you may feel severe pain. It is associated with both intensivity and severity of the headache. Usually migraine does not have pericranial muscle tenderness. So it is important to differentiate TTH and migraine.

Triggers for Tension Type Headache

Stress and mental tension are the most common triggers for tension type headache (TTH). Apart from that some food items, hunger and odor also can trigger TTH. Frequent head movement is also a precipitating factor.

Relationship with Migraine

As you know, migraine is a common episodic headache in world. You may feel throbbing type headache in one side of your head together with nausea and vomiting. Most of the time it is associated with photophobia or phonophobia. Sometimes clinicians mistakenly diagnose TTH as migraine. But if you know the different symptoms of both conditions it is very easy to diagnose.

According to several studies both migraine and TTH are related conditions. Migraine can precipitate TTH in individuals who has both types of headache. Also the severity and duration of TTH episodes are higher in patients with migraine than patients without migraine.

Diagnosis

Diagnosis of tension type headache (TTH) is very much like in migraine. It is a clinical diagnosis. Which means doctors can diagnose TTH with the symptoms you have. There are no special investigations.

But your headache may always not be due to migraine or TTH. Sometimes patients are coming with very severe headache without any past experience. At that time we have to do neuroimaging studies such as CT or MRI brain. Because it might be a serious condition. But usually those investigations are not needed.

For your knowledge here are some instances which we do neuroimaging in headache patients;

• An unexplained abnormality in neurological examination.
• Atypical headache features which are not in the other primary headache disorders.

Some patients may experience sudden ‘thunderclap’ like headache. They usually describes it as the most severe headache they experienced ever. In this situation we have to do a CT scan. Because this is the usual presentation of subarachnoid hemorrhage in the brain due to the rupture of aneurysm.

Usually blood tests have a lesser effect in the diagnosis of headache disorders. But it is better to do lipid profiles and fasting blood sugar levels as high levels of cholesterol and sometimes glucose can cause headache.

Treatment

Treatment of Tension Type Headache (TTH) has two separate entities. Acute management and preventive treatment as in migraine. Unfortunately there are limited treatment options as there is lack of scientific understanding.

Acute treatment of tension type headache (TTH)

The headache in TTH is not much severe than that of in migraine. There are non pharmacological and pharmacological therapies in acute attacks.

Following are some acute pharmacological treatment options.

• Simple analgesics such as paracetamol, non-steroidal anti inflammatory drugs (NSAIDS) are commonly used drugs. Paracetamol has less effect than NSAIDS. So NSAIDS are the mainstays of acute TTH treatment. But they have some side effects such as gastric irrigation. Ibuprofen and Diclofenac are common NSAIDS. All those drugs are over the counter medications.
• Aspirin is also very effective in TTH. Ketoprofen and Naproxen are some alternatives.
• Codeine is another drug which shows some benefits.
• Triptans like Sumatriptan are used to treat acute migraine headache. Some studies show those triptants are effective in treating TTH in patients with migraine.
• There are studies showing intravenous chlorpromazine and metoclopramide have benefits.
• Some clinicians practice muscles relaxants and trigger point injections. But available clinical data regarding those methods are very minimal.

There are several non pharmacological treatment options for TTH. But their effectiveness is a doubt. However many people are using them. Following are some examples;

• Applying heat or ice
• Massaging
• Cognitive behavioural therapy
• Relaxation techniques
• Acupuncture

But most of these non pharmacological treatment options are belong to preventive treatment options.

Preventive treatment of tension type headache (TTH)

Preventive therapy also ranges from drugs to non pharmacological therapies such as cognitive and behavioural therapy. Those are more benefitted in chronic TTH.

If you are having frequent and long lasting headache it is better to have prophylactic medications. There are several pharmacological agents.

• Tricyclic antidepressants such as Amitriptyline has a strong effect on TTH. Other than that, mirtazapine and venlafaxine are also useful.
• Topiramate is an anticonvulsant drug which is effective in treating TTH. Gabapentin is another example.
• There are some muscle relaxants such as tizanidine which is effective in treating TTH.

Botulinum toxin injections and trigger point injections are also common nowadays. But there are not enough clinical trials regarding them.

Non pharmacological interventions include behavioural and cognitive training, biofeedback and relaxation techniques. Combination of drugs and those non pharmacological interventions also show some better results.

Finally, as a summary Tension Type Headache (TTH) is headache in both sides without other typical symptoms of migraine. Pericranial muscle tenderness is an important clinical feature. It has few subtypes and treatment depends on them. It has some triggering factors as in migraine and treatment can be divided into acute treatment and preventive treatment.