Definition

Tension-type headache (TTH), commonly known as tension headache, is the most frequently experienced type of headache by the general population and is not dangerous. TTH is a primary headache, meaning its exact cause is unknown (i.e. there is no specific disease-causing these headache symptoms). TTH is characterized by recurrent episodes of head pain with symptoms including pressing pain around the forehead or the back of the head extending to the neck, mild to moderate intensity on both sides of the head, and not influenced by activity. TTH can occur periodically (called episodic) with less than 15 days per month or daily (called chronic) if it occurs more than 15 days per month.

Causes

The exact cause of TTH is still unknown. TTH is classified as a primary headache, meaning its exact cause is not known. However, experts predict that some cases can be triggered by several factors, including:

• Stress from work
• School or other social relationship issues
• Emotional issues, depression, and anxiety
• Lack of rest and physical exhaustion
• Lack of exercise
• Hunger or dehydration
• Use of over-the-counter painkillers

Risk factor

Research has identified several factors that can trigger TTH, including stress, irregular meal times, fatigue, and lack of sleep. TTH is also associated with decreased activity, irregular sleep patterns, consumption of alcohol or caffeine, weather changes, and menstruation. Even dental pain, eye strain, and dehydration can trigger TTH. However, the main risk factors for most TTH cases are stress and mental tension.

Symptoms

Symptoms of TTH include:

• Sharp or dull head pain
• Pressing pain sensation around the forehead or back of the head extending to the neck
• Muscle tension in the head, neck, and shoulders

TTH is divided into two categories: episodic and chronic.

• Episodic TTH: This type can last from 30 minutes to one week, with a frequency of less than 15 days per month or at least within three months. Episodic TTH often becomes chronic.
• Chronic TTH: This type can last for hours or continuously. Chronic TTH occurs more than 15 days per month or at least within three months.

Diagnosis

Diagnosis of TTH is obtained through a detailed patient interview (anamnesis). A physical examination is usually performed to rule out other diseases that may cause TTH, and additional tests may help exclude other illnesses. Some questions that doctors may ask include whether the headache feels dull accompanied by a pressing or clamping sensation if the headache is usually felt on both sides of the head, and if the pain location can change, such as the forehead, neck, back of the head, or the right/left side of the head (temporal). The pain intensity can vary from mild to moderate. The duration of TTH ranges from 30 minutes to 7 days. Headaches can occur periodically or continuously. A distinctive feature of TTH is that symptoms are not influenced by activity, sound, or light, do not cause watery eyes, are not accompanied by nausea/vomiting, and are not associated with neurological disorders.

In physical and additional examinations of TTH, no abnormalities are found, such as no partial limb weakness, no loss of balance, and no vision or hearing disturbances. There is no fever, decreased consciousness, nausea, or vomiting.

Management

Treatment of TTH can be done with or without medication. Non-drug therapies include paying attention to diet and nutrition, physical therapy such as posture and position exercises, exercise, massage or hot/cold compresses, and trying acupuncture or transcutaneous electrical nerve stimulation (TENS).

For TTH that rarely recurs (episodic), pain relief medications such as paracetamol or ibuprofen, nonsteroidal anti-inflammatory drugs (NSAIDs), or aspirin can be given. However, aspirin should not be given to children under 16. In some cases, a combination of analgesics (pain relievers) with caffeine can be more effective, but side effects such as rebound headaches (causing the headache to return) may occur. TTH can also be treated with antidepressants like amitriptyline because most TTH is caused by stress and mental tension. If TTH recurs frequently, lasts long, and disrupts daily activities, doctors may prescribe antidepressants like amitriptyline to prevent chronic TTH.

Complications

TTH is not dangerous and has a high recovery rate. TTH is quite common, and the effects can impact work productivity and quality of life, especially in chronic TTH. The pain can prevent you from working and require you to stay home. Other complications of TTH can include dependence on painkillers and gastrointestinal bleeding from NSAID use.

Prevention

TTH can be prevented by maintaining regular eating patterns, balanced nutrition, regular exercise, regular and sufficient sleep, avoiding alcohol and caffeine, and avoiding smoking.

Additionally, there are exercises to reduce stress:

• Biofeedback: A training technique where you learn to control your body's responses to help reduce pain. During training, you are connected to a device that monitors and provides information about bodily functions. Here, you will learn how to reduce muscle tension, regulate heart rate, and control breathing patterns.
• Cognitive Behavioral Therapy (CBT): This type of therapy can help you manage stress and reduce the frequency and severity of headaches.
• Other Relaxation Techniques: Techniques such as yoga, meditation, and breathing exercises can help you stay relaxed. You can learn relaxation techniques in classes or at home using books, videos, or apps.

For TTH sufferers, it is recommended to record the occurrence and duration of headaches to help doctors assess frequency and prevent TTH from worsening. In some cases, antidepressants like amitriptyline can be given to prevent chronic TTH, although there is no definitive research proving their effectiveness.

When to see a doctor?

You should see a doctor immediately if you experience severe headaches that interfere with daily activities, headaches accompanied by decreased consciousness, blurred vision, nausea, vomiting, slurred speech, fever, or weakness in parts of the body.

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