Tension Type Headache: Symptoms, Causes and Treatments

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February 3, 2022
November 12, 2021
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Tension Type Headache: Symptoms, Causes and Treatments

Not everyone can experience every type of headache, but everyone can experience tension type headaches (TTH).  Epidemiologists estimate that 99% of the population experience tension type headaches at some point in their life, and some people can experience important subtypes.  It is rarely as debilitating as migraine or other headache subtypes, but is important to recognize and differentiate so it can be treated appropriately. 


What it is, and what it isn’t


TTH is almost better understood for what features it doesn’t have. As opposed to migraine, and many other headaches where the duration of a headache attack is specific, TTH attacks can vary from minutes to hours to days.  Although the classic description of TTH pain is dull, squeezing and vise-like, it can vary significantly as well and does not have to be consistent with a specific type of pain.  


There should not be any other symptoms associated with the headache pain, such as nausea, light or sound sensitivity or vertigo.  It should not be preceded by any neurological symptom like migraine aura precedes a migraine attack. And most importantly, it should not worsen with exertion.  


Subtypes of Tension Type Headache


The vast majority of TTH comes and goes episodically.  It is possible to experience 15 or more days of headache with TTH as well, and we call this chronic tension type headache.  We really only consider preventive treatments for chronic rather than episodic tension type headache.  


We also distinguish TTH that occurs with tenderness of the muscles around the head (pericranial tenderness) or not.  Your doctor might consider specific treatments for each of these different kinds of headaches. 


Work-Up 


Because TTH is less specific of a headache than most other headache disorders, some concerning medical problems can mimic TTH.  For this reason, it is actually more likely that your doctor will recommend imaging tests, such as an MRI, if your headache has fewer features than a typical migraine and appears to resemble TTH.  There is also a growing body of evidence in the medical literature that associates certain vitamin deficiencies with worsening TTH, and your doctor will likely recommend specific blood test that will look for these. 


Treatment 

 

The primary focus of TTH treatment is in the acute phase - stopping the headache when it comes.  Over the counter medications typically are effective enough for TTH attacks, and if you experience pericranial tenderness your doctor might also consider adding a muscle relaxant.  


There does not appear to be a “rebound effect” or medication overuse associated with TTH - the effect that increasing amounts of a specific medication can lead to more frequent headaches.  That said, most acute medications are not meant to be taken very frequently.  Frequent Tylenol use risks liver toxicity, most antiinflammatories can lead to stomach ulcers or kidney disease if taken to excess.  


Specific preventive medications can help chronic TTH, specifically two classes of antidepressants.  The tricyclic antidepressants, or TCAs are an older class of medication that is frequently used for migraine prevention, and other medications in this class can help TTH when it becomes chronic as well - such as imipramine.  The serotonin and norepinephrine reuptake inhibitors are another class of antidepressants that help migraine and chronic TTH, duloxetine (Cymbalta) and venlafaxine (Effexor) are most commonly used.  

If you'd like to speak with a neurologist specializing in headaches about how you can best prepare yourself and manage your headaches, join Neura Health today.

 

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Thomas Berk, MD
Thomas Berk is Medical Director at Neura Health and a Clinical Assistant Professor at the Department of Neurology at NYU Grossman School of Medicine
About the Author
Dr. Thomas Berk is Medical Director of Neura Health and a neurologist and headache specialist based in New York City. He has over 12 years of clinical experience, having graduated from the NYU Grossman School of Medicine in 2010. He completed his neurology residency at NYU as well and is a board-certified headache specialist, having completed a headache fellowship at the Jefferson Headache Center. He is an emerging leader of the American Headache Society and has been on the Super Doctors list of rising stars for the past five years.

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