Tension-Type Headache — The World's Most Common Headache, Properly Managed

Recognizing the three TTH patterns

ICHD-3 divides TTH by frequency: infrequent (<1 day/month), frequent (1–14 days/month) and chronic (≥15 days/month for >3 months). Chronic TTH is the form most often seen in specialty clinics and most often entangled with medication overuse, sleep disturbance and mood factors. Photophobia or phonophobia may occur in chronic TTH but both together, with nausea, point toward migraine.

• Bilateral, pressing/tightening (non-pulsating) quality, mild-to-moderate intensity
• No vomiting; only mild nausea allowed; not aggravated by routine physical activity
• Pericranial tenderness on palpation supports diagnosis and tracks treatment response
• Chronic TTH (≥15 days/month) frequently coexists with medication-overuse headache

Management principles at the clinic

Infrequent TTH needs simple acute relief and reassurance. Frequent and chronic forms benefit from non-drug foundations — regular sleep, hydration, meals, exercise, stress management and physiotherapy-style attention to pericranial and neck muscles — with preventives considered when burden remains high. Amitriptyline has the best evidence among preventives for chronic TTH; it is introduced low-and-slow with explicit discussion of side effects. Acute-medication limits are set explicitly to prevent iatrogenic progression into MOH.

• Diary-based classification first — treat the right headache
• Address contributors: sleep apnea symptoms, posture and desk ergonomics, jaw clenching, caffeine patterns
• Simple analgesics only on limited days — never daily 'background' use
• Preventive discussion (e.g., low-dose amitriptyline) for chronic TTH with functional impact
• Follow-up with the same consultant to measure frequency trend, not just severity

Guidelines referenced:

• ICHD-3 tension-type headache criteria
• EFNS guideline on TTH management
• Ashina S et al. Tension-type headache. Nat Rev Dis Primers