Tension-type headache

Tension-type headache (TTH) is usually a dull, bilateral headache without accompanying symptoms. It is divided into three subtypes: infrequent episodic TTH (< 1 headache day per month), frequent episodic TTH (1–14 headache days per month), and chronic TTH (≥ 15 headache days per month). This division is highly relevant for three reasons. Firstly, impact on quality of life differs considerably between the three subtypes. Secondly, the pathophysiological mechanisms also differ. Peripheral mechanisms such as muscle tension are more important in episodic TTH, whereas central pain sensitization with reduced antinociceptive mechanisms are pivotal in chronic TTH. Thirdly, treatment differs between the subtypes, with symptomatic and prophylactic treatment being more appropriate for episodic and chronic TTH, respectively. Non-pharmacological management should always be part of the treatment. Patients with episodic TTH are treated with analgesics, while prophylactic drugs (in particular antidepressants) should be considered in patients with very frequent episodic or chronic TTH.