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MANAGEMENT OF TENSION-TYPE HEADACHES
Akhmadov Jakhongir Akmal ugli
Asian International University, Bukhara, Uzbekistan.
https://doi.org/10.5281/zenodo.15515709
Abstract. Tension-type headache (TTH) is the most prevalent form of primary headache,
often described as a bilateral, mild to moderate pain resembling a tight band around the head.
Despite its frequency, the underlying mechanisms remain inadequately understood. Management
typically involves a combination of lifestyle modifications, non-pharmacological methods, and
appropriate medication use. This article provides a detailed overview of current strategies for
both episodic and chronic TTH, focusing on prevention, treatment, and the integration of
pharmacologic and non-pharmacologic therapies.
Introduction
Tension-type headache (TTH) represents the most frequently diagnosed category of
primary headache. It is also known as a stress-related, psychogenic, or muscle contraction
headache. Patients often describe muscle sensitivity, which tends to increase with headache
frequency and intensity. TTH can be episodic—either frequent or infrequent—or chronic, based
on how often the headaches occur.
TTH is typically diagnosed by using criteria established by the International Headache
Society (IHS). Episodes can range from 30 minutes to several days and are generally
characterized by non-pulsating, bilateral pain that feels like pressing or tightening. These
headaches are not aggravated by regular physical activity and often do not include nausea or
vomiting, distinguishing them from migraines.
Treatment and Management
1. Episodic Tension-Type Headache (ETTH)
For managing ETTH, acute interventions are usually sufficient. Over-the-counter
analgesics like ibuprofen (400 mg) and acetaminophen (1,000 mg) are among the most effective
first-line treatments. Combined use of these drugs has shown better outcomes than using either
alone. In contrast, aspirin (500 mg) has not demonstrated significant superiority over placebo in
some studies.
Patients at risk of gastrointestinal issues or renal complications may be better managed
with acetaminophen rather than NSAIDs. Other NSAIDs such as naproxen sodium, ketoprofen,
and diclofenac have also been found effective, but overuse can lead to medication-overuse
headaches. Muscle relaxants are generally not recommended due to limited effectiveness and
risk of dependence.
Topical treatments, including peppermint oil (10% in ethanol), have been shown to
relieve pain in both children and adults, with results comparable to acetaminophen. This non-
drug approach is endorsed by several clinical guidelines for treating acute episodes of TTH.
2. Chronic Tension-Type Headache (CTTH)
Pharmacological Approaches
Chronic TTH, which often evolves from the episodic form, requires preventive strategies.
Amitriptyline, a tricyclic antidepressant (TCA), is the most widely studied and effective drug for
prevention. It is typically started at 10–25 mg daily, increasing gradually until the therapeutic
effect is achieved. Common side effects include dry mouth, sedation, and urinary retention. A
full response usually appears after 3–4 weeks of treatment.
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Other antidepressants such as mirtazapine and venlafaxine have shown some benefit,
though SSRIs and SNRIs appear less effective than TCAs for TTH. Anticonvulsants such as
gabapentin, topiramate, and sodium valproate have weaker evidence supporting their use.
Although botulinum toxin has shown some promise in reducing pain severity, it is not considered
a first-line therapy and may be reserved for treatment-resistant cases.
Non-Pharmacological Approaches
Non-drug interventions play a key role in managing chronic TTH. Effective methods
include cognitive behavioral therapy, acupuncture, biofeedback, physical therapy, and manual
joint mobilization. These therapies aim to reduce stress, correct posture, and relieve muscle
tension.
Strength-based neck and shoulder exercise programs have demonstrated benefits in pain
reduction and improved quality of life. Techniques such as transcutaneous electrical nerve
stimulation (TENS) and trigger point therapy have also shown efficacy in short-term symptom
relief.
Biofeedback—used alone or in combination with behavioral therapy—has proven useful
in lowering headache frequency. Acupuncture, especially when paired with exercise or manual
therapy, has shown positive outcomes in both episodic and chronic TTH cases. Furthermore,
massage therapy, particularly when combined with spinal manipulation, increases cervical range
of motion and reduces headache intensity.
Recent evidence also supports the use of moxibustion, warming acupuncture, and the
antidepressant Deanxit for symptom control. Techniques such as autogenic training, cervical
kinesitherapy, and posture correction exercises have demonstrated effectiveness in preventing
psychophysical contributors to chronic headaches.
Conclusion
Most individuals with TTH do not seek medical treatment unless the condition becomes
chronic or the headaches increase in frequency. The clinical diagnosis relies on symptom
exclusion and thorough history-taking, especially when neurological signs are absent. Coexisting
conditions such as migraines or medication-overuse headaches must be ruled out.
Chronic TTH can be challenging to manage but is responsive to an integrative treatment
approach. Preventive pharmacologic therapy, particularly with amitriptyline, combined with
non-pharmacologic interventions, offers the best outcomes. Attention to psychological
comorbidities and correction of analgesic overuse are also crucial for long-term success.
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