a) Tension Type Headache

Type

There are two types:- Episodic TTH and chronic TTH (over 15 headache days per month, over 3 month duration)  
Practice Point
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Clinical Features

Tension type headache is generally an over diagnosed headache condition. Often what has been considered to be TTH is often migraine. Always consider if the patient has migrainous components to their TTH. If they have it is most likely to be migraine.
 
Typically TTH is a featureless generalised headache of mild to moderate severity. Features of photophobia, phonophobia visual or sensorimotor disturbance are absent. Mild nausea can occur, especially in the setting of analgesic overuse. Profound nausea, or vomiting should not occur.
It is often may be associated with other comorbidities such as depression.
 
 
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Management

Non-pharmaceutical
Reassurance
Address triggers/comorbidities- eg depression, anxiety, analgesic overuse
Acupuncture
Cognitive behavioural


Pharmaceutical

 
Acute treatments are not generally appropriate.


Tricyclics


Try amitrypiline, nortriptiline or imipramine many be less sedating.
Starting dose amitrypiline 10 mg and increase by 10mg each week. Max dose 100mg. In practice patients often can’t tolerate doses over 50mg


SNRI


SSRI
Little evidence


Practice Points
Prophylaxis
Patient compliance with medication can be relatively poor
 
Start in low dose, increase slowly, carefully explain the side effects.
 
Manage patient expectations. Patients otherwise may give up on the medication after an appropriately short period of time because of perceived lack of efficacy.
 
Explain that the prophylaxis medications are slow to take effect and that the starting dose is to make sure that they tolerate the medication, but that the dose increases are gradual and it can take a couple of months at least of weekly dose increases till an assessment of treatment efficacy can be made.
 
If prophylaxis helps the continue on the medication for approximately 6 months before slowly weaning to see if it is still required
 
Analgesic overuse is very important to address.

 
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