Pain: Tension-Type-Headache (TTH)

Question 1

Pain: Tension-Type-Headache (TTH)

Background info: read card :-)

Answer 1

A primary headache disorder as classified by the international classification of headache disorders (ICHD‐III)

Most common type of headache

Exact pathophysiology unknown, often precipitated by mental stress and tension

Significant overlapping features with migraines but they are different disorders that can often co‐exist

May be episodic or chronic ( ≥15 days per month)

Prevalence around 80% (3% chronic)

More prevalent in women, declines with age

Question 2

Pain: Tension-Type-Headache (TTH)

Diagnosis: reard card :-)

Answer 2

A. Episodes fulfilling criteria B‐D. The frequency of the
episodes determine the TTH class.

B. Headache lasting from 30 min – 7 days

C. Headache has at least 2 of the following
characteristics:
◦ Bilateral location
◦ Pressing/tightening (non‐pulsating) quality
◦ Mild or moderate intensity
◦ Not aggravated by routine physical activity such as
walking or climbing stairs

D. Both of the following:
◦ No nausea or vomiting (anorexia may occur)
◦ No more than one of photophobia or phonophobia

E. Not attributed to another disorder

Question 3

Pain: Tension-Type-Headache (TTH)

Differences between TTH and Migraine in terms of
Quality of headache

Answer 3

TTH:
Pressing/tightening (nonpulsating)

Migraine:
Throbbing/pulsating (at least part of the time)

Question 4

Pain: Tension-Type-Headache (TTH)

Differences between TTH and Migraine in terms of
Severity

Answer 4

TTH:
mild to moderate

Migraine:
usually moderate to severe, although can be mild

Question 5

Pain: Tension-Type-Headache (TTH)

Differences between TTH and Migraine in terms of
Location

Answer 5

TTH:
bilateral

Migraine:
Usually unilateral (can be bilateral, especially in
children)

Question 6

Pain: Tension-Type-Headache (TTH)

Differences between TTH and Migraine in terms of
Frequency

Answer 6

TTH:
Episodic (< 15 days/month) or chronic (>= 15
days/month)

Migraine:
Episodic (< 15 days/month) or chronic (>= 15
days/month)

Question 7

Pain: Tension-Type-Headache (TTH)

Differences between TTH and Migraine in terms of
Duration

Answer 7

TTH:
30 min to 7 days

Migraine:
4 - 72 hours

Question 8

Pain: Tension-Type-Headache (TTH)

Differences between TTH and Migraine in terms of
Aggravated by physical activity

Answer 8

TTH:
No

Migraine:
Yes

Question 9

Pain: Tension-Type-Headache (TTH)
Differences between TTH and Migraine in terms of
Associated symptoms

Answer 9

TTH:
No nausea/vomiting (anorexia may occur)
Photophobia or phonophobia but not both

Migraine:
At least 1 of the following:
1. nausea and or vomiting
2. Photophobia and phonophobia

May occur with or without aura (usually visual)

Question 10

Pain: Tension-Type-Headache (TTH)

TTH Assessment:
Medical history &
Headache history - what to ask?

Answer 10

◦ Headache diary
◦ Age of onset, frequency, duration, severity, location
◦ Associated symptoms
◦ Precipitating, aggravating, and relieving factors
◦ Red flags

Question 11

Pain: Tension-Type-Headache (TTH)

Assessment and Management of patients with headache flowchart.

Answer 11

Look at flowchart on slide 67

Question 12

Pain: Tension-Type-Headache (TTH)

TTH – Red Flags:

Possible change in pain level, characteristics?

Answer 12

Severe/abrupt onset (“worst headache ever”)

Question 13

Pain: Tension-Type-Headache (TTH)

TTH – Red Flags:

Possible change in onset with age, characteristics?

Answer 13

Onset in middle age or older (> 40 years)

Question 14

Pain: Tension-Type-Headache (TTH)

TTH – Red Flags:

Possible Neurologic signs, characteristics?

Answer 14

stiff neck, focal signs, reduced consciousness

Question 15

Pain: Tension-Type-Headache (TTH)

TTH – Red Flags:

Possible Systemic signs, characteristics?

Answer 15

appears ill, fever, nausea/vomiting (not explained by migraine or systemic illness)

Question 16

Pain: Tension-Type-Headache (TTH)

TTH – Red Flags:

Significant change in pattern of headaches, characteristics?

Answer 16

increased frequency and/or progressive severity

Question 17

Pain: Tension-Type-Headache (TTH)

TTH – Red Flags:

Nocturnal occurrence or on awakening in the morning, characteristics?

Answer 17

if patient consistently has headache on awakening or is awakened by a headache, brain tumour is a possible cause; however, migraines sometimes occur on awakening

Question 18

Pain: Tension-Type-Headache (TTH)

TTH – Red Flags:

Onset with activities, characteristics?

Answer 18

Onset with exercise or sexual activity (may be benign or serious)

Question 19

Pain: Tension-Type-Headache (TTH)

TTH – Differential Diagnosis:

Primary headache types such as ___, ___, ___, ___

Answer 19

benign cough headache

benign exertional headache

cluster headache

cold‐stimulus headache

Question 20

Pain: Tension-Type-Headache (TTH)

TTH – Differential Diagnosis:

Infections such as ___ and ___

Answer 20

meningitis

encephalitis

Question 21

Pain: Tension-Type-Headache (TTH)

TTH – Differential Diagnosis:

___ (if left untreated, often leads to permanent
blindness)

Answer 21

Temporal arteritis

Question 22

Pain: Tension-Type-Headache (TTH)

TTH – Differential Diagnosis:

___, headache following stroke or transient ischemic
attack (TIA)

Answer 22

Cerebral ischemia

Question 23

Pain: Tension-Type-Headache (TTH)

TTH – Differential Diagnosis:

___ (originating from the neck)

Answer 23

Cervicogenic headache

Question 24

Pain: Tension-Type-Headache (TTH)

TTH – Differential Diagnosis:

___ due to sinus infection (fever, purulent nasal
discharge)

Answer 24

“Sinus” headache

Question 25

Pain: Tension-Type-Headache (TTH)

TTH – Differential Diagnosis:

___ (can be any drug!)

Answer 25

Medications

Question 26

Pain: Tension-Type-Headache (TTH)

What is the acronym for the signs of Stroke?

Answer 26

Face - is it drooping?
Arms - can you raise both?
Speech - is it slurred or jumbled?
Time - to call 9-1-1 right away

Question 27

Pain: Tension-Type-Headache (TTH)

Goals of Therapy (3)

Answer 27

• Relieve pain and associated symptoms (e.g., nausea/vomiting) so that patient can return to normal functioning
• Prevent recurrence of headache
• Prevent complication and adverse effects of drug therapy

Question 28

Pain: Tension-Type-Headache (TTH)

Non-pharm (5)

Answer 28

• Patient education and reassurance
• Avoid triggers (eg. Stress, foods, poor sleep habits, smoking)
• Ice pack
• Maintain adequate sleep pattern
• Rest in a dark, quiet room

Question 29

Pain: Tension-Type-Headache (TTH)

pharm
drugs?
how long can they be used?
is prophylaxis needed?

Answer 29

Treated with analgesics
◦ NSAIDs
◦ Ibuprofen, ASA, naproxen
◦ Acetaminophen

• not more than 15 days/month to avoid medication overuse headache (MOH)

Prophylaxis generally not needed but may be considered if severe, frequent (>2 attacks/week),
or analgesics contraindicated
◦ Examples: amitriptyline, mirtazapine, nortriptyline, venlafaxine

Question 30

Pain: Tension-Type-Headache (TTH)

Monitoring + F/U

when should there by relief of symptoms?

what should pt write in headache calendar? (5)

Answer 30

Relief of symptoms within 2 hours (with medication)

Advise patient to keep a headache calendar

• Headache severity
• Associated symptoms
• Frequency of headache
• Adverse reactions
• Use and efficacy of certain agents