Tension headache

Overview

TTH is a clinical diagnosis of exclusion - red flags must be ruled out first. The exam question highlights that a child with headache, visual field defect, and growth failure points away from TTH.

•Thunderclap onset - suspect subarachnoid haemorrhage

•Fever, neck stiffness, photophobia - suspect meningitis/encephalitis

•New focal neurological signs, papilloedema - suspect raised ICP or space-occupying lesion

•Headache worsened by Valsalva - suspect raised ICP

•Morning headache worsening on waking - suspect raised ICP

•Headache + visual field defect + growth failure in a child - consider craniopharyngioma or pituitary lesion

🎯
Bitemporal superior quadrantanopia + short stature + headache = pituitary adenoma. Craniopharyngioma gives bitemporal INFERIOR quadrantanopia. Do not confuse the two.

Investigations

•TTH is a clinical diagnosis - investigations not routinely required

•Document: blood pressure, optic fundi (papilloedema), pericranial muscle tenderness

•Neuroimaging only if red flag features present - routine imaging is not indicated and does not alter management

Management

•Non-pharmacological (all patients): identify and address triggers (stress, dehydration, skipped meals, poor sleep, posture); regular aerobic exercise; treat co-existing anxiety/depression

•First-line (acute): paracetamol or ibuprofen - taken as early as possible after onset

•Avoid aspirin in children under 16 - risk of Reye syndrome

•Prophylaxis (chronic/frequent TTH): amitriptyline (low-dose, e.g. 10 mg nocte, titrating up) - off-label use; acts via central serotonergic and noradrenergic pathways

⚠️
Medication overuse headache (MOH): taking acute analgesia on ≥10 days/month for >3 months causes paradoxical daily headache. Counsel every patient not to use analgesia on more than 2 days per week.

Differential Diagnosis - Key Comparisons

TTH vs migraine vs raised ICP headache in children
FeatureTTHMigraineRaised ICP / SOL
QualityPressing/tightening, band-likePulsating/throbbingProgressive, often dull
LocationBilateralUnilateral (commonly)Variable
Nausea/vomitingNoneCommonCommon (morning vomiting)
AuraAbsentMay be present (5-60 min)Visual field defect (persistent)
Physical activityNot aggravatedAggravatedMay worsen with Valsalva
Associated featuresPericranial tendernessPhoto/phonophobia, auraPapilloedema, focal signs, growth failure

Feature	TTH	Migraine	Raised ICP / SOL
Quality	Pressing/tightening, band-like	Pulsating/throbbing	Progressive, often dull
Location	Bilateral	Unilateral (commonly)	Variable
Nausea/vomiting	None	Common	Common (morning vomiting)
Aura	Absent	May be present (5-60 min)	Visual field defect (persistent)
Physical activity	Not aggravated	Aggravated	May worsen with Valsalva
Associated features	Pericranial tenderness	Photo/phonophobia, aura	Papilloedema, focal signs, growth failure

Presentation (ICHD-3 Criteria)

Requires at least 2 of the following 4 pain characteristics, with no nausea/vomiting, and no more than one of photophobia or phonophobia.

•Quality - pressing or tightening (non-pulsating); 'band around the head'

•Location - bilateral

•Severity - mild to moderate; not prohibiting activity

•Activity - not aggravated by routine physical activity

•Duration - 30 minutes to 7 days (episodic); may be continuous in chronic TTH