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Headache
7 notes available
1 Last Minute Review 2 Migraine 3 TTH, NDPH & Other Primary Headaches 4 Trigeminal Autonomic Cephalalgias 5 Secondary Headache Red Flags 6 Headache Pharmacology 7 Headache Mimics & Facial Pain
Clinical › Headache

TTH, NDPH & Other Primary Headaches

TTH, NDPH & Other Primary Headaches

What You'll Learn

  • Tension-type headache (TTH) is the most common primary headache worldwide — bilateral, pressing, mild-moderate, not worsened by activity
  • NDPH: daily and unremitting from onset — the patient can tell you the exact date it started (key diagnostic feature)
  • Hypnic headache: elderly patient + nocturnal headache waking from sleep + no autonomic features → first-line treatment is bedtime caffeine (safer and better tolerated in older adults); lithium is effective but second-line given its narrow therapeutic index in the elderly
  • Primary cough headache: always exclude Chiari I malformation with MRI brain before diagnosing
  • Thunderclap headache = SAH until proven otherwise — CT head → LP → CTA/MRA; it is a diagnosis of exclusion
  • Indomethacin response: absolute response is diagnostic for paroxysmal hemicrania and hemicrania continua; primary cough, exercise, sexual, and stabbing headaches are often treated with indomethacin after secondary causes are excluded (response is therapeutic, not diagnostic)
HighYield Pearls
  • TTH criteria: bilateral + non-pulsatile (pressing) + mild-moderate + NOT aggravated by routine activity + no nausea + photophobia OR phonophobia (only one, never both); chronic TTH = ≥15 d/mo × >3 mo
  • TTH preventive: amitriptyline first-line; mirtazapine, venlafaxine, NSAID prophylaxis alternatives; AVOID butalbital, opioids, and chronic combination analgesics (MOH risk)
  • NDPH: patient remembers the exact day headache began, unremitting from day 1, >3 mo — must exclude secondary causes (SIH/low CSF, CVT, GCA, RCVS, tumor, post-viral/COVID)
  • Primary cough HA: bilateral, seconds-30 min, with Valsalva — image to exclude Chiari I (#1 secondary cause) and posterior fossa pathology; indomethacin responsive
  • Primary exercise / sexual HA: image to exclude SAH, RCVS, dissection; treat with indomethacin or β-blocker
  • Hypnic (“alarm clock”) HA: strictly nocturnal, awakens patient, >50 yo, 15 min–4 hr → bedtime caffeine first-line (paradoxical); lithium, amitriptyline, melatonin alternatives
  • Indomethacin response: absolute response is diagnostic for paroxysmal hemicrania and hemicrania continua only. Primary cough, exercise, sexual, and stabbing headaches are often treated with indomethacin after secondary causes are excluded (response is therapeutic, not diagnostic)
  • MOH: ≥15 d/mo simple analgesics OR ≥10 d/mo triptans/ergots/opioids/combination/butalbital × >3 mo + preexisting headache disorder; treat by withdrawing offending agent + starting preventive as bridge
  • SNOOP red flags for secondary headache: Systemic symptoms, Neurologic deficit, Onset abrupt/thunderclap, Older >50, Pattern change / Positional / Progressive — exclude before labeling primary
  • Thunderclap HA: SAH until proven otherwise → CT → LP → CTA/MRA; also consider RCVS, dissection, CVT, pituitary apoplexy, SIH — “primary thunderclap” is a diagnosis of exclusion
🔍 Quick ReferenceClinical phenotype · Triggers / pattern · Treatment
Clinical phenotype
  • Bilateral pressing/tightening band-like, mild-moderate, no nausea → Tension-type headache
  • “I can tell you the exact day it started” — continuous from day 1, >3 mo → NDPH (new daily persistent headache)
  • Awakens patient from sleep nightly, >50 yo, 15 min–4 hr, no autonomic features → Hypnic (“alarm clock”) headache
  • Brief 1–10 second jabs in scattered locations, “ice pick” → Primary stabbing headache
  • Coin-shaped, sharply demarcated focal scalp pain → Nummular headache
  • Unilateral, continuous baseline + autonomic features + absolute indomethacin response → Hemicrania continua
  • Pericranial muscle tenderness on palpation, normal neuro exam → Tension-type headache
Triggers / pattern
  • Cough, sneeze, Valsalva → brief bilateral HA in older adult → Primary cough HA (rule out Chiari I)
  • Sustained physical exertion / running → bilateral pulsatile HA lasting minutes-hours → Primary exercise HA (rule out SAH/dissection)
  • Onset at orgasm, explosive → Primary headache associated with sexual activity (rule out RCVS/SAH)
  • Daily medication use ≥10–15 d/mo × >3 mo with worsening headache → Medication overuse headache (MOH)
  • Post-viral or post-COVID abrupt-onset persistent daily headache → NDPH
  • Stress, poor sleep, posture, jaw clenching → TTH triggers
  • Recurrent monthly nocturnal awakening at same time → Hypnic headache
Treatment / pearls
  • Amitriptyline first-line preventive → Chronic TTH
  • Bedtime caffeine first-line → Hypnic headache (paradoxical)
  • Indomethacin 25 mg TID → 75 mg TID with GI prophylaxis, absolute response → Paroxysmal hemicrania & hemicrania continua (diagnostic trial)
  • Indomethacin responsive → Primary cough, exercise, sexual, stabbing headaches
  • β-blocker preventive → Primary exercise & sexual headache
  • Withdraw offending analgesic + bridge with preventive → Medication overuse headache
  • NSAIDs / acetaminophen / ASA episodic; AVOID opioids & butalbital → TTH acute
  • Treat as migraine if migraine-like features (CGRP mAbs, gepants may help) → NDPH with migraine phenotype
Tension-Type Headache

Overview

  • Most common primary headache disorder; lifetime prevalence ~30–78%
  • Often underdiagnosed — many patients self-treat and never present to a physician
  • Pathophysiology is incompletely understood — peripheral myofascial mechanisms in episodic form; central sensitization in chronic form

ICHD-3 Diagnostic Criteria

  • At least 10 episodes fulfilling below criteria
  • Duration: 30 minutes to 7 days
  • At least 2 of the following 4 characteristics:
    • Bilateral location
    • Pressing or tightening (non-pulsating) quality
    • Mild or moderate intensity
    • Not aggravated by routine physical activity (walking, climbing stairs)
  • Episodic TTH (infrequent or frequent) — both of the following:
    • No nausea or vomiting
    • No more than one of photophobia or phonophobia (not both)
  • Chronic TTH — both of the following (ICHD-3):
    • No more than one of photophobia, phonophobia, or mild nausea
    • Neither moderate or severe nausea, nor vomiting

Subtypes

  • Infrequent episodic TTH: <1 day/month (<12 days/year)
  • Frequent episodic TTH: 1–14 days/month on average for >3 months (12–180 days/year)
  • Chronic TTH: ≥15 days/month for >3 months (>180 days/year)
  • Each subtype further specified ± pericranial tenderness

Examination Findings

  • Pericranial tenderness on manual palpation — most significant abnormal finding
  • Increased tenderness in temporalis, masseter, sternocleidomastoid, trapezius, and suboccipital muscles
  • Neurologic exam is normal — any focal findings mandate workup for secondary causes

Treatment

Acute Treatment

  • Simple analgesics: NSAIDs (ibuprofen 400–800 mg, naproxen 500 mg), acetaminophen 1000 mg
  • Aspirin 500–1000 mg is also effective
  • Limit use to <15 days/month to avoid medication overuse headache
  • Triptans are not indicated for pure TTH

Preventive Treatment (for Chronic TTH)

  • Amitriptyline 25–75 mg at bedtime — best-studied preventive; first-line
  • Other TCAs: nortriptyline (less sedating)
  • Mirtazapine, venlafaxine — second-line options
  • Non-pharmacologic: physical therapy, stress management, biofeedback, cognitive behavioral therapy

TTH vs. Migraine

Feature TTH Migraine
Location Bilateral Unilateral (60%)
Quality Pressing/tightening Pulsating/throbbing
Intensity Mild–moderate Moderate–severe
Activity Not aggravated Worsened by activity
Nausea/Vomiting Absent (episodic); mild nausea permitted in chronic Common
Photo/Phonophobia One only (not both) Both present
Aura Never ~25–30% of cases
Acute Tx NSAIDs only NSAIDs + triptans
Preventive Amitriptyline Multiple options (topiramate, propranolol, CGRP mAbs, etc.)
💎 Board Pearl
  • Episodic TTH allows photophobia OR phonophobia but not both — and no nausea/vomiting at all. Chronic TTH permits only one of: mild nausea, photophobia, or phonophobia (and never moderate/severe nausea or vomiting). If both photophobia and phonophobia are present with nausea → think migraine. The hallmark distinguishing feature is that TTH is NOT aggravated by routine physical activity.
  • Amitriptyline is the only preventive with strong evidence for chronic TTH.
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