The importance of a thorough history and examination in any patient with headache cannot be overestimated. It is essential to exclude other entities that present with nondescript headaches (secondary headaches), to recognize comorbid conditions (especially depression), and to establish whether the TTH coexists with migraine. A good history also affords an opportunity to discover trigger factors and to determine whether the headaches are being aggravated by overuse of medications. In most cases, particularly in patients with a long history of headaches and with nothing on enquiry or examination to suggest disease, the diagnosis of TTH can be made without special investigations—though clearly these should be done when necessary.

The very fact that the physician is taking an interest in the problem often has a therapeutic effect, particularly if the patient’s understandable concern about serious disease (e.g., brain tumor) can be allayed. Explanation is crucial. It may be helpful to couch this in terms of a disturbance of the brain’s pain-modulating mechanisms, so that normally innocuous stimuli are perceived as painful, with the secondary development of increased muscle tension, anxiety, and depression. It is usually better not to attribute the condition to a single mechanism such as “muscle spasm” or to employ the term “psychosomatic,” which is frequently perceived negatively by the patient. The patient should be told that cure of headaches is rare, but control is possible if both the physician and patient do their parts.

Few controlled trials of medication have been done in patients with TTH. Most medications used have long been on the market, and there is little incentive for pharmaceutical companies to test them systematically or to develop new ones for this purpose. There are more trials of nonpharmacologic treatment. Many of the earlier trials were done in patients with diagnoses made by inconsistent criteria, who may have been unwittingly overusing analgesics (5). In most studies, the response rates are similar between therapeutic modalities and difficult to distinguish from the placebo effect exerted by a caring therapist (Table 80-1).

Before starting treatment, it may be useful to have the patient keep a written record of the frequency and severity of attacks and of the medication consumed for them. This will establish a baseline against which to measure progress, may reveal headache triggers, and may unmask medication overuse (patients frequently underestimate their drug use and are surprised by what the figures show).

Analgesic overuse, long known to worsen migraine, may also increase the frequency of TTH and render it refractory to treatment. Narcotic, butalbital, and/or caffeine-containing analgesics are particularly likely to do this, but there is a growing tendency to implicate simple analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) as well. Triptans have been found useful for the TTH that occurs in people with migraine (3) and are also, when overused, capable of worsening headaches. Eliminating overuse of these medications is an important part of treatment.

Similarly, estrogenic hormones have long been implicated as potential exacerbators of migraine, but there is now evidence that they may also worsen TTH (4). The
sex hormones in general are neurosteroids, and estradiol serves as a nociceptive modulator in the brain. If in a patient with TTH there is any suggestion that oral contraceptives or hormonal replacement therapy may be worsening the situation, consideration should be given to a trial of discontinuation.