• Clinical science
  • Physician

Tension-type headache (Tension headache)

Summary

Tension-type headache (TTH) is a primary headache disorder and the most common type of headache overall. Tension-type headaches are characterized by a dull, nonpulsating, band-like pain that is often bilateral. Autonomic symptoms like photophobia, phonophobia, or nausea are usually not present. Depending on the frequency and duration of episodes, tension-type headaches are classified as episodic or chronic. Infrequent episodic tension-type headaches are treated with NSAIDs, while chronic and frequent episodic forms may benefit from prophylactic amitriptyline. Nonpharmacological treatment options include lifestyle modification (e.g., stress reduction) and cognitive behavioral therapy.

Epidemiology

  • Most common type of headache
    • ∼ 70% of primary headaches
    • ∼ 50% of the population will have had at least one episode in their lifetime.
  • Sex: >
  • Peak incidence: 30–40 years
  • Ethnicity: increased prevalence in white populations

References:[1][2][3][4][5]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • The exact pathophysiology of tension headaches remains unknown.
  • Exacerbating factors: fatigue, lack of sleep, poor posture, anxiety, stress, depression

References:[6][2][7]

Clinical features

  • Episodic nature
  • Headaches last 30 minutes to a couple of days. [8]
  • Holocranial or bifrontal, band-like headache (mild to moderate intensity)
  • Dull, pressing, nonpulsating ("vice-like”) quality
  • Headache does not increase with exertion.
  • Maximum of one autonomic symptom (nausea, phonophobia, or photophobia)
  • No vomiting or aura
  • Palpation of muscles of the head may reveal increased pericranial tenderness.

References: [2]

Diagnostics

Tension-type headache is primarily a clinical diagnosis based on a history of typical features and normal neurological examination. Severe underlying conditions should be ruled out (see red flags for headache and “Diagnostics” in headache). A headache diary can be helpful to establish the diagnosis and guide management. [9]

Diagnostic criteria for tension-type headaches [8][9]

  • At least two of the following:
    • Dull, pressing, nonpulsating quality
    • Mild to moderate intensity
    • Bilateral
    • No increase in intensity with exertion
  • Not better explained by any other headache disorder
  • Categorized into three entities (which guide treatment); all criteria have to be fulfilled for the diagnosis [8]
Classification of tension-type headache [8]
Characteristics Infrequent episodic tension-type headache Frequent episodic tension-type headache Chronic tension-type headache
Frequency
  • ≥ 10 episodes
  • < 1 day/month or < 12 days/year
  • ≥ 10 episodes on 1–14 days/month
  • For > 3 months (≥ 12 and < 180 days/year)
  • ≥ 15 days/month
  • For > 3 months (≥ 180 days/year)
Duration
  • 30 minutes to 7 days
  • 30 minutes to 7 days
  • Hours–days; may be continuous
Autonomic symptoms
  • No nausea or vomiting
  • No more than one of photophobia or phonophobia
  • Only one of the following:
    • Photophobia
    • Phonophobia
    • Mild nausea
  • No moderate or severe nausea; no vomiting

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

General principles [8]

Both pharmacologic and non-pharmacologic strategies can be used for the treatment of tension-type headache. In addition, any underlying conditions (e.g., depression) should be identified and treated.

Avoid prolonged use (> 15 days/month) of NSAIDs for chronic tension headache, as this may cause medication overuse headaches. [8]

Pharmacological therapy

Episodic tension-type headache [9][10]

Prophylactic therapy for chronic tension-type headache and frequent episodic tension-type headache [9] [10]

Nonpharmacological treatment [11][9]

  • Lifestyle and behavioral changes (identification and management of triggers)
  • Treatment of underlying conditions (e.g., depression)
  • Additional nonpharmacological therapies include: [9]

Acute management checklist

  • Rule out red flags for headache and check for signs of high-risk headache. [8]
  • Pharmacotherapy with NSAIDs, aspirin, or acetaminophen (see “Treatment” above) [9]
  • Counsel patient against taking NSAIDs for more than 15 days per month.
  • Recommend lifestyle and behavioral changes.
  • 1. Kasper DL, Fauci AS, Hauser S, Longo D, Jameson LJ, Loscalzo J . Harrisons Principles of Internal Medicine . New York, NY: McGraw-Hill Medical Publishing Division; 2016.
  • 2. Olesen J. The International Classification of Headache Disorders 3rd Edition. https://www.ichd-3.org/. Updated January 1, 2016. Accessed April 2, 2017.
  • 3. Taylor FR. Tension-Type Headache in Adults: Pathophysiology, Clinical Features, and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/tension-type-headache-in-adults-pathophysiology-clinical-features-and-diagnosis. Last updated July 30, 2014. Accessed April 2, 2017.
  • 4. Giamberardino MA, Martelletti P. Comorbidities in Headache Disorders. Springer; 2016.
  • 5. Chowdhury D. Tension type headache. Ann Indian Acad Neurol. 2012; 15(5): pp. 83–88. doi: 10.4103/0972-2327.100023.
  • 6. Jenkins B, McInnis M, Lewis C. Step-Up to USMLE Step 2 CK. Lippincott Williams & Wilkins; 2015.
  • 7. Blanda M. Tension Headache. In: Tension Headache. New York, NY: WebMD. http://emedicine.medscape.com/article/792384-overview#showall. Updated May 11, 2016. Accessed April 2, 2017.
  • 8. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38(1): pp. 1–211. doi: 10.1177/0333102417738202.
  • 9. Bendtsen L, et al. EFNS guideline on the treatment of tension-type headache - Report of an EFNS task force. European Journal of Neurology. 2010; 17(11): pp. 1318–1325. doi: 10.1111/j.1468-1331.2010.03070.x.
  • 10. Steiner TJ, Jensen R, Katsarava Z, et al. Aids to management of headache disorders in primary care (2nd edition). The Journal of Headache and Pain. 2019; 20(1). doi: 10.1186/s10194-018-0899-2.
  • 11. Millea PJ, Brodie JJ. Tension-type headache. Am Fam Physician. 2002; 66(5): pp. 797–804. pmid: 12322770.
  • Agabegi SS, Agabegi ED. Step-Up To Medicine. Baltimore, MD, USA: Lippincott Williams & Wilkins; 2013.
  • Medication-overuse headache (MOH). url: https://ichd-3.org/8-headache-attributed-to-a-substance-or-its-withdrawal/8-2-medication-overuse-headache-moh/ Accessed November 3, 2019.
  • Tension-type headache (TTH). url: https://ichd-3.org/2-tension-type-headache/. Accessed November 3, 2019.
  • Rains JC, Penzien DB, McCrory DC, Gray RN. Behavioral Headache Treatment: History, Review of the Empirical Literature, and Methodological Critique. Headache: The Journal of Head and Face Pain. 2005; 45(s2): pp. S92–S109. doi: 10.1111/j.1526-4610.2005.4502003.x.
last updated 04/22/2020
{{uncollapseSections(['gwaFR5', '3waSi5', 'PTcWIb0', 'jwa_i5', 'Z3cZSX0', 'lwavQ5', 'Nwa-Q5', 'xh1ETg0'])}}