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.
- The exact pathophysiology of tension headaches remains unknown.
- Exacerbating factors: fatigue, lack of sleep, poor posture, anxiety, stress, depression
- Episodic nature
- Headaches last 30 minutes to a couple of days. 
- 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 (phonophobia or photophobia)
- No nausea, vomiting, or aura
- Palpation of muscles of the head may reveal increased pericranial tenderness.
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. 
Diagnostic criteria for tension-type headaches 
- At least two of the following:
- Dull, pressing, nonpulsating quality
- Mild to moderate intensity
- 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 
|Classification of tension-type headache |
|Characteristics||Infrequent episodic tension-type headache||Frequent episodic tension-type headache||Chronic tension-type headache|
|Frequency|| || || |
|Duration|| || || |
|Autonomic symptoms|| || |
Tension-type headaches may be difficult to differentiate from mild forms of migraine without aura, and some patients may have both disorders. 
See “Primary headaches” in “Differential diagnosis of headache.”
The differential diagnoses listed here are not exhaustive.
General principles 
Both pharmacologic and nonpharmacologic strategies can be used for the treatment of tension-type headache. In addition, any underlying conditions (e.g., depression) should be identified and treated.
- Episodic tension-type headache: NSAIDs (e.g., ibuprofen, aspirin) or acetaminophen
- Chronic tension-type headache; and frequent episodic type: consider prophylactic therapy (e.g., with amitriptyline).
- All types of tension-type headache:
Non-pharmacological therapy: Consider if there is a significant decrease in patient's quality of life.
- Lifestyle and behavioral modification (e.g., exercise, weight reduction)
- Psychobehavioral treatments (e.g., cognitive-behavioral therapy, relaxation training)
Avoid prolonged use (> 15 days/month) of NSAIDs for chronic tension headache, as this may cause medication overuse headaches. 
Episodic tension-type headache 
- One of the following NSAIDs:
- Ketorolac IM 
- Caffeine can be used in combination with ibuprofen or acetaminophen to augment the analgetic effect. 
- Counsel patient against taking acute pain medication for more than 15 days/month to avoid medication overuse headache.
Opioids are not recommended for tension-type headaches and increase the risk of developing medication overuse headache. 
Prophylactic therapy for chronic tension-type headache and frequent episodic tension-type headache 
- First-line: amitriptyline
- Second-line 
- SSRIs (e.g., venlafaxine )
Nonpharmacological treatment 
- Lifestyle and behavioral changes (identification and management of triggers)
- Reduction of caffeine intake
- Smoking cessation
- Stress reduction
- Sleep hygiene
- Physical activity
- Treatment of underlying conditions (e.g., depression)
- Additional nonpharmacological therapies include: 
- Relaxation training (e.g., progressive muscle relaxation)
- Cognitive behavioral therapy
- Physical therapy (including posture training, massage, spinal manipulation)
Acute management checklist
- Rule out red flags for headache and check for signs of high-risk headache. 
- Pharmacotherapy with NSAIDs, aspirin, or acetaminophen (see “Treatment” above) 
- Counsel patient against taking NSAIDs for more than 15 days per month.
- Recommend lifestyle and behavioral changes.