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  • Physician

Tension-type headache (Tension headache)


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.


  • 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


Epidemiological data refers to the US, unless otherwise specified.


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


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]


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
  • ≥ 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)
  • 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.


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
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