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Tension-type headache

Last updated: April 22, 2022

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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.

  • Occurrence
    • Most common type of headache
    • ∼ 86% of the population will have had at least one episode in their lifetime. [1][2]
  • Sex: : ♀ > ♂ [2]
  • Peak incidence: 30–39 years [3]

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

References:[4]

  • Episodic nature
  • Headaches last 30 minutes to a couple of days. [4]
  • 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. [5]

Diagnostic criteria for tension-type headaches [4][5]

  • 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 [4]
Classification of tension-type headache [4]
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

Tension-type headaches may be difficult to differentiate from mild forms of migraine without aura, and some patients may have both disorders. [4]

See “Primary headaches” in “Differential diagnosis of headache.”

The differential diagnoses listed here are not exhaustive.

General principles [4]

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.

Avoid prolonged use (> 15 days/month) of NSAIDs for chronic tension headache, as this may cause medication overuse headaches. [4]

Pharmacological therapy

Episodic tension-type headache [5][6]

Opioids are not recommended for tension-type headaches and increase the risk of developing medication overuse headache. [5]

Prophylactic therapy for chronic tension-type headache and frequent episodic tension-type headache [5][6]

Nonpharmacological treatment [5][7]

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