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  • Physician

Tension headaches


Tension-type headaches (TTH) are a primary headache disorder, occurring commonly in young females and usually precipitated by stress or lack of sleep. They are the most common type of headache and are typically described as bilateral, band-like, or vice-like. Nausea, vomiting, and photophobia, which are characteristic of migraines, are usually not present in the case of tension headaches. Tension headaches are classified as episodic TTH and chronic TTH, depending on the number of episodes that occur. While the episodic form may be treated with over-the-counter NSAIDs, it is important to avoid medication overuse headache in the case of the chronic form. Chronic tension headaches are predominantly treated with amitriptyline.


  • 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



Depending on the onset of headaches and their duration, tension headaches may be classified as:

  • Episodic tension headaches: 1–14 episodes of headaches per month
    • Infrequent type: at least 10 episodes occurring < 1 day/month (or ≤ 12 days/year)
    • Frequent type: at least 10 episodes occurring 1–14 days/month over the course of at least 3 months
  • Chronic tension headaches: episodes occur ≥ 15 days/month for more than 3 months


Clinical features

A tension headache has the following characteristics:

  • Episodic nature: headaches last 30 minutes to a couple days
  • Holocranial or bifrontal, dull headache (mild to moderate intensity)
  • Dull, pressing, non-pulsating ("vice"-like) quality
  • Headache does not increase with exertion.
  • No autonomic symptoms (vomiting, nausea, phonophobia, or photophobia) are present.



  • TTH is primarily a clinical diagnosis.
  • Additional tests are only required if any red flags suggestive of secondary causes of headache are present (see "Diagnostics" in headache).


Differential diagnoses

The differential diagnoses listed here are not exhaustive.


  • Medical therapy
  • Lifestyle and behavioral modification: regular exercise, adequate sleep, avoidance of stress, muscle relaxation exercises, treatment of depression

Prolonged use of NSAIDs for chronic tension headache may cause medication-overuse headaches. This precipitates a vicious cycle in which the patient unwittingly and unsuccessfully tries to manage his/her headache with ever-increasing doses of NSAIDs! References:[1]

last updated 03/30/2020
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