Tension-type headache

Last updated: September 11, 2023

Summarytoggle arrow icon

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.

Epidemiologytoggle arrow icon

  • 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.

Etiologytoggle arrow icon

  • The exact pathophysiology of tension headaches remains unknown.
  • Exacerbating factors: fatigue, lack of sleep, poor posture, anxiety, stress, depression [4]

Clinical featurestoggle arrow icon

  • 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.

Diagnosticstoggle arrow icon

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
  • ≥ 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

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

Differential diagnosestoggle arrow icon

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

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

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]

Acute management checklisttoggle arrow icon

Referencestoggle arrow icon

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  12. $Tension-type headache (TTH).
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