ambossIconambossIcon
Start free trialLog in

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
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]

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

  1. Russell MB, Levi N, Saltyte-Benth J, Fenger K. Tension-type headache in adolescents and adults: a population based study of 33,764 twins.. Eur J Epidemiol. 2006; 21 (2): p.153-60.doi: 10.1007/s10654-005-6031-3 . | Open in Read by QxMD
  2. Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population--a prevalence study.. J Clin Epidemiol. 1991; 44 (11): p.1147-57.doi: 10.1016/0895-4356(91)90147-2 . | Open in Read by QxMD
  3. Schwartz BS, Stewart WF, Simon D, Lipton RB. Epidemiology of tension-type headache.. JAMA. 1998; 279 (5): p.381-3.doi: 10.1001/jama.279.5.381 . | Open in Read by QxMD
  4. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38 (1): p.1-211.doi: 10.1177/0333102417738202 . | Open in Read by QxMD
  5. 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): p.1318-1325.doi: 10.1111/j.1468-1331.2010.03070.x . | Open in Read by QxMD
  6. 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 . | Open in Read by QxMD
  7. Millea PJ, Brodie JJ. Tension-type headache.. Am Fam Physician. 2002; 66 (5): p.797-804.
  8. Agabegi SS, Agabegi ED. Step-Up To Medicine. Lippincott Williams & Wilkins ; 2013
  9. Lee SL, Ananthakrishnan S. Overview of follicular thyroid cancer. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-follicular-thyroid-cancer. Last updated: January 17, 2014. Accessed: January 26, 2017.
  10. Garza I, Schwedt TJ. Medication overuse headache: Etiology, clinical features, and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/medication-overuse-headache-etiology-clinical-features-and-diagnosis?source=search_result&search=medication%20overuse%20headache&selectedTitle=1~45. Last updated: December 15, 2014. Accessed: April 2, 2017.
  11. $Medication-overuse headache (MOH).
  12. $Tension-type headache (TTH).
  13. 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): p.S92-S109.doi: 10.1111/j.1526-4610.2005.4502003.x . | Open in Read by QxMD
  14. Rossi P, Lorenzo CD, Faroni J, Cesarino F, Nappi G. Advice Alone Vs. Structured Detoxification Programmes for Medication Overuse Headache: A Prospective, Randomized, Open-Label Trial in Transformed Migraine Patients With Low Medical Needs. Cephalalgia. 2006; 26 (9): p.1097-1105.doi: 10.1111/j.1468-2982.2006.01175.x . | Open in Read by QxMD
  15. Evers S, Jensen R. Treatment of medication overuse headache - guideline of the EFNS headache panel. Eur J Neurol. 2011; 18 (9): p.1115-1121.doi: 10.1111/j.1468-1331.2011.03497.x . | Open in Read by QxMD
  16. Altieri M, Di Giambattista R, Di Clemente L, et al. Combined Pharmacological and Short-Term Psychodynamic Psychotherapy for Probable Medication Overuse Headache: A Pilot Study. Cephalalgia. 2009; 29 (3): p.293-299.doi: 10.1111/j.1468-2982.2008.01717.x . | Open in Read by QxMD
  17. Krymchantowski A, Barbosa J. Prednisone as Initial Treatment of Analgesic-Induced Daily Headache. Cephalalgia. 2000; 20 (2): p.107-113.doi: 10.1046/j.1468-2982.2000.00028.x . | Open in Read by QxMD
  18. Wakerley BR et al.. Medication-overuse headache.. Pract Neurol. 2019; 19 (5): p.399-403.doi: 10.1136/practneurol-2018-002048 . | Open in Read by QxMD
  19. Kristoffersen ES, Lundqvist C. Medication-overuse headache: epidemiology, diagnosis and treatment.. Therapeutic advances in drug safety. 2014; 5 (2): p.87-99.doi: 10.1177/2042098614522683 . | Open in Read by QxMD
  20. Pascual J, Colás R, Castillo J, et al.. Epidemiology of chronic daily headache.. Curr Pain Headache Rep. 2001; 5 (6): p.529-36.doi: 10.1007/s11916-001-0070-6 . | Open in Read by QxMD
  21. Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem.. The Lancet. Neurology. 2004; 3 (8): p.475-83.doi: 10.1016/S1474-4422(04)00824-5 . | Open in Read by QxMD
  22. Da Silva AN, Lake AE. Clinical Aspects of Medication Overuse Headaches. Headache: The Journal of Head and Face Pain. 2013; 54 (1): p.211-217.doi: 10.1111/head.12223 . | Open in Read by QxMD
  23. Katsarava Z, Obermann M. Medication-overuse headache. Curr Opin Neurol. 2013; 26 (3): p.276-281.doi: 10.1097/wco.0b013e328360d596 . | Open in Read by QxMD
  24. Créac’h C, Frappe P, Cancade M, et al. In-patient versus out-patient withdrawal programmes for medication overuse headache: A 2-year randomized trial. Cephalalgia. 2011; 31 (11): p.1189-1198.doi: 10.1177/0333102411412088 . | Open in Read by QxMD
  25. Tassorelli C, Jensen R, Allena M, et al. A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study. Cephalalgia. 2014; 34 (9): p.645-655.doi: 10.1177/0333102414521508 . | Open in Read by QxMD
  26. Tepper SJ. Medication-Overuse Headache. CONTINUUM: Lifelong Learning in Neurology. 2012; 18: p.807-822.doi: 10.1212/01.con.0000418644.32032.7b . | Open in Read by QxMD
  27. Drucker P, Tepper S. Daily sumatriptan for detoxification from rebound.. Headache. 1998; 38 (9): p.687-90.doi: 10.1046/j.1526-4610.1998.3809687.x . | Open in Read by QxMD
  28. Krymchantowski AV, Moreira PF. Out-patient detoxification in chronic migraine: comparison of strategies.. Cephalalgia. 2003; 23 (10): p.982-93.doi: 10.1046/j.1468-2982.2003.00648.x . | Open in Read by QxMD
  29. Pageler L, Katsarava Z, Diener H, Limmroth V. Prednisone vs. Placebo in Withdrawal Therapy Following Medication Overuse Headache. Cephalalgia. 2007; 28 (2): p.152-156.doi: 10.1111/j.1468-2982.2007.01488.x . | Open in Read by QxMD
  30. Diener H-C, Bussone G, Oene JV, Lahaye M, Schwalen S, Goadsby P. Topiramate Reduces Headache Days in Chronic Migraine: A Randomized, Double-Blind, Placebo-Controlled Study. Cephalalgia. 2007; 27 (7): p.814-823.doi: 10.1111/j.1468-2982.2007.01326.x . | Open in Read by QxMD
  31. Rizzato B, Leone G, Misaggi G, Zivi I, Diomedi M. Efficacy and Tolerability of Pregabalin Versus Topiramate in the Prophylaxis of Chronic Daily Headache With Analgesic Overuse. Clin Neuropharmacol. 2011: p.74-78.doi: 10.1097/wnf.0b013e318210ecc9 . | Open in Read by QxMD
  32. Silberstein SD, Blumenfeld AM, Cady RK, et al. OnabotulinumtoxinA for treatment of chronic migraine: PREEMPT 24-week pooled subgroup analysis of patients who had acute headache medication overuse at baseline. J Neurol Sci. 2013; 331 (1-2): p.48-56.doi: 10.1016/j.jns.2013.05.003 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer