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Tension-type headache

Last updated: November 26, 2020

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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 (nausea, phonophobia, or photophobia)
  • No 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
  • No nausea or vomiting
  • No more than one of photophobia or phonophobia
  • Only one of the following:
  • No moderate or severe nausea or vomiting

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]

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

Nonpharmacological treatment [5][7]

  • Lifestyle and behavioral changes (identification and management of triggers)
  • Treatment of underlying conditions (e.g., depression)
  • Additional nonpharmacological therapies include: [5]
  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).
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