Last updated: September 11, 2023
- Most common type of headache
∼ 86% of the population will have had at least one episode in their lifetime. 
Sex: : ♀ > ♂ 
Peak incidence: 30–39 years 
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 
- Episodic nature
Headaches last 30 minutes to a couple of days. 
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. 
Diagnostic criteria for tension-type headaches 
- At least two of the following:
- Dull, pressing, nonpulsating quality
- Mild to moderate intensity
- 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 
| Classification of tension-type headache 
|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)
- 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. 
General principles 
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.
Non-pharmacological therapy: Consider if there is a significant decrease in patient's quality of life.
Lifestyle and behavioral modification (e.g., exercise, weight reduction)
- Psychobehavioral treatments (e.g., cognitive-behavioral therapy, relaxation training)
Avoid prolonged use (> 15 days/month) of NSAIDs for chronic tension headache, as this may cause medication overuse headaches. 
Episodic tension-type headache 
Opioids are not recommended for tension-type headaches and increase the risk of developing medication overuse headache. 
Nonpharmacological treatment 
- Lifestyle and behavioral changes (identification and management of triggers)
- Treatment of underlying conditions (e.g., depression)
- Additional nonpharmacological therapies include: 
Acute management checklist
- 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
- 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
- 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
- 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
- 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
- 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
- Millea PJ, Brodie JJ. Tension-type headache.. Am Fam Physician. 2002; 66 (5): p.797-804.
- Agabegi SS, Agabegi ED. Step-Up To Medicine. Lippincott Williams & Wilkins ; 2013
- 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.
- 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.
- $Medication-overuse headache (MOH).
- $Tension-type headache (TTH).
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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