Tension-type Headache

Tension-type headache is characterized as a diffuse, dull pain or tightness around the forehead also called muscle contraction headache or stress headache. ICHD diagnostic criteria should be used to categorize the headache. Chronic tension-type headache at baseline, coexisting migraine disorder, and sleep disorders are associated with poor outcomes. A physician needs proper insight into provoking and preventing factors to best educate the patients.


  • Characterized as a diffuse, dull pain or tightness around the forehead.
  • Can also involve the back of the head and neck.
  • Not associated with any other symptom; nausea and vomiting.
  • Also called muscle contraction headache or stress headache.
  • Most commonly leads to fatigability, irritability and sleep disturbance amongst patients.


  • It is classified into 2 main types based on the frequency of headache
    • Episodic tension-type headaches (ETTH)

    • Can be an infrequent or frequent episodic headache.
    • Infrequent type occurs once or twice a month.
    • Frequent type occurs less than 15 days per month.
    • It usually starts slowly and progresses throughout the day.
    • It can last from 30 minutes to a week.
    • Chronic tension-type headaches (Chronic TTH)

    • Occurs more than 15 days a month for at least 3 months consecutively.
    • It starts slowly and lasts for days. The pain can exacerbate or ease as the day progresses, but it is always there.
      Tension-type Headache Infrequent ETTH
      • Less than 12 days/year
      Frequent ETTH
      • More than 12 days and less than 180 days/year
      • At least 10 episodes occurring more than 1 day and less than 15 days per month for at least 3 months
      Chronic TTH
      • More than 180 days/year
      • More than 15 days per month for at least 3 months
      Source: Tension type headache. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444224/


  • Most common type of headache and second most prevalent disorder worldwide.
  • Has a lifetime prevalence of 30% to 78% among the general population according to many different studies.
  • Occurs during the teenage years and persists as long as into the 6th decade of life.
  • More common in women, affecting them in a ratio of 3 women to every 2 men.


  • An important mechanism of headache in patients with TTH is the increased sensitivity of the pericranial facial muscles to pain.
  • Continuous nociceptive input from peripheral myofascial structures may induce central sensitization and thereby chronification of the headache.
  • Sensitization of second-order neurons at the level of the spinal dorsal horn or trigeminal nucleus play a major role in the pathophysiology of chronic tension-type headache.
  • The sensitization of supraspinal neurons is also seen.
  • There is decreased descending inhibition from supraspinal structures.
  • Chronic tension headaches lasting longer than 5 years tend to have a lower cortisol level.
  • Another mechanism of pain is decreased antinociception or inability of the body to stop painful stimuli to the supraspinal structures.

Etiology and Common Precipitating Factors

  • Stress due to sustained contraction of the face, scalp and neck muscles is the most important cause.
  • It can be triggered by;
    • Alcohol
    • Smoking
    • Squinting
    • Poor posture
    • Fatigue
    • Anxiety
    • Dehydration
    • Missing meals
    • Bright sunlight
    • Certain smells
    • Noise
    • Flu or cold
    • Sinusitis
    • Caffeine
    • Low iron levels

Diagnostic Criteria

International Classification of Headache Disorders Diagnostic Criteria for Tension-Type Headache
Criteria A:
  • <1 day/month (for Infrequent) or ≥1 but <15 days/month for ≥3 months (for frequent), and fulfilling criteria B-D.
Criteria B:
  • Headache lasting from 30 minutes to 7 days.
Criteria C:
  • At least 2 of the following characteristics:
    • Bilateral location
    • Pressing or tightening (non pulsating) quality
    • Mild or moderate intensity
    • Not aggravated by routine physical activity
Criteria D:
  • Both of the following:
    • No nausea or vomiting.
    • No more than 1 of photophobia or phonophobia.
Source: Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808. doi: 10.1177/0333102413485658. PMID: 23771276.

Differential Diagnosis

  • Acute Angle-Closure Glaucoma
  • Acute Subdural Hematoma
  • Brain Abscess
  • Acute Otitis Media
  • Subarachnoid Hemorrhage
  • Encephalitis
  • Cluster Headache
  • Meningitis
  • Migraine Headache
  • Sinusitis (Rhinosinusitis)
  • Ischemic and Hemorrhagic Stroke
  • Temporal Arteritis
  • Temporomandibular Joint Syndrome
  • Trigeminal Neuralgia


Treatment and Management

  • Treatment is directed at the cause.
  • Depends on the type, cause and frequency of headache.

Home remedies for all types include:

  • Applying heat or cold packs to the head.
  • Doing stretching exercises.
  • Massaging the head, neck or back.
  • Resting in a dark and quiet room.
  • Taking a walk.


  • Physical therapy
  • Cognitive Behavioral Therapy
  • Acupuncture
  • Various Local Injections
  • Relaxation Techniques
    • Deep breathing exercises
    • Yoga
    • Meditation
    • Progressive muscle relaxation
  • Biofeedback Method
    • Monitoring body functions such as muscle tension, heart rate and blood pressure and giving feedback.
  • Lifestyle Modifications
    • Improved sleep hygiene.
    • Smoking cessation.
    • Regular exercise.
    • Balanced diet.
    • Hydrate.
    • Decrease use of alcohol and caffeine.

Abortive Therapy

  • Simple and compound OTC analgesics containing caffeine.

Preventive Therapy

  • Tricyclic Antidepressants
    • Amitriptyline; 10-100 mg nightly
    • Nortriptyline; 25-75 mg nightly
    • Imipramine; 25-50 mg daily
  • Muscle Relaxants
    • Baclofen; 5-20 mg tid–qid
    • Carisoprodol; 350 mg bid (short-term use, subject to abuse)
    • Cyclobenzaprine; 5-10 mg bid
    • Tizanidine; 2 mg qid
  • Others
    • Memantine; 20-40 mg daily
    • SSRI/SNRI - Banzi 2015 Cochrane review showed none of these worked


  • Over-reliance on non-prescription caffeine-containing analgesics
  • Dependence on/addiction to narcotic analgesics
  • GI bleed from use of NSAIDs
  • Risk of epilepsy 4 times greater than that of the general population
  • Medication overuse headache
  • Overall quality of life is compromised
  • Absence from school and work
  • Decreased productivity at work
  • Inability to take part in physical activities


  • The prognosis is favourable in the general population.
  • 45% of adults with chronic headache were in remission when examined 3 years later.
  • Poor outcome was associated with
    • Chronic tension-type headache at baseline
    • Coexisting migraine disorder
    • Sleep disorders
    • Being single
  • Factors associated with remission were
    • Old age
    • Absence of chronic tension-type headache

Further Reading


  1. Tension headaches - Symptoms, causes, and treatment. (2002, March 27). WebMD. https://www.webmd.com/migraines-headaches/tension-headaches
  1. Tension headaches: Symptoms, causes, & treatments. (n.d.). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8257-tension-type-headaches
  1. Tension headache - Symptoms and causes. (2019, June 11). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/tension-headache/symptoms-causes/syc-20353977
  1. Tension-type headache. (2020, September 21). American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/tension-type-headache/
  1. Tension headache: Background, pathophysiology, etiology. (2021, July 12). Diseases & Conditions - Medscape Reference. https://emedicine.medscape.com/article/792384-overview#a6
  1. Tension type headache. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444224/
  1. Tension-type headache. AAFP American Academy of Family Physicians. https://www.aafp.org/afp/2002/0901/p797.html
  1. UpToDate. (n.d.). https://www.uptodate.com/contents/tension-type-headache-in-adults-pathophysiology-clinical-features-and-diagnosis
  1. The effect of autogenic relaxation on chronic tension... : Indian Journal of anaesthesia. (n.d.). LWW.https://journals.lww.com/ijaweb/Abstract/2005/49060/THE_EFFECT_OF_AUTOGENIC_RELAXATION_ON_CHRONIC.5.aspx
  1. 2.3 chronic tension-type headache. (n.d.). ICHD-3. https://ichd-3.org/2-tension-type-headache/2-3-chronic-tension-type-headache/
  1. Tension-type headache. (n.d.). Physiopedia. https://www.physio-pedia.com/Tension-type_headache#cite_note-:0-2