Highlights & Basics
- Tension-type headaches (TTHs) can be either episodic or chronic.
- Stress and mental tension are common triggers.
- Symptoms include dull, nonpulsatile, bilateral, pressing/pressure-like pain (mild to moderate in intensity); pericranial tenderness is common but not invariable.
- Unlike migraine, there is no significant nausea, no vomiting, little or no photophobia or phonophobia, and a lack of aggravation by routine physical activity.
- Usually responds to simple analgesics; preventive treatments, including amitriptyline, venlafaxine, and mirtazapine, should be considered in patients with frequent episodic and chronic TTHs.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Citations
Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 Jan 25;38(1):1-211.[Full Text]
Ashina S, Mitsikostas DD, Lee MJ, et al. Tension-type headache. Nat Rev Dis Primers. 2021 Mar 25;7(1):24.[Abstract]
Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol. 2010 Nov;17(11):1318-25.[Abstract][Full Text]
Headaches in pregnancy and postpartum: ACOG clinical practice guideline No. 3. Obstet Gynecol. 2022 May 1;139(5):944-72.[Abstract]
Banzi R, Cusi C, Randazzo C, et al. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults. Cochrane Database Syst Rev. 2015;(5):CD011681.[Abstract][Full Text]
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;(4):CD007587.[Abstract][Full Text]
1. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 Jan 25;38(1):1-211.[Full Text]
2. Jensen RH. Tension-type headache - the normal and most prevalent headache. Headache. 2018 Feb;58(2):339-45.[Abstract]
3. Ashina S, Mitsikostas DD, Lee MJ, et al. Tension-type headache. Nat Rev Dis Primers. 2021 Mar 25;7(1):24.[Abstract]
4. Stovner Lj, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007 Mar;27(3):193-210.[Abstract][Full Text]
5. Russell MB, Levi N, Saltyte-Benth J, et al. Tension-type headache in adolescents and adults: a population based study of 33,764 twins. Eur J Epidemiol. 2006;21(2):153-60.[Abstract]
6. Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol. 2010 Nov;17(11):1318-25.[Abstract][Full Text]
7. Russell MB. Genetics of tension-type headache. J Headache Pain. 2007 Apr;8(2):71-6.[Abstract][Full Text]
8. Ligthart L, Huijgen A, Willemsen G, et al. Are migraine and tension-type headache genetically related? An investigation of twin family data. Twin Res Hum Genet. 2018 Apr;21(2):112-8.[Abstract][Full Text]
9. Russell MB, Ostergaard S, Bendtsen L, et al. Familial occurrence of chronic tension-type headache. Cephalalgia. 1999 May;19(4):207-10.[Abstract][Full Text]
10. Ulrich V, Gervil M, Olesen J. The relative influence of environment and genes in episodic tension-type headache. Neurology. 2004 Jun 8;62(11):2065-9.[Abstract]
11. Rains JC, Davis RE, Smitherman TA. Tension-type headache and sleep. Curr Neurol Neurosci Rep. 2015;15:520.[Abstract]
12. Silberstein SD. Tension-type and chronic daily headache. Neurology. 1993;43:1644-9.[Abstract]
13. Olesen J. Clinical and pathophysiological observations in migraine and tension-type headache explained by integration of vascular, supraspinal and myofascial inputs. Pain. 1991;46:125-32.[Abstract]
14. Bezov D, Ashina S, Jensen R, et al. Pain perception studies in tension-type headache. Headache. 2011;51:262-71.[Abstract]
15. Spierings EL, Ranke AH, Honkoop PC. Precipitating and aggravating factors of migraine versus tension-type headache. Headache. 2001 Jun;41(6):554-8.[Abstract]
16. Winter AC, Berger K, Buring JE, et al. Associations of socioeconomic status with migraine and non-migraine headache. Cephalalgia. 2012 Jan;32(2):159-70.[Abstract][Full Text]
17. American College of Radiology. Ten things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation. 2021 [internet publication].[Full Text]
18. Silva-Néto RP, Peres MF, Valença MM, et al. Accuracy of osmophobia in the differential diagnosis between migraine and tension-type headache. J Neurol Sci. 2014 Apr 15;339(1-2):118-22.[Abstract]
19. American College of Radiology. ACR Appropriateness Criteria® headache. 2022 [internet publication].[Abstract][Full Text]
20. American Academy of Neurology. Five things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation. 2022 [internet publication].[Full Text]
21. Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache. 2001 Jul-Aug;41(7):638-45.[Abstract][Full Text]
22. Stephens G, Derry S, Moore RA. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev. 2016;(6):CD011889.[Abstract][Full Text]
23. Derry S, Wiffen PJ, Moore RA, et al. Ibuprofen for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev 2015;(7):CD011474.[Abstract][Full Text]
24. Derry S, Wiffen PJ, Moore RA. Aspirin for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev. 2017;(1):CD011888.[Abstract][Full Text]
25. Headaches in pregnancy and postpartum: ACOG clinical practice guideline No. 3. Obstet Gynecol. 2022 May 1;139(5):944-72.[Abstract]
26. Weinman D, Nicastro O, Akala O, et al. Parenteral treatment of episodic tension-type headache: a systematic review. Headache. 2014 Feb;54(2):260-8.[Abstract]
27. Friedman BW, Adewunmi V, Campbell C, et al. A randomized trial of intravenous ketorolac versus intravenous metoclopramide plus diphenhydramine for tension-type and all nonmigraine, noncluster recurrent headaches. Ann Emerg Med. 2013 Oct;62(4):311-8;e4.[Abstract][Full Text]
28. Ovadia C. Prescribing for pregnancy: managing chronic headache and migraine. Drug Ther Bull. 2021 Oct;59(10):152-6.[Abstract]
29. Negro A, Delaruelle Z, Ivanova TA, et al. Headache and pregnancy: a systematic review. J Headache Pain. 2017 Oct 19;18(1):106.[Abstract][Full Text]
30. Food and Drug Administration. FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later because they can result in low amniotic fluid: NSAIDs may cause rare kidney problems in unborn babies. Sep 2022 [internet publication].[Full Text]
31. Medicines in Pregnancy. Ibuprofen. 2023 [internet publication].[Full Text]
32. Aoki KR. Evidence for the antinociceptive activity of the botulinum toxin type A in pain management. Headache. 2003 Jul-Aug;43(suppl 1):S9-15.[Abstract]
33. Holroyd KA, O'Donnell FJ, Stensland M, et al. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. JAMA. 2001 May 2;285(17):2208-15.[Abstract][Full Text]
34. Banzi R, Cusi C, Randazzo C, et al. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults. Cochrane Database Syst Rev. 2015;(5):CD011681.[Abstract][Full Text]
35. Fogelholm R, Murros K. Tizanidine in chronic tension-type headache: a placebo controlled double-blind cross-over study. Headache. 1992 Nov;32(10):509-13.[Abstract]
36. Saper JR, Lake AE 3rd, Cantrell DT, et al. Chronic daily headache prophylaxis with tizanidine: a double-blind, placebo-controlled, multicenter outcome study. Headache. 2002 Jun;42(6):470-82.[Abstract]
37. Almasi A, Meza CE. Doxepin. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. [Full Text]
38. Jilani TN, Gibbons JR, Faizy RM, et al. Mirtazapine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. [Full Text]
39. Nestoriuc Y, Rief W, Martin A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J Consult Clin Psychol. 2008 Jun;76(3):379-96.[Abstract]
40. Moraska AF, Stenerson L, Butryn N, et al. Myofascial trigger point-focused head and neck massage for recurrent tension-type headache: a randomized, placebo-controlled clinical trial. Clin J Pain. 2015 Feb;31(2):159-68.[Abstract][Full Text]
41. Koenig J, Oelkers-Ax R, Kaess M, et al. Specific music therapy techniques in the treatment of primary headache disorders in adolescents: a randomized attention-placebo-controlled trial. J Pain. 2013 Oct;14(10):1196-207.[Abstract]
42. Cathcart S, Galatis N, Immink M, et al. Brief mindfulness-based therapy for chronic tension-type headache: a randomized controlled pilot study. Behav Cogn Psychother. 2014 Jan;42(1):1-15.[Abstract]
43. Fisher E, Law E, Palermo TM, et al. Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev. 2015;(3):CD011118.[Abstract][Full Text]
44. Repiso-Guardeño A, Moreno-Morales N, Armenta-Pendón MA, et al. Physical therapy in tension-type headache: a systematic review of randomized controlled trials. Int J Environ Res Public Health. 2023 Mar 2;20(5):4466.[Abstract][Full Text]
45. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;(4):CD007587.[Abstract][Full Text]
46. Fernández-de-Las-Peñas C, Cleland JA, Palomeque-Del-Cerro L, et al. Development of a clinical prediction rule for identifying women with tension-type headache who are likely to achieve short-term success with joint mobilization and muscle trigger point therapy. Headache. 2011 Feb;51(2):246-61.[Abstract]
47. Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016 May 10;86(19):1818-26.[Abstract][Full Text]
48. Silberstein SD, Gobel H, Jensen R, et al. Botulinum toxin type A in the prophylactic treatment of chronic tension-type headache: a multicentre, double-blind, randomized, placebo-controlled, parallel-group study. Cephalalgia. 2006 Jul;26(7):790-800.[Abstract]
49. Karadaş O, Ipekdal IH, Ulaş UH, et al. Botulinum neuro-toxin type-A in the treatment of chronic tension type headache associated with pericranial tenderness [in Turkish]. Agri. 2012;24(1):9-14.[Abstract][Full Text]
50. Dhanasekara CS, Payberah D, Chyu JY, et al. The effectiveness of botulinum toxin for chronic tension-type headache prophylaxis: a systematic review and meta-analysis. Cephalalgia. 2023 Mar;43(3):3331024221150231.[Abstract][Full Text]
51. Schou WS, Ashina S, Amin FM, et al. Calcitonin gene-related peptide and pain: a systematic review. J Headache Pain. 2017 Dec;18(1):34.[Abstract][Full Text]
52. Abu Bakar N, Tanprawate S, Lambru G, et al. Quality of life in primary headache disorders: a review. Cephalalgia. 2016 Jan;36(1):67-91.[Abstract][Full Text]
53. Probyn K, Bowers H, Caldwell F, et al. Prognostic factors for chronic headache: a systematic review. Neurology. 2017 Jul 18;89(3):291-301.[Abstract][Full Text]
54. Sriuttha P, Sirichanchuen B, Permsuwan U. Hepatotoxicity of nonsteroidal anti-inflammatory drugs: a systematic review of randomized controlled trials. Int J Hepatol. 2018;2018:5253623.[Abstract][Full Text]
55. Warner TD, Mitchell JA. COX-2 selectivity alone does not define the cardiovascular risks associated with non-steroidal anti-inflammatory drugs. Lancet. 2008 Jan 19;371(9608):270-3.[Abstract]
56. Wilson SL, Poulter NR. The effect of non-steroidal anti-inflammatory drugs and other commonly used non-narcotic analgesics on blood pressure level in adults. J Hypertens. 2006 Aug;24(8):1457-69.[Abstract]
57. Varga Z, Sabzwari SRA, Vargova V. Cardiovascular risk of nonsteroidal ati-inflammatory drugs: an under-recognized public health iIssue. Cureus. 2017 Apr 8;9(4):e1144.[Abstract][Full Text]
