Overview
Tension-Type Headache
Quick Reference
Critical Alerts
- Rule out secondary causes first: Red flags require imaging/workup
- Most common primary headache: But diagnosis of exclusion
- Bilateral, pressing, mild-moderate: Unlike migraine/cluster
- No nausea, vomiting, or autonomic features: Key differentiator
- Simple analgesics are first-line: NSAIDs, acetaminophen
- Avoid medication overuse: Can cause chronic daily headache
Key Features
| Feature | Tension-Type Headache |
|---|---|
| Location | Bilateral (band-like) |
| Quality | Pressing, tightening (non-pulsating) |
| Intensity | Mild to moderate |
| Duration | 30 minutes to 7 days |
| Nausea/Vomiting | No (or mild nausea only) |
| Photophobia/Phonophobia | May have one (not both) |
| Activity | Not worsened by routine physical activity |
Emergency Treatments
| Treatment | Dose |
|---|---|
| Ibuprofen | 400-600 mg PO |
| Naproxen | 500 mg PO |
| Acetaminophen | 1000 mg PO |
| Aspirin | 500-1000 mg PO |
Definition
Overview
Tension-type headache (TTH) is the most common primary headache disorder, characterized by bilateral, pressing or tightening pain of mild-to-moderate intensity. Unlike migraine, TTH lacks nausea, vomiting, and significant photophobia/phonophobia. Treatment involves simple analgesics for acute episodes and lifestyle modifications for prevention.
Classification
By Frequency:
| Type | Frequency |
|---|---|
| Infrequent episodic | <1 day/month (<12 days/year) |
| Frequent episodic | 1-14 days/month (≥12, <180 days/year) |
| Chronic | ≥15 days/month for > months |
Epidemiology
- Lifetime prevalence: 30-78%
- Most common headache type
- Slight female predominance: 5:4
- Peak age: 30-39 years
Etiology
Proposed Mechanisms:
| Factor | Role |
|---|---|
| Peripheral | Pericranial muscle tenderness |
| Central | Altered pain processing, sensitization |
| Psychological | Stress, anxiety, depression |
Triggers:
| Trigger | Notes |
|---|---|
| Stress | Most common trigger |
| Fatigue | Lack of sleep |
| Poor posture | Computer work, driving |
| Eye strain | Prolonged reading/screens |
| Caffeine withdrawal | |
| Dehydration |
Pathophysiology
Mechanism
Episodic TTH:
- Peripheral mechanisms predominate
- Pericranial muscle tenderness
- Myofascial trigger points
Chronic TTH:
- Central sensitization
- Impaired descending pain inhibition
- Overlap with chronic migraine
Clinical Presentation
Symptoms
| Feature | Description |
|---|---|
| Location | Bilateral (occipital, frontal, or diffuse) |
| Quality | Pressing, tightening ("band around head") |
| Intensity | Mild to moderate |
| Duration | 30 minutes to 7 days |
| Aggravating | Not worsened by physical activity |
| Associated | May have mild nausea OR photophobia OR phonophobia (not multiple) |
History
Key Questions:
Physical Examination
General:
Neurological Exam:
Head/Neck Exam:
| Finding | Significance |
|---|---|
| Pericranial muscle tenderness | Common in TTH |
| Cervical muscle tension | Associated |
| No autonomic features | Differentiates from cluster |
Headache location, quality, intensity
Common presentation.
Duration and frequency
Common presentation.
Nausea, vomiting, light/sound sensitivity
Common presentation.
Worsened by routine activity?
Common presentation.
Triggers (stress, fatigue)?
Common presentation.
Prior similar headaches?
Common presentation.
Red flag symptoms?
Common presentation.
Medication use (frequency)?
Common presentation.
Red Flags
Secondary Headache Warning Signs
| Finding | Concern | Action |
|---|---|---|
| Thunderclap onset | SAH | CT, LP |
| Fever + neck stiffness | Meningitis | LP |
| Focal neurological deficits | Stroke, mass | CT/MRI |
| Papilledema | Increased ICP | Imaging |
| New headache >0 years | GCA, malignancy | ESR, imaging |
| Progressively worsening | Secondary cause | Imaging |
Differential Diagnosis
Other Headache Types
| Diagnosis | Key Differentiators |
|---|---|
| Migraine | Unilateral, pulsating, moderate-severe, nausea, photophobia, phonophobia |
| Cluster | Strictly unilateral, severe, short duration, autonomic features |
| Medication overuse headache | Frequent analgesic use, daily headaches |
| Secondary headaches | Red flags, abnormal exam |
| Cervicogenic | Associated with neck movement, cervical pathology |
Diagnostic Approach
Clinical Diagnosis
- TTH is a clinical diagnosis
- Based on ICHD-3 criteria
- Imaging only for red flags
ICHD-3 Criteria (Summary)
- At least 10 headache episodes
- Duration: 30 min to 7 days
- At least 2 of:
- Bilateral location
- Pressing/tightening (non-pulsating)
- Mild or moderate intensity
- Not aggravated by routine physical activity
- Both of:
- No nausea or vomiting
- No more than one of photophobia or phonophobia
- Not better explained by another diagnosis
Imaging
- Not indicated for typical TTH
- Indicated for red flags or atypical features
Treatment
Principles
- Simple analgesics for acute attacks
- Limit analgesic use: ≤2-3 days/week to prevent MOH
- Identify and address triggers: Stress, posture, sleep
- Preventive therapy for frequent episodic or chronic: Non-pharmacological first
Acute Treatment
First-Line:
| Agent | Dose | Notes |
|---|---|---|
| Ibuprofen | 400-600 mg PO | Most evidence |
| Naproxen | 500 mg PO | Long-acting |
| Aspirin | 500-1000 mg PO | Effective |
| Acetaminophen | 1000 mg PO | If NSAIDs contraindicated |
Combination Analgesics:
| Agent | Notes |
|---|---|
| ASA + acetaminophen + caffeine | More effective than monotherapy |
NOT Recommended for TTH:
- Triptans (not effective)
- Opioids (risk of MOH, not indicated)
Non-Pharmacological
| Intervention | Notes |
|---|---|
| Rest | Quiet, dark room may help |
| Massage | Pericranial muscles |
| Heat/cold application | Local relief |
| Relaxation techniques | Stress reduction |
| Physical therapy | For cervical component |
Preventive Therapy (Chronic TTH)
First-Line (if ≥15 days/month):
| Agent | Dose |
|---|---|
| Amitriptyline | 10-75 mg at bedtime |
Alternatives:
| Agent | Notes |
|---|---|
| Mirtazapine | 15-30 mg |
| Venlafaxine | 150 mg |
Non-Pharmacological Prevention:
- Cognitive behavioral therapy
- Biofeedback
- Physical therapy
- Stress management
- Regular exercise
Disposition
Discharge Criteria
- Red flags absent
- Neurological exam normal
- Pain controlled
- Educated on appropriate analgesic use
Admission Criteria
- Rarely needed for TTH
- Consider if secondary cause identified
Referral
| Indication | Referral |
|---|---|
| Chronic TTH (≥15 days/month) | Neurology/Headache specialist |
| Medication overuse | Headache specialist |
| Refractory to treatment | Neurology |
Patient Education
Condition Explanation
- "Tension-type headache is the most common type of headache."
- "It is not dangerous and can usually be treated with over-the-counter pain relievers."
- "Managing stress and getting enough sleep can help prevent them."
Home Care
- Take analgesics early in the headache
- Limit analgesic use to ≤2-3 days/week
- Stay hydrated
- Get adequate sleep
- Manage stress
Warning Signs to Return
- Worst headache of your life
- Sudden thunderclap onset
- Fever with headache
- Weakness, numbness, or vision changes
- Headaches becoming more frequent or severe
Special Populations
Pregnant Women
- Avoid NSAIDs in 3rd trimester
- Acetaminophen is first-line
- Non-pharmacological approaches preferred
Elderly
- Be cautious with NSAIDs (GI, renal, CV risk)
- Consider acetaminophen first
- Rule out secondary causes (GCA, malignancy)
Medication Overuse Headache
- Headaches ≥15 days/month + frequent analgesic use
- Treat by withdrawing overused medication
- May need preventive therapy
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Red flag assessment | 100% | Rule out secondary |
| Neuro exam documented | 100% | Standard of care |
| Analgesic limitation counseled | >0% | Prevent MOH |
| Avoid opioids for TTH | >5% | Not indicated |
Documentation Requirements
- Headache features (bilateral, pressing, intensity)
- Red flag assessment
- Neurological exam
- Treatment and response
- Education on analgesic limits
Key Clinical Pearls
Diagnostic Pearls
- Bilateral, pressing, mild-moderate = TTH: Migraine is unilateral, pulsating, severe
- No nausea or vomiting in TTH: Key differentiator
- Not worsened by activity: Unlike migraine
- Clinical diagnosis: No imaging for typical presentation
- Most common headache type: But always consider red flags
- Pericranial tenderness common: On palpation
Treatment Pearls
- Simple analgesics work: NSAIDs, acetaminophen
- Triptans don't work for TTH: Only for migraine
- Limit analgesics to 2-3 days/week: Prevent medication overuse
- Amitriptyline for prevention: Low dose at bedtime
- Address triggers: Stress, sleep, posture
- Opioids not indicated: For TTH
Disposition Pearls
- Almost all can be discharged: With analgesics and education
- Refer chronic TTH: For preventive management
- Educate on medication limits: Crucial to prevent MOH
- Non-pharmacological approaches: Important for prevention
References
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
- Bendtsen L, et al. EFNS guideline on the treatment of tension-type headache. Eur J Neurol. 2010;17(11):1318-1325.
- Derry S, et al. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache. Cochrane Database Syst Rev. 2017;1:CD011888.
- Stephens G, et al. Pathophysiology of chronic tension-type headache. Curr Pain Headache Rep. 2018;22(2):9.
- Loder E, et al. Choosing wisely in headache medicine: the American Headache Society's list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659.
- Robbins MS. Diagnosis and Management of Headache: A Review. JAMA. 2021;325(18):1874-1885.
- Silberstein SD. Tension-type headache. In: Wolff's Headache. 8th ed. 2008.
- UpToDate. Tension-type headache in adults: Acute treatment. 2024.