Tension-Type Headache

Name: Tension-Type Headache
Creator: MedVellum Editorial Team

1. Clinical Overview

Summary

Tension-Type Headache (TTH) is the Most Common Primary Headache Disorder, affecting up to 80% of the population at some point in their lives. [1,9] It is characterised by Bilateral, Non-Pulsating, Pressing or Tightening ("Band-Like") pain of Mild to Moderate Intensity that does NOT worsen with routine physical activity. [1,2] Unlike migraine, TTH is typically NOT associated with nausea, vomiting, photophobia, or phonophobia (though mild versions of one of these may be present). [1] The pathophysiology involves Peripheral Mechanisms (myofascial tenderness, pericranial muscle dysfunction) and Central Sensitisation in chronic forms. [10,16] TTH is classified as Episodic (Infrequent or Frequent) or Chronic based on frequency. The International Classification of Headache Disorders (ICHD-3) provides diagnostic criteria. [1] Management includes Simple Analgesics (paracetamol, NSAIDs) for acute episodes and Amitriptyline as first-line prophylaxis for chronic TTH. [2,8] Non-Pharmacological approaches (stress management, physiotherapy, relaxation techniques) are essential components of treatment. [6] Although benign, TTH can significantly impact quality of life and productivity, with chronic TTH being particularly disabling. [17,18]

Key Facts

Fact	Value
Definition	Bilateral, non-pulsating, pressing/tightening headache of mild-moderate intensity
Prevalence	Lifetime ~80%, 1-year ~40-60%
Peak Age	30-40 years
Sex Ratio	Female > Male (Slight predominance)
Gold Standard Diagnosis	Clinical – ICHD-3 Criteria
First-Line Acute Treatment	Paracetamol 1g or Ibuprofen 400mg
First-Line Prophylaxis	Amitriptyline 10-75mg nocte
Prognosis	Generally good. Chronic TTH more challenging

Clinical Pearls

"Band-Like Pressure Around the Head": Classic description. Not pulsating.

"No Nausea, No Throbbing, No Worsening with Activity": Key distinctions from migraine.

"Amitriptyline for Chronic TTH": Low-dose tricyclic is first-line prophylaxis.

"Rule Out Medication Overuse Headache": In frequent TTH patients using regular analgesics.

"Pericranial Tenderness": Often present on examination – useful supporting sign.

Why This Matters Clinically

Tension-type headache is the most prevalent headache disorder and a leading cause of disability worldwide. [9,17] While individual episodes are typically not severe, the cumulative burden of frequent or chronic TTH significantly impacts quality of life, work productivity, and healthcare utilisation. [17,18] Accurate diagnosis prevents unnecessary investigations and inappropriate treatments. Recognition of chronic TTH and medication overuse headache is essential to prevent treatment escalation and analgesic dependency. TTH is frequently examined in postgraduate assessments as part of headache classification and differential diagnosis.

2. Epidemiology

Incidence & Prevalence

Measure	Value	Notes
Lifetime Prevalence	~80%	Most common headache type [9]
1-Year Prevalence (Global)	40-60%	Higher in developed countries [9,15]
1-Year Prevalence (Europe)	60-80%	Highest prevalence region [15]
1-Year Prevalence (Asia)	20-40%	Lower than Western countries [9]
Episodic TTH (Infrequent)	60-70% of TTH	Most have infrequent episodes [17]
Episodic TTH (Frequent)	20-30% of TTH	May require management [17]
Chronic TTH	2-3% global population	Significant disability burden [17,18]
Chronic TTH (Europe)	3-4%	Highest chronic rates [17]

Demographics

Factor	Details	Clinical Significance
Age of Onset	Can begin at any age	Peak prevalence 30-40 years [15]
Childhood TTH	Prevalence 10-30%	Often underdiagnosed
Adolescent TTH	Prevalence 15-30%	Academic stress contributor
Adult Peak (30-40)	Highest prevalence	Work/family stress peak
Elderly TTH	Decreases after 50-60	May transition to other types
Sex Ratio	Female:Male ~1.2-1.5:1	Less marked than migraine (3:1) [15]
Socioeconomic Status	Higher with stress	Work-related factors important
Occupation	Office workers, Students, Professionals	Sedentary, stress, posture
Geographic Variation	Higher in Western/Developed countries	Lifestyle factors [9]

Global Burden

Metric	Details
Disability-Adjusted Life Years (DALYs)	6th leading cause of disability globally [9]
Years Lived with Disability (YLDs)	2nd leading cause after low back pain [9,17]
Economic Impact	Billions per year in lost productivity [17,18]
Healthcare Utilisation	Accounts for ~4-5% of GP consultations [17]
Presenteeism	Greater impact than absenteeism in TTH [18]

Risk Factors and Associations

Non-Modifiable Risk Factors:

Factor	Relative Risk	Mechanism
Female Sex	RR 1.2-1.5	Hormonal factors, Pain processing differences, Psychosocial factors [15]
Family History	RR 2-4	First-degree relatives with TTH. Genetic predisposition to pain sensitivity
Age 30-50	Peak incidence	Life-stage stressors, Work demands
Genetics	Under investigation	Polygenic. Serotonin transporter gene variants. COMT polymorphisms

Modifiable Risk Factors:

Factor	Relative Risk	Mechanism	Intervention
Psychological Stress	RR 2-3	HPA axis activation, Muscle tension, Central sensitisation [16]	Stress management, CBT, Relaxation
Anxiety	RR 2-3	Increased muscle tension, Hypervigilance to pain [18]	Treat underlying anxiety
Depression	RR 2-4	Shared serotonergic dysfunction, Central pain amplification [18]	Treat depression (Dual benefit with amitriptyline)
Poor Sleep Quality	RR 1.5-2	Impaired descending pain modulation, Fatigue [18]	Sleep hygiene, Treat sleep disorders
Sleep Deprivation	RR 1.5	Lowered pain threshold	Regular sleep schedule
Poor Posture	RR 1.5	Cervical/shoulder muscle strain, Myofascial dysfunction [19]	Ergonomic correction, Physiotherapy
Prolonged Screen Use	RR 1.5-2	Eye strain, Neck posture, Reduced blinking	Screen breaks, Ergonomics, Blue light filters
Physical Inactivity	RR 1.3-1.5	Reduced endorphins, Muscle weakness	Regular aerobic exercise
Caffeine Overuse	Variable	Rebound headache, Central effects	Moderate intake (less than 200mg/day)
Caffeine Withdrawal	Common trigger	Adenosine receptor upregulation	Gradual reduction, Consistent intake
Medication Overuse	Major risk for chronification	Central sensitisation, MOH [3]	Limit acute analgesics to less than 10-15 days/month
Smoking	RR 1.2-1.5	Vascular effects, Stress association	Smoking cessation
Alcohol	Variable	May trigger or relieve	Moderation
Dehydration	Common trigger	Unknown mechanism	Adequate hydration
Skipping Meals	Common trigger	Hypoglycaemia, Stress response	Regular meals

Associated Conditions:

Condition	Association	Clinical Implication
Migraine	Overlap in 30-40% [20]	Mixed headache types. May coexist.
Temporomandibular Disorder (TMD)	Common comorbidity [19]	Shared myofascial dysfunction
Fibromyalgia	Increased prevalence in TTH	Central sensitisation overlap [16]
Cervicogenic Headache	May mimic or coexist [19]	Careful differential
Chronic Fatigue Syndrome	Associated	Central mechanisms
Irritable Bowel Syndrome	Increased	Visceral hypersensitivity
Generalised Anxiety Disorder	Common [18]	Treat both
Major Depression	Common [18]	Treat both

3. Pathophysiology

Overview

The pathophysiology of TTH involves a complex interplay between Peripheral Mechanisms (pericranial muscle dysfunction, myofascial trigger points) and Central Mechanisms (central sensitisation, impaired pain modulation). [10,16] The relative contribution shifts from peripheral to central as TTH progresses from episodic to chronic. [16]

Mechanism (Stepwise)

Step 1: Peripheral Nociceptive Activation (Episodic TTH)

The initiating events typically involve activation of peripheral nociceptors in pericranial muscles: [10,16,19]

Component	Details
Myofascial Trigger Points	Hyperirritable spots in taut muscle bands. Release nociceptive signals. [19]
Muscle Tension	Sustained or inappropriate muscle contraction
Muscle Ischaemia	Reduced blood flow during excessive contraction
Local Inflammatory Mediators	Substance P, CGRP, Bradykinin, Prostaglandins, Potassium, Hydrogen ions [16]
Nociceptor Sensitisation	Lowered threshold for activation [16]
Pain Signal Transmission	Via trigeminal (V1, V2, V3) and upper cervical (C1-C3) afferents [10]

Pericranial Muscles Involved:

Muscle	Location	Innervation	Role in TTH
Temporalis	Temporal region	Trigeminal (V3)	Often tenderness to palpation [19]
Frontalis	Forehead	Facial nerve (VII)	Furrowing with stress
Occipitalis	Occiput	Facial/Occipital nerves	Posterior head pain
Masseter	Jaw	Trigeminal (V3)	Clenching, TMJ involvement [19]
Pterygoids (Medial/Lateral)	Deep jaw	Trigeminal (V3)	Jaw tension
Sternocleidomastoid (SCM)	Neck	Accessory nerve (XI)	Neck pain, Postural [19]
Trapezius (Upper)	Shoulder/Neck	Accessory nerve (XI)	Shoulder tension, Posture [19]
Splenius Capitis	Posterior neck	Cervical nerves	Neck extension strain
Suboccipital Muscles	Base of skull	C1	Fine head movements

Trigger Points:

Localised areas of hyperirritability [19]
Palpable taut bands
Cause referred pain patterns
May activate central sensitisation with repeated stimulation [16]

Step 2: Trigeminal Nucleus Caudalis Processing

Process	Details
First-Order Neurons	Transmit from pericranial tissues via V and C1-C3 [10]
Synapse	Trigeminal nucleus caudalis (TNC) in brainstem [10]
Second-Order Neurons	Relay to thalamus
Convergence	Input from multiple sources converges [10,19]
Wind-Up Phenomenon	Repeated stimulation increases neuron excitability [16]
Glial Activation	Microglia and astrocytes amplify signalling [16]

Step 3: Transition to Central Sensitisation (Chronic TTH)

With repeated or persistent peripheral input, central nervous system changes occur: [16,21]

Mechanism	Description	Effect
Reduced Pain Threshold	Less stimulus needed to evoke pain [16]	Hyperalgesia
Expanded Receptive Fields	Neurons respond to larger area [16]	Spread of pain
Increased Spontaneous Activity	Neurons fire without stimulus [16]	Background pain
Impaired Descending Inhibition	Serotonergic/noradrenergic pathways weakened [10,16]	Pain persists
Cortical Reorganisation	Altered pain processing in cortex [21]	Chronic pain state
NMDA Receptor Upregulation	Enhanced excitatory neurotransmission [16]	Sensitisation maintains
Nitric Oxide Dysregulation	NO may play key role in chronification [16]	Peripheral and central effects

Step 4: Impaired Descending Pain Modulation

Pathway	Neurotransmitters	Status in Chronic TTH
Periaqueductal Grey (PAG)	Enkephalins, Endorphins	Reduced activity [10]
Nucleus Raphe Magnus	Serotonin (5-HT)	Dysfunction [10,16]
Locus Coeruleus	Noradrenaline (NE)	Reduced inhibition [10]
Rostral Ventromedial Medulla (RVM)	GABA, 5-HT	Impaired [10]

This is why tricyclic antidepressants (enhance 5-HT and NE) are effective for chronic TTH. [8]

Step 5: Perpetuating and Modulating Factors

Factor	Mechanism	Clinical Relevance
Psychological Stress	Increases muscle tension, HPA axis activation, Affects pain processing [16]	Stress management essential
Sleep Disturbance	Impairs descending modulation, Increases pain sensitivity [18]	Sleep hygiene important
Mood Disorders	Depression/Anxiety share serotonergic dysfunction, Amplify pain [18]	Treat comorbidity
Medication Overuse	Further central sensitisation, MOH development [3]	Limit analgesics
Inactivity	Muscle weakness, Reduced endogenous analgesia	Encourage exercise
Posture	Sustained muscle activation, Myofascial strain [19]	Ergonomic education

Step 6: Clinical Implications (Treatment Targets)

Target	Modality	Examples
Peripheral (Muscles)	Physiotherapy [6,19]	Massage, Trigger point release, Stretching, Exercises
Peripheral (Inflammation)	NSAIDs [5]	Ibuprofen for acute
Central (Serotonin/NE)	Tricyclic antidepressants [4,8]	Amitriptyline
Central (NMDA)	NMDA antagonists	Limited evidence (Ketamine)
Psychological	CBT, Relaxation, Biofeedback [6]	Address stress, Catastrophising
Lifestyle	Sleep, Exercise, Posture	Holistic management

Pathophysiology Diagram

Tension-Type Headache Management Algorithm

Classification (ICHD-3)

Overview:

Subtype	Frequency Criteria	Duration	Notes
Infrequent Episodic TTH	Less than 1 day/month (Less than 12 days/year)	30 min - 7 days	Minimal clinical significance. Most population. [1]
Frequent Episodic TTH	1-14 days/month (12-180 days/year) for 3 months or more	30 min - 7 days	May cause significant disability. Consider prophylaxis. [1,2]
Chronic TTH	15 days or more per month (180 or more days/year) for more than 3 months	Hours to continuous	Significant impact. Prophylaxis recommended. [1,2]

With/Without Pericranial Tenderness: Each subtype further classified by presence or absence of pericranial muscle tenderness on manual palpation. [1,19]

Classification	Clinical Significance
With Pericranial Tenderness	Suggests peripheral component. May respond to physiotherapy. [19]
Without Pericranial Tenderness	Central mechanisms may predominate. [16]

4. Clinical Presentation

Symptoms - Detailed Analysis

Core Diagnostic Features (ICHD-3): [1]

Feature	Description	Frequency	Diagnostic Weight
Bilateral Location	Both sides of head, May be temporal, Frontal, Occipital, Or generalised	~90%	Essential differentiator from migraine [1,20]
Pressing/Tightening Quality	"Band around the head"

"Vice-like"
"Cap-like", Non-pulsating | ~90% | Classic description. Non-pulsating key. [1] | | Mild-Moderate Intensity | VAS 3-6/10. Does NOT significantly impair function. | ~95% | Severe = Question diagnosis [1] | | Not Aggravated by Activity | Walking, Climbing stairs, Routine activities tolerated | Essential | Key distinction from migraine [1,20] | | Duration | 30 minutes to 7 days per episode | Variable | Chronic may be continuous [1] |

Pain Characteristics:

Characteristic	TTH	Migraine (Comparison)
Location	Bilateral, Generalised [1]	Often unilateral (60%) [20]
Quality	Pressing, Tightening, Dull [1]	Pulsating, Throbbing [20]
Intensity	Mild-Moderate [1]	Moderate-Severe [20]
Effect of Activity	No worsening [1]	Worsens with activity [20]
Duration	30 min - 7 days [1]	4-72 hours [20]
Aura	Never [1]	Present in 20-30% [20]
Nausea/Vomiting	Absent [1]	Often present [20]
Photophobia	Absent or mild (1 only) [1]	Present [20]
Phonophobia	Absent or mild (1 only) [1]	Present [20]

Associated Features (Typically ABSENT or Mild):

Feature	Status in TTH	Notes
Nausea	Absent in episodic. Mild may occur in chronic. [1]	Vomiting = Not TTH
Vomiting	Always absent [1]	Present = Consider migraine
Photophobia	Absent OR mild [1]	Max ONE of photo/phonophobia
Phonophobia	Absent OR mild [1]	Max ONE of photo/phonophobia
Osmophobia	Absent	Smell sensitivity = Migraine [20]
Allodynia	Mild in chronic [16]	Cutaneous hypersensitivity
Aura	Never [1]	If aura present = Not TTH
Autonomic Features	Absent [1]	Tearing, Rhinorrhoea = Trigeminal autonomic cephalalgias

Symptom Patterns:

Pattern	Description	Implications
Morning Onset	May relate to poor sleep, Bruxism [19]	Assess sleep, TMD
End-of-Day Worsening	Common in frequent TTH [18]	Work stress, Posture
Work-Related	Worse at work, Better on weekends	Occupational factors
Stress-Related	Temporally linked to stressful events [16]	Stress management
Menstrual Timing	Some women report cyclical pattern	Hormonal component
Weekend Headache	May occur with caffeine withdrawal	Caffeine education
Waking with Headache	Less common in TTH	If prominent, Exclude sleep apnoea, IIH

Chronicity Spectrum:

Type	Frequency	Duration	Associated Features	Impact
Infrequent Episodic	Less than 1/month	30 min - 7 days	Minimal [17]	Low
Frequent Episodic	1-14 days/month	30 min - 7 days	Mild tenderness [19]	Moderate
Chronic	15+ days/month	Hours-Continuous	Tenderness, Mild nausea [16,18]	High

Atypical Presentations:

Presentation	Frequency	Considerations
Unilateral TTH	~10%	May still be TTH if other criteria met. Consider cervicogenic. [19]
Severe Intensity	Rare	Question diagnosis. Consider migraine. [20]
With Mild Nausea (Chronic)	Allowed in chronic [1]	But vomiting = Not TTH
Diffuse/Global	Common	"Whole head" pain
Occipital Predominant	Occasional	Check cervicogenic contribution [19]
Frontal Predominant	Common	Often stress-related

Pericranial Tenderness:

Finding	Description	Clinical Significance
Present	Tenderness on manual palpation of pericranial muscles [19]	Supports peripheral component. Better response to physiotherapy.
Absent	No tenderness on palpation	Central mechanisms may predominate. [16]
Severe	Very tender, Patient withdraws [19]	Correlates with chronicity and severity.

Total Tenderness Score (TTS): [19]

Palpate 8 muscle pairs (Temporalis, Frontalis, Masseter, Pterygoid lateral, SCM, Splenius, Trapezius, Suboccipital)
Grade each 0-3 (0=None, 1=Mild, 2=Moderate, 3=Severe)
Total score 0-48
Score greater than 8 suggests significant tenderness

Temporal Pattern

Pattern	Description	Clinical Relevance
Episodic Discrete	Clear attacks with pain-free intervals	Easier to manage acutely
Episodic Frequent	Multiple attacks per month	Consider prophylaxis [2]
Continuous Background	Constant low-grade headache [18]	Suggests chronic TTH
Fluctuating Continuous	Background pain with exacerbations [18]	Common in chronic
Progressive	Worsening over time	Consider MOH, Secondary causes [3]

Impact and Disability

Domain	Impact in Episodic	Impact in Chronic
Work	Occasional reduced productivity [17]	Significant absenteeism, Presenteeism [17,18]
Social	Minimal	May avoid activities [18]
Mood	Transient frustration	Anxiety, Depression common [18]
Sleep	Usually unaffected	May be disrupted [18]
Quality of Life	Mild reduction	Severely reduced (Comparable to migraine) [17,18]

Red Flags (Detailed Analysis)

[!CAUTION] SNOOP Mnemonic for Secondary Headache Red Flags:

Systemic symptoms (Fever, Weight loss, Malaise) or Systemic disease (Cancer, HIV, Immunocompromise)

Neurological symptoms or abnormal signs (Papilloedema, Focal deficits, Confusion)

Onset sudden (Thunderclap - Peak within seconds to 1 minute)

Older age (New headache after 50 years - Consider GCA)

Previous headache history change (First, Worst, Different pattern, Progressive)

Positional component (Worse lying/standing - CSF leak, IIH)

Precipitated by Valsalva (Cough, Sneeze, Strain - Chiari, Mass)

Papilloedema or Pregnancy/Postpartum

Red Flag Details:

Red Flag	Consider	Investigation
Thunderclap Onset	SAH, RCVS, Dissection, Pituitary apoplexy	CT Brain, LP, CTA/MRA
New Onset greater than 50 years	Giant Cell Arteritis, Mass, Subdural	ESR/CRP, MRI, Temporal artery biopsy
Neurological Signs	Mass lesion, Stroke, Infection	MRI Brain, LP if infection
Papilloedema	IIH, Mass, Cerebral venous thrombosis	MRI/MRV, LP with opening pressure
Fever	Meningitis, Encephalitis, Abscess	LP, MRI
Weight Loss	Malignancy	CT/MRI, Systemic workup
HIV/Immunocompromise	Opportunistic infections, Lymphoma	MRI, LP, HIV test
Postural Component	CSF leak (Low pressure), IIH (High pressure)	MRI, LP
Pregnancy/Postpartum	Pre-eclampsia, CVST, Pituitary apoplexy	BP, MRV, Endocrine
Waking from Sleep	Mass lesion (Raised ICP), Sleep apnoea	MRI, Sleep study
Progressive Worsening	Mass, Chronic subdural, MOH [3]	MRI
Cancer History	Brain metastases	MRI with contrast
Trauma	Subdural, Dissection	CT/MRI, CTA
Anticoagulation	Intracranial haemorrhage	CT Brain

5. Clinical Examination

Structured Approach

Order of Examination:

General observation
Vital signs
Head and neck examination
Pericranial muscle palpation
Cervical spine examination
TMJ examination
Neurological examination
Fundoscopy

General Observation:

Finding	Expected in TTH	Red Flag Consideration
Appearance	Well, Not in acute distress	Unwell, Toxic = Infection, Systemic disease
Posture	May have forward head posture [19]	-
Distress Level	Minimal to moderate	Severe distress = Consider migraine, Secondary cause
Photophobia Behaviour	Not avoiding light [1]	Avoiding light = Consider migraine. Or meningitis with fever.
Movement	Moves normally	Moving slowly, Neck stiffness = Red flag

Vital Signs:

Parameter	Expected in TTH	Red Flag
Temperature	Normal	Fever = Infection, GCA
Blood Pressure	Normal	Severe hypertension = Secondary cause
Heart Rate	Normal	Tachycardia with fever = Concerning

Neurological Examination (Must Be Normal in TTH):

Domain	What to Examine	Expected Finding
Consciousness	GCS, Orientation	Alert, Oriented
Speech	Dysphasia, Dysarthria	Normal
Cranial Nerves	Pupils, Visual fields, Eye movements, Facial movement, Hearing, Palate, Tongue	All normal
Fundoscopy	Optic disc margins, Venous pulsations	No papilloedema
Motor	Tone, Power, Drift	Normal
Sensory	Light touch, Pinprick	Normal
Reflexes	Upper and lower limb reflexes, Plantars	Normal
Coordination	Finger-nose, Heel-shin	Normal
Gait	Walk, Turn, Tandem	Normal

ANY NEUROLOGICAL ABNORMALITY = NOT PURE TTH. Investigate.

Head and Neck Specific Examination:

Area	Technique	Findings in TTH
Scalp Inspection	Look for lesions, Scars, Erythema	Usually normal
Scalp Palpation	Assess for tenderness, Masses	Usually non-tender (Except pericranial muscles)
Temporal Arteries	Palpate for tenderness, Nodularity, Absent pulse	Normal. If abnormal consider GCA (Age greater than 50)
Sinuses	Palpate frontal and maxillary	Non-tender
Cervical Lymph Nodes	Palpate anterior and posterior chains	Non-palpable/Normal

Pericranial Muscle Palpation (Key Examination)

Technique: [19]

Use the second and third fingers, Apply firm rotating pressure
Grade tenderness 0-3 at each site (0 = None, 1 = Mild, 2 = Moderate, 3 = Severe/Withdraws)
Calculate Total Tenderness Score (TTS) by summing all sites

Muscle Sites to Palpate:

Muscle	Location	How to Palpate
Temporalis	Temporal fossa (Side of head)	Palpate anterior and posterior fibres
Frontalis	Forehead	Palpate across forehead
Occipitalis	Occiput	Palpate nuchal line
Masseter	Angle of jaw	Ask patient to clench teeth, Palpate
Lateral Pterygoid	Deep to mandible	Difficult. Behind last molar.
Sternocleidomastoid (SCM)	Lateral neck	Palpate from mastoid to clavicle
Trapezius (Upper)	Upper shoulder/neck	Palpate upper fibres
Splenius Capitis	Posterior neck	Deep palpation lateral to spinous processes
Suboccipital Muscles	Base of skull	Palpate below occipital ridge

Total Tenderness Score (TTS):

Score	Interpretation
0	No tenderness
1-8	Mild tenderness (Common in general population) [19]
9-16	Moderate tenderness (Supports TTH diagnosis) [19]
17+	Severe tenderness (Correlates with chronic TTH, Poor prognosis) [19]

Clinical Significance: [19]

Pericranial tenderness is more common in TTH than controls
Higher TTS correlates with headache frequency and chronicity
Patients with tenderness may benefit more from physiotherapy

Cervical Spine Examination

Test	Technique	Significance
Range of Motion	Flexion, Extension, Rotation, Lateral flexion	Limitation may suggest cervicogenic component [19]
Tenderness	Palpate cervical spinous processes and paraspinals	Upper cervical tenderness common in TTH [19]
Spurling's Test	Neck extension + Rotation + Axial compression	Radicular pain = Cervical radiculopathy (Not TTH)

TMJ Examination

Finding	Description	Significance
Tenderness	Pre-auricular palpation	Common comorbidity (TMD) [19]
Clicking/Crepitus	Noted on opening/closing	TMJ dysfunction [19]
Limited Opening	Less than 40mm	TMD [19]
Deviation	Jaw deviates on opening	TMD [19]

Special Tests

Test	Technique	Positive Finding	Significance
Total Tenderness Score (TTS)	Systematic palpation of 8 pericranial muscle pairs, Grade 0-3 [19]	Score greater than 8	Supports TTH diagnosis, Correlates with severity
Cervical ROM	Flexion/Extension, Rotation, Lateral flexion	Limited, Painful	Cervicogenic contribution [19]
TMJ Assessment	Palpation, Opening, Clicking	Tenderness, Limitation	Comorbid TMJ dysfunction [19]
Pull Test (Hair)	Gentle traction on hair	Pain = Allodynia	Present in chronic TTH with central sensitisation [16]

6. Investigations

First-Line (Bedside)

Clinical Diagnosis: TTH is a clinical diagnosis based on ICHD-3 criteria [1]
No investigations required if typical presentation and normal examination [2,3]
Headache Diary: Essential for classification and treatment monitoring [2]

When to Investigate (Red Flags)

Investigation	Indication
MRI Brain (± Contrast, ± MRV)	Atypical features, Red flags, Neurological signs
CT Brain	Acute severe headache, Thunderclap
Lumbar Puncture	Suspected SAH (CT-negative), Infection, Idiopathic Intracranial Hypertension
ESR/CRP	Age > 50 (Giant Cell Arteritis)
Blood Tests	Exclude systemic causes if indicated

ICHD-3 Diagnostic Criteria

Episodic TTH (Infrequent or Frequent): [1]

A. At least 10 episodes fulfilling criteria B-D B. Duration 30 minutes to 7 days C. At least 2 of:

Bilateral location
Pressing/tightening (non-pulsating) quality
Mild or moderate intensity
Not aggravated by routine physical activity D. Both of:
No nausea or vomiting
No more than one of photophobia or phonophobia E. Not better accounted for by another ICHD-3 diagnosis

Chronic TTH: ≥15 days/month for > 3 months + above features (Mild nausea permitted). [1]

7. Management

Management Algorithm

General Principles

Principle	Details
Explanation	Explain diagnosis, Reassure benign, Explain mechanisms [2]
Headache Diary	Track frequency, Intensity, Triggers, Medication use before and during treatment [2]
Set Expectations	Chronic TTH difficult to cure. Goal is reduction, Not elimination. [2]
Multimodal Approach	Combine pharmacological and non-pharmacological [2,6]
Address Comorbidities	Treat depression, Anxiety, Sleep disorders [18]
Avoid Medication Overuse	Limit acute analgesics to less than 10-15 days/month [3]
Regular Follow-Up	Monitor response, Adjust treatment, Prevent MOH [2,3]

Acute Treatment

First-Line Analgesics - Detailed:

Drug	Dose	Maximum Daily	Onset	Duration	Notes
Paracetamol (Acetaminophen)	1000mg PO	4000mg/day (3000mg in elderly/liver disease)	30-60 min	4-6 hours	First choice. Safe. No GI effects. Hepatotoxicity if overdose. [5]
Ibuprofen	400mg PO	1200-2400mg/day	30-60 min	4-6 hours	Effective. GI caution. CI in renal disease, CV risk, Pregnancy. [5]
Aspirin	600-900mg PO	3600mg/day	30-60 min	4-6 hours	Alternative NSAID. Avoid in under 16s (Reye syndrome).
Naproxen	500mg PO	1000mg/day	1-2 hours	8-12 hours	Longer acting. Good for persistent episodes.
Diclofenac	50mg PO	150mg/day	30-60 min	6-8 hours	Alternative NSAID.

Number Needed to Treat (NNT) for Pain-Free at 2 Hours: [5]

Drug	Dose	NNT vs Placebo
Ibuprofen	400mg	~4-5
Paracetamol	1000mg	~5-6
Aspirin	1000mg	~4-5

Combination Analgesics:

Combination	Evidence	Notes
Paracetamol + Caffeine (65-130mg)	Slightly more effective than paracetamol alone [5]	NNT ~4
Aspirin + Caffeine	Slightly more effective	Available OTC
Paracetamol + Codeine	Not recommended [2,3]	Risk of MOH, Dependence
Compound analgesics with multiple agents	Not recommended [3]	Higher MOH risk

Acute Treatment Principles:

Principle	Details
Treat Early	Take medication at first sign of headache [2]
Adequate Dose	Subtherapeutic doses are ineffective [2]
Limit Frequency	Maximum 2 days/week to prevent MOH [2,3]
Avoid Opioids	High MOH risk. NOT indicated for TTH. [2,3]
Avoid Triptans	Not effective for pure TTH (No evidence of efficacy) [2]
Track Usage	Headache diary to monitor medication days [2]

Side Effects of Acute Treatments:

Drug Class	Side Effects	Cautions/Contraindications
Paracetamol	Hepatotoxicity (overdose). Generally safe.	Liver disease. Alcohol abuse. Max 4g/day.
NSAIDs	GI ulceration, Bleeding, Renal impairment, CV events, Fluid retention	Renal disease, GI ulcer history, CV disease, Pregnancy, Aspirin-sensitive asthma
Caffeine	Insomnia, Anxiety, Palpitations, Rebound headache	Anxiety disorders. Evening dosing.

Prophylactic Treatment

Indications for Prophylaxis: [2]

Indication	Details
Frequency	2 or more headache days/week (8 or more days/month)
Chronic TTH	15 or more days/month
Significant Disability	Impact on work, Social life, Quality of life
Medication Overuse Risk	Using acute treatments 10 or more days/month or approaching this
Poor Acute Response	Inadequate relief from analgesics
Patient Preference	Prefers preventive approach

First-Line Prophylaxis - Amitriptyline: [2,4,8]

Parameter	Details
Drug	Amitriptyline (Tricyclic antidepressant)
Starting Dose	10-25mg nocte
Titration	Increase by 10-25mg every 1-2 weeks
Target Dose	30-75mg nocte (Some patients need 100mg)
Time to Efficacy	4-6 weeks at adequate dose
Mechanism	Enhances serotonin and noradrenaline, Modulates descending pain pathways [8]

Amitriptyline Side Effects:

Side Effect	Frequency	Management
Sedation/Drowsiness	Common	Take at night. Dose-related. May reduce over time.
Dry Mouth	Common	Sugar-free gum/sweets. Adequate hydration.
Weight Gain	Common	Dietary advice. Exercise. Consider nortriptyline.
Constipation	Common	Fibre, Fluids, Laxatives.
Urinary Retention	Occasional	Caution in prostate disease.
Blurred Vision	Occasional	Usually transient.
Cognitive Slowing	Occasional	Start low. May limit use in elderly.
Cardiac Effects	Rare	ECG if cardiac history. QT prolongation.
Overdose Toxicity	Serious	Prescribe limited quantities.

Contraindications to Amitriptyline:

Contraindication	Alternative
Recent MI	Venlafaxine, Non-pharmacological
Arrhythmia	Avoid tricyclics
Narrow-angle Glaucoma	Consider venlafaxine
Urinary Retention/Prostate	Use with caution or avoid
Pregnancy	Avoid or discuss with obstetrics
Elderly with Falls Risk	Low dose or alternative

Second-Line Prophylaxis: [2,8]

Drug	Dose	Mechanism	Notes
Nortriptyline	10-75mg nocte	Tricyclic (NE greater than 5-HT)	Less sedating than amitriptyline. Less anticholinergic.
Mirtazapine	15-30mg nocte	Noradrenergic and specific serotonergic (NaSSA)	Sedating. Weight gain. Good if depression comorbid.
Venlafaxine	75-150mg OD	SNRI	Less sedating. GI side effects. Withdrawal syndrome. [22]
Duloxetine	30-60mg OD	SNRI	Alternative to venlafaxine.

Third-Line/Specialist:

Drug	Dose	Notes
Topiramate	50-100mg BD	Weight loss. Cognitive effects. Limited evidence in TTH.
Gabapentin	300-600mg TDS	May help some patients.
Botulinum Toxin A	Injections	Not approved for TTH. Limited evidence.
Muscle Relaxants (Tizanidine)	2-8mg nocte	Some evidence. Sedating.

Prophylaxis Trial and Duration:

Phase	Details
Adequate Trial	4-6 weeks at target dose (Not just starting dose) [2]
If Ineffective	Switch to alternative class [2]
If Effective	Continue for 6-12 months [2]
Withdrawal	Taper slowly. Monitor for recurrence. [2]
Reassess	If headaches return, Consider reinstitution. [2]

Non-Pharmacological Management (Essential)

Importance: [2,6]

Must be part of management for ALL patients with frequent/chronic TTH
May be as effective as medication in some patients
Reduces medication dependence
Addresses underlying mechanisms

Stress Management:

Intervention	Details
Identify Stressors	Work, Family, Financial. Diary can help.
Lifestyle Modification	Reduce overcommitment. Time management.
Work-Life Balance	Boundaries. Holidays.
Social Support	Friends, Family, Support groups.

Relaxation Techniques: [6]

Technique	Description	Evidence
Progressive Muscle Relaxation (PMR)	Sequential tensing and relaxing of muscle groups	Strong
Diaphragmatic Breathing	Slow, Deep abdominal breathing	Strong
Guided Imagery	Visualisation of relaxing scenes	Moderate
Mindfulness Meditation	Present-moment awareness. Non-judgemental.	Growing
Yoga	Combines physical postures, Breathing, Relaxation	Moderate

Cognitive Behavioural Therapy (CBT): [6]

Aspect	Details
Targets	Negative thought patterns, Pain catastrophising, Avoidance behaviours
Components	Cognitive restructuring, Behavioural activation, Relaxation training
Delivery	Individual or group. 6-10 sessions typically.
Evidence	Strong for chronic TTH. Equal to amitriptyline in some studies. [6]
Access	IAPT (NHS), Private, Online programmes (e.g., Headspace, apps)

Biofeedback: [6]

Type	Description	Mechanism
EMG Biofeedback	Measures muscle tension (e.g., Frontalis). Visual/audio feedback.	Patient learns to reduce muscle tension.
Thermal Biofeedback	Measures skin temperature (peripheral blood flow)	Promotes relaxation response.
Evidence	Strong for TTH. Often combined with relaxation. [6]
Availability	Limited. Specialist centres.

Physiotherapy: [6,19]

Intervention	Details
Postural Assessment	Identify forward head posture, Rounded shoulders
Postural Correction	Exercises, Ergonomic advice, Strengthening
Manual Therapy	Massage, Mobilisation of cervical spine, Trigger point release
Stretching	Neck, Shoulder, Upper back stretches
Strengthening	Deep neck flexors, Scapular stabilisers
Evidence	Moderate. May reduce headache frequency. [6]

Exercise:

Details	Recommendation
Type	Aerobic (Walking, Swimming, Cycling)
Frequency	3-5 times/week
Duration	30-45 minutes
Intensity	Moderate
Mechanism	Endorphin release, Stress reduction, Improved sleep
Evidence	Moderate for headache prevention

Acupuncture: [6]

Details	Description
Traditional Chinese	Needling of specific points
Mechanism Proposed	Endorphin release, Central modulation
Evidence (Cochrane)	Moderate. As effective as sham in some studies. May be helpful. [6]
Recommendation	Can consider if available and patient interested

Sleep Hygiene: [18]

Recommendation	Details
Regular Schedule	Same bedtime and wake time
Environment	Dark, Quiet, Cool bedroom
Avoid Screens	1 hour before bed
No Caffeine	After 2pm
No Alcohol	As sleep aid (Disrupts sleep architecture)
Treat Sleep Disorders	Sleep apnoea, Insomnia

Ergonomic Assessment:

Area	Intervention
Desk Setup	Monitor at eye level, Keyboard at elbow height, Chair support
Screen Breaks	20-20-20 rule (Every 20 min, Look 20 feet away, 20 seconds)
Driving	Adjust seat and mirrors, Take breaks on long journeys
Reading/Phone	Avoid prolonged neck flexion

Medication Overuse Headache (MOH)

[!WARNING] Suspect MOH if: [3]

Headache occurs 15 or more days/month

Regular use of acute medication for 3 months or more

Threshold: Simple analgesics 15 or more days/month OR Triptans/Opioids/Ergots/Combinations 10 or more days/month

MOH Management Protocol: [3]

Step	Details
1. Recognise and Diagnose	History of escalating medication use. Headache worsening.
2. Educate Patient	Explain concept. Medication is perpetuating, Not helping.
3. Set Expectations	Withdrawal will cause temporary worsening (1-4 weeks). Improvement expected after.
4. Plan Withdrawal	Abrupt (Preferred for simple analgesics) OR Gradual (Opioids, Barbiturates).
5. Bridge Therapy	Start prophylactic medication (Amitriptyline). Consider short course of bridge analgesic (Naproxen 500mg BD for 2 weeks).
6. Support	Regular follow-up. Manage withdrawal symptoms (Nausea, Anxiety, Insomnia).
7. Post-Withdrawal	Maintain headache diary. Limit acute use to less than 10 days/month.

Withdrawal Symptoms: [3]

Symptom	Duration
Worsening Headache	Peak 2-7 days. Improves 2-4 weeks.
Nausea/Vomiting	1-2 weeks
Anxiety	Variable
Sleep Disturbance	1-2 weeks
Tachycardia, Sweating	If opioids

Referral Criteria

Indication	Referral Target
Diagnostic Uncertainty	Neurology/Headache Specialist
Red Flags / Need Investigation	Neurology, Emergency if acute
Treatment Failure	Headache Specialist. After 2-3 medication trials.
Chronic TTH	Consider specialist for multidisciplinary approach
Medication Overuse Headache	Specialist, Headache clinic [3]
Significant Psychiatric Comorbidity	Liaison Psychiatry, Psychology [18]
Workplace Disability	Occupational Health
Physiotherapy Needs	Musculoskeletal Physiotherapy [19]

8. Complications

Overview

Complication Type	Timeframe	Key Concerns
Immediate	During attack	Functional impairment, Medication side effects
Short-term	Days-Weeks	Medication overuse, Acute treatment side effects
Long-term	Months-Years	Chronification, Psychiatric comorbidity, Quality of life [17,18]

Immediate Complications

Complication	Description	Management
Functional Impairment	Reduced concentration, Productivity loss despite continuing activities	Acute treatment, Rest if needed
Work/School Impact	Reduced performance, Presenteeism [17,18]	Treat attack, Modify activities
Mood Effects	Irritability, Frustration during attacks	Reassurance, Resolve headache
Analgesic Side Effects (Acute)	GI upset (NSAIDs), Drowsiness (Some combinations)	Use appropriate medications

Short-Term Complications (Days-Weeks)

Complication	Incidence	Description	Prevention/Management
Medication Overuse Headache (MOH)	1-2% of population [3]	Paradoxical worsening with frequent analgesic use. Threshold: Simple analgesics 15+ days/month, Triptans/Opioids 10+ days/month.	Limit acute medications to less than 10-15 days/month. Educate. Withdraw if established. [3]
NSAID-Related GI Complications	Variable	Gastritis, Peptic ulcer, GI bleeding with frequent use	Use lowest effective dose. Short courses. PPI if recurrent NSAID needed.
Paracetamol Hepatotoxicity	Rare if dosed correctly	Risk with overdose or chronic excess (greater than 4g/day)	Dose correctly. Avoid in liver disease.
NSAID Renal Effects	Rare with episodic use	Reduced GFR, Salt/water retention with chronic use	Avoid in renal impairment. Monitor if chronic use.
Prophylactic Medication Side Effects	Variable	Amitriptyline: Dry mouth, Sedation, Weight gain, Constipation	Start low, Titrate slowly, Manage side effects.

Long-Term Complications (Months-Years)

Complication	Description	Risk Factors	Prevention/Management
Chronification	Transition from Episodic TTH to Chronic TTH (15+ days/month) [17]	Frequent episodes, Medication overuse, Stress, Psychiatric comorbidity, Poor sleep [16,18]	Early prophylaxis, Avoid MOH, Stress management, Treat comorbidites
Medication Overuse Headache	Chronic daily/near-daily headache perpetuated by frequent acute medication use [3]	Frequent analgesic use, Pre-existing high frequency	Patient education, Limit acute use, Monitor headache diary [3]
Depression	Significantly elevated risk in chronic TTH [18]	Chronic pain, Disability, Central sensitisation overlap	Screen routinely (PHQ-9). Treat if present. Amitriptyline has dual benefit.
Anxiety	Common comorbidity [18]	Chronic pain, Worry about headaches, Anticipatory anxiety	Screen (GAD-7). CBT. Treat if indicated. [6]
Reduced Quality of Life	TTH underestimated. Chronic TTH can be as disabling as migraine. [17,18]	Chronic disease, Psychiatric comorbidity	Comprehensive management, Psychological support
Social Isolation	May avoid activities due to headaches [18]	Chronic, Severe	Encourage activity, Psychological support
Occupational Disability	Lost workdays, Reduced career progression [17]	Chronic, frequent TTH	Occupational health input, Workplace modifications
Healthcare Overutilisation	Repeated consultations, Investigations, Referrals	Diagnostic uncertainty, Treatment failure	Clear diagnosis, Management plan, Follow-up
Polypharmacy	Multiple failed medications	Treatment-resistant chronic TTH	Rationalise. Specialist input.

Medication Overuse Headache - Detailed

Aspect	Details
Definition	Headache 15+ days/month in patient with pre-existing headache, with regular overuse of acute medication for greater than 3 months [3]
Thresholds	Simple analgesics: 15+ days/month. Triptans, Opioids, Ergots, Combinations: 10+ days/month. [3]
Mechanism	Central sensitisation, Reduced descending inhibition, Receptor changes [3,16]
Recognition	Escalating medication use, Worsening headache despite treatment, Daily/near-daily headache [3]
Prognosis	Most improve after withdrawal. 40-50% relapse at 1 year. [3]
Prevention	Patient education. Headache diary. Limit acute use. Early prophylaxis. [2,3]

9. Prognosis & Outcomes

Natural History

Subtype	Natural History	Notes
Infrequent Episodic TTH	Self-limiting. Many never seek medical attention. [17]	Excellent prognosis.
Frequent Episodic TTH	May persist. Risk of chronification if risk factors present. [17]	May require prophylaxis. [2]
Chronic TTH	Persistent in many. May fluctuate. Spontaneous remission possible but uncommon. [17]	Challenging to treat.

Outcomes with Treatment

Intervention	Outcome	Notes
Acute Treatment (Paracetamol/NSAIDs)	Pain relief in 60-70% [5]	NNT ~4-6 for pain-free at 2 hours
Amitriptyline Prophylaxis	40-50% achieve 50% or greater reduction in headache days [4,8]	Considered successful response
Non-Pharmacological (CBT, Relaxation)	Comparable to medication in some studies [6]	Particularly effective in chronic TTH
Combined Approach	May be more effective than single modality [2]	Recommended for chronic TTH

Long-Term Outcomes

Outcome	Timeframe	Details
Remission (Chronic TTH)	3 years	~15-20% achieve remission [17]
Improvement	1-3 years	Many improve with treatment, Even if not remission [2]
Fluctuation	Variable	Chronic may become episodic and vice versa
MOH Resolution	2-4 weeks	Improvement expected after withdrawal period [3]

Disability Impact

Condition	Disability Level	Comparison
Infrequent Episodic TTH	Minimal	-
Frequent Episodic TTH	Mild-Moderate [17]	Intermittent productivity loss
Chronic TTH	Significant [17,18]	Comparable to chronic migraine

Prognostic Factors

Factors Associated with Good Prognosis:

Factor	Reason
Infrequent Episodes	Low risk of progression [17]
Short Duration of Chronic TTH	Earlier intervention
No Medication Overuse	Avoids MOH complication [3]
Good Response to Acute Treatment	Disease control achievable
No Psychiatric Comorbidity	Fewer perpetuating factors [18]
Identifiable Modifiable Triggers	Can address directly
Engagement with Non-Pharmacological Treatment	Addresses underlying mechanisms [6]
Good Social Support	Resources for coping

Factors Associated with Poor Prognosis:

Factor	Reason	Intervention
Chronic TTH	Established central sensitisation [16]	Comprehensive, Long-term management
Medication Overuse	Perpetuates headache [3]	Withdraw, Educate
Depression/Anxiety	Amplifies pain, Reduces coping [18]	Treat aggressively
Poor Sleep	Affects pain modulation [18]	Sleep hygiene, Treat disorders
High Pericranial Tenderness	Marker of severity, Peripheral input [19]	Physiotherapy
Multiple Failed Treatments	Treatment-resistant	Specialist referral
High Baseline Frequency	Harder to reduce	Intensive management
Low Socioeconomic Status	Limited access to care	Address barriers

Mortality

TTH is a benign condition with no direct mortality. However:

Chronic pain syndromes are associated with reduced life expectancy due to comorbidities (Depression, Reduced activity)
Medication complications (NSAID-related events) can rarely be serious

10. Evidence & Guidelines

Key Guidelines

Guideline	Organisation	Key Recommendations
ICHD-3 Classification	International Headache Society (2018) [1]	Diagnostic criteria for TTH subtypes
EFNS Guideline	European Federation of Neurological Societies [2]	Paracetamol/NSAIDs acute; Amitriptyline prophylaxis
NICE Headache Guideline	NICE CG150 (2012, Updated 2021) [3]	Diagnosis, Acute treatment, Prophylaxis, MOH management

Landmark Trials/Evidence

Amitriptyline for Chronic TTH (Bendtsen et al., 2000) [4]

RCT, n=60, Chronic TTH
Amitriptyline vs Placebo
Result: Significant reduction in headache area-under-curve, myofascial tenderness, and analgesic use
Impact: Established amitriptyline as first-line prophylaxis
PMID: 11075846

NSAIDs for Episodic TTH (Cochrane Review, 2015) [5]

Meta-analysis of RCTs
Result: Ibuprofen 400mg, Aspirin 1000mg superior to placebo
NNT ~4-5 for pain-free at 2 hours
PMID: 26230487

Acupuncture for TTH (Cochrane Review, 2016) [6]

Meta-analysis of RCTs
Result: Acupuncture more effective than no treatment. May be as effective as prophylactic drugs.
PMID: 27045188

Tricyclic Antidepressants Meta-Analysis (Jackson et al., 2010) [8]

Systematic review and meta-analysis
Result: Tricyclics reduce chronic TTH headache frequency
NNT ~3 for 50% reduction in headaches
PMID: 20961988

Evidence Strength

Intervention	Level	Key Evidence
Simple Analgesics (Acute)	1a	Multiple RCTs, Cochrane review [5]
Amitriptyline (Prophylaxis)	1b	RCTs (Bendtsen et al.) [4,8]
Physiotherapy	2a	Multiple RCTs [6]
CBT/Relaxation	2a	Multiple RCTs [6]

11. Patient/Layperson Explanation

What is Tension-Type Headache?

Tension-type headache is the most common type of headache – most people will experience it at some point. [9] It feels like a tight band or pressure around your head, like wearing a hat that's too tight.

Key Features:

Pain is usually on both sides of your head [1]
It feels like pressing or tightening (not throbbing) [1]
The pain is mild to moderate – annoying but doesn't usually stop you doing things [1]
Unlike migraine, walking around or activity doesn't make it worse [1]
You don't usually feel sick or need to lie in a dark room [1]

Why Does It Happen?

The exact cause isn't fully understood, but it involves several factors: [10,16]

Factor	Explanation
Muscle Tension	Tight muscles in the head, Neck, And shoulders can trigger pain [19]
Stress	Mental stress and tension contribute to muscle tightness and pain sensitivity [16]
Central Sensitisation	In chronic cases, The brain's pain system becomes more sensitive [16]
Poor Sleep	Lack of sleep or poor quality sleep can trigger headaches [18]
Posture	Poor posture (e.g., At a desk, Looking at screens) strains muscles [19]
Anxiety and Depression	These can make headaches worse and more difficult to treat [18]
Dehydration and Skipped Meals	Common triggers for some people
Eye Strain	Prolonged screen use without breaks

Types of Tension-Type Headache

Type	How Often	What It Means
Infrequent Episodic	Less than once a month [1]	Very common. Usually no treatment needed.
Frequent Episodic	1-14 days per month [1]	May need treatment to prevent headaches
Chronic	15 or more days per month [1]	Needs preventive treatment. See a doctor.

How is it Different from Migraine?

Feature	Tension-Type Headache	Migraine
Location	Both sides of head [1]	Often one side [20]
How it Feels	Pressing, Tightening [1]	Throbbing, Pulsating [20]
Intensity	Mild-Moderate [1]	Moderate-Severe [20]
Activity	Doesn't make it worse [1]	Makes it worse [20]
Nausea	No (Maybe mild in chronic) [1]	Often present [20]
Light/Sound Sensitivity	Usually none [1]	Common [20]
Aura (Visual symptoms)	Never [1]	Sometimes before migraine [20]

Many people have both migraine and tension headaches at different times. [20]

How is it Treated?

For Occasional Headaches (Less Than 2 Days Per Week):

Medication	How to Use	Important Points
Paracetamol	1000mg (2 x 500mg tablets) [5]	Safe for most people. Can take every 4-6 hours. Max 8 tablets (4g) in 24 hours.
Ibuprofen	400mg (2 x 200mg tablets) [5]	Take with food. Avoid if you have stomach problems, Kidney disease, Or heart disease.
Aspirin	600-900mg	Alternative to ibuprofen. Not for under 16s.

Tips for Taking Painkillers:

Take them early – They work better at the start of a headache [2]
Take the full dose – Half a dose often doesn't work [2]
Don't use too often – Using painkillers more than 10-15 days per month can make headaches worse (Medication Overuse Headache) [3]

For Frequent Headaches (More Than 2 Days Per Week):

If you're having headaches this often, You should see your doctor. They may recommend: [2]

Treatment	What It Is	What to Expect
Amitriptyline	A low-dose tablet taken at night [2,4,8]	Takes 4-6 weeks to work. May cause drowsiness, Dry mouth. Not an antidepressant at this dose.
Other Preventive Medications	Alternatives if amitriptyline doesn't work [2]	Your doctor will discuss options

Self-Help Strategies

Stress Management:

Identify what's causing stress in your life
Take regular breaks during work
Make time for activities you enjoy
Consider apps like Headspace or Calm for relaxation

Relaxation Techniques: [6]

Breathing exercises – Slow, Deep breaths from your belly
Progressive muscle relaxation – Tense then relax each muscle group
Meditation – Even 10 minutes a day can help
Yoga – Combines relaxation with gentle exercise

Sleep: [18]

Aim for 7-8 hours per night
Keep a regular sleep schedule
Avoid screens for 1 hour before bed
Make your bedroom dark, Quiet, And cool

Exercise:

Regular moderate exercise (Walking, Swimming, Cycling) helps prevent headaches
Aim for 30 minutes, 3-5 times per week
Exercise releases natural painkillers (endorphins)

Posture and Ergonomics: [19]

If you work at a desk, Make sure your screen is at eye level
Take breaks every 30 minutes – Look away from the screen
Check your posture – Shoulders back, Head not jutting forward

Hydration and Meals:

Drink plenty of water throughout the day
Don't skip meals
Limit caffeine (Coffee, Tea, Cola) – Too much can cause rebound headaches

Medication Overuse Headache – Important Warning

[!WARNING] Using Painkillers Too Often Can Make Headaches WORSE [3]

If you're taking painkillers for headaches more than 10-15 days per month for 3 months or more, You may develop Medication Overuse Headache. This is a frustrating cycle where the painkillers that were helping now make the headaches come back more often.

Signs of Medication Overuse Headache:

Headaches are more frequent than before

Painkillers don't work as well as they used to

You feel you need painkillers every day

What to Do:

See your doctor – They can help you stop the cycle

Stopping the overused painkillers is the treatment (This is hard, But headaches improve after 2-4 weeks) [3]

When to See a Doctor

See Your GP if:

Headaches are getting more frequent or severe
You're using painkillers more than 2 days per week
Headaches are affecting your work or daily life
Treatment isn't working

Seek Urgent Medical Attention if:

Sudden severe headache – The worst headache of your life (Call 999)
New headache after age 50
Fever with headache
Vision changes, Weakness, Numbness, Confusion, or Difficulty speaking
Headache after head injury
Headache with stiff neck (Unable to touch chin to chest)

Frequently Asked Questions

Q: Is tension-type headache caused by actual tension or stress? A: The name is a bit misleading. While stress can trigger them, The "tension" refers to tight muscles in the head and neck. [19] Central brain mechanisms are also involved, Especially in chronic cases. [16]

Q: Can I become addicted to painkillers? A: Simple painkillers like paracetamol and ibuprofen are not addictive in the classic sense. However, Using them too often can cause Medication Overuse Headache, Where your body becomes dependent on them and headaches get worse. [3]

Q: Is amitriptyline an antidepressant? Am I depressed? A: No, You're not being treated for depression. Amitriptyline is also used at low doses for pain prevention. The doses used for headaches are much lower than those for depression. [8]

Q: How long will I need to take preventive medication? A: Usually 6-12 months. After that, Your doctor may suggest slowly stopping to see if headaches stay improved. [2]

Q: Will I have these headaches forever? A: Many people's headaches improve over time, Especially with good management. Chronic TTH is more persistent, But treatments can reduce how often you get headaches. [17]

Q: Are there any tests to diagnose tension-type headache? A: No, It's diagnosed based on your symptoms. Tests (Brain scans) are only needed if there are warning signs of something else. [1,2]

Support Resources

Resource	Details
NHS Website	www.nhs.uk – Search "Tension headache" for information
Migraine Trust	www.migrainetrust.org – Also covers tension headache information
Headache UK	www.headache.org.uk – Patient resources
Your GP	First point of contact for persistent headaches

12. References

Primary Guidelines

Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1-211. PMID: 29368949
Bendtsen L, et al. EFNS guideline on the treatment of tension-type headache. Eur J Neurol. 2010;17(11):1318-25. PMID: 20482606
National Institute for Health and Care Excellence. Headaches in over 12 s: diagnosis and management (CG150). NICE. 2012, Updated 2021. Link

Landmark Trials

Bendtsen L, Jensen R. Amitriptyline reduces myofascial tenderness in patients with chronic tension-type headache. Cephalalgia. 2000;20(6):603-10. PMID: 11075846
Derry S, et al. Ibuprofen for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev. 2015;7:CD011474. PMID: 26230487
Linde K, et al. Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2016;4:CD007587. PMID: 27045188

Systematic Reviews

Verhagen AP, et al. Treatment of tension-type headache: a systematic review. Cephalalgia. 2010;30(12):1-16.
Jackson JL, et al. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ. 2010;341:c5222. PMID: 20961988

Additional References

Stovner LJ, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27(3):193-210. PMID: 17381554
Jensen R. Pathophysiological mechanisms of tension-type headache. Cephalalgia. 2001;21(7):786-9. PMID: 11595012
Ashina S, et al. Tension-type headache. Nat Rev Dis Primers. 2021;7(1):24. PMID: 33790276
Silberstein SD. Tension-type headache: classification and management. Continuum (Minneap Minn). 2015;21(4):968-981. PMID: 26252584
Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. 2008;7(1):70-83. PMID: 18093564
Bendtsen L, et al. Guidelines for controlled trials of drugs in tension-type headache. Cephalalgia. 2010;30(1):1-16. PMID: 19614702
Crystal SC, Robbins MS. Epidemiology of tension-type headache. Curr Pain Headache Rep. 2010;14(6):449-454. PMID: 20865353
Bendtsen L, Fernández-de-la-Peñas C. The role of muscles in tension-type headache. Curr Pain Headache Rep. 2011;15(6):451-458. PMID: 21735049
Schwartz BS, et al. Epidemiology of tension-type headache. JAMA. 1998;279(5):381-3. PMID: 9459472
Fernández-de-las-Peñas C, et al. The burden of headache is associated to pain interference, depression and headache duration in chronic tension type headache: a 1-year longitudinal study. J Headache Pain. 2018;19(1):2. PMID: 29285577
Fernández-de-las-Peñas C, et al. Manual palpation of trigger points in the cranio-cervical muscles increases pain and headache intensity in chronic tension type headache. J Headache Pain. 2018;19(1):89. PMID: 30255447
Kaniecki RG. Debate: differences and similarities between tension-type headache and migraine. Headache. 2023;63(7):860-866. PMID: 37474899
Schmidt-Wilcke T, et al. Neurobiology of chronic tension-type headache. CNS Spectr. 2004;9(3):192-8. PMID: 15009009
Holroyd KA, et al. Venlafaxine in the prophylaxis of chronic tension-type headache: a randomized, placebo-controlled trial. Cephalalgia. 2010;30(3):346-353. PMID: 19614686

13. Examination Focus

Common Exam Questions

MRCP/MRCGP: "A 35-year-old office worker presents with bilateral, pressing headaches for 3 months, occurring 10 days/month. No nausea. Not worsened by activity. What is the most likely diagnosis and first-line prophylaxis?"
- Answer: Frequent Episodic Tension-Type Headache. First-line prophylaxis: Amitriptyline. [2,8]
Clinical Exam: "How do you differentiate tension-type headache from migraine?"
- Answer: TTH: Bilateral, Pressing/non-pulsating, Mild-moderate, Not worsened by activity, No nausea/vomiting. [1] Migraine: Often unilateral, Pulsating, Moderate-severe, Worsened by activity, Nausea/vomiting, Photo/phonophobia. [20]
Short Answer: "What clinical sign supports a diagnosis of TTH on examination?"
- Answer: Pericranial muscle tenderness on palpation. [19]
Therapeutics: "What medication would you use for prophylaxis of chronic tension-type headache?"
- Answer: Amitriptyline 10-75mg nocte. [2,4,8]
Clinical Scenario: "A patient with frequent headaches has been taking paracetamol daily for 6 months. What diagnosis and management?"
- Answer: Medication Overuse Headache. Educate, Withdraw analgesics, Bridge with preventive, Support through withdrawal. [3]

Viva Points

Opening Statement:

"Tension-type headache is the most common primary headache disorder, characterised by bilateral, non-pulsating, pressing headache of mild-moderate intensity that is not aggravated by physical activity. It is classified by ICHD-3 as infrequent episodic, frequent episodic, or chronic based on frequency." [1]

Key Facts to Mention:

Lifetime prevalence ~80% [9]
Bilateral, pressing, mild-moderate, not worsened by activity [1]
No nausea/vomiting (Max 1 of photo/phonophobia) [1]
Paracetamol/NSAIDs for acute [5]
Amitriptyline for prophylaxis [2,4,8]

Classification to Quote:

"ICHD-3 classifies TTH into Infrequent Episodic (less than 1 day/month), Frequent Episodic (1-14 days/month), and Chronic (≥15 days/month)" [1]

Evidence to Cite:

"The EFNS guideline recommends amitriptyline as first-line prophylaxis" [2]
"Cochrane reviews support NSAIDs for acute treatment" [5]

Common Mistakes

What fails candidates:

❌ Confusing TTH with migraine (Especially regarding nausea/activity)
❌ Not knowing ICHD-3 diagnostic criteria
❌ Forgetting to mention amitriptyline for prophylaxis
❌ Ignoring medication overuse headache in frequent analgesic users
❌ Ordering unnecessary investigations for typical TTH

Dangerous Errors:

⚠️ Missing red flags for secondary headache
⚠️ Prescribing opioids or codeine (Risk of MOH) [3]

Outdated Practices:

Describing TTH as purely "muscular" – Central sensitisation is key in chronic [16]
Using "tension" to mean stress – Pericranial muscle mechanisms are peripheral component [19]

Examiner Follow-Up Questions

"What would you do if amitriptyline fails?"
- Answer: Try nortriptyline, mirtazapine, or venlafaxine. Combine with non-pharmacological therapies. [2,22]
"What is the evidence for physiotherapy?"
- Answer: Moderate evidence from RCTs. Manual therapy and exercise beneficial as adjuncts. [6]
"How long would you trial prophylaxis before deeming it ineffective?"
- Answer: 4-6 weeks at adequate dose. [2]
"When would you image this patient?"
- Answer: Red flags (Thunderclap, > 50yo new onset, Neurological signs, Systemic symptoms).

14. Pharmacology Deep Dive: Beyond Amitriptyline

When the first line fails, we move to "cleaner" or different mechanisms.

A. Second-Line Prophylaxis

Venlafaxine (SNRI): [22]
- Mechanism: Dual Serotonin/Noradrenaline reuptake inhibition.
- Dose: 75-150 mg XR daily.
- Evidence: RCT supports efficacy in chronic TTH (CTTH). [22]
Mirtazapine (NaSSA):
- Role: Excellent for patients with Insomnia (Sedating).
- Dose: 15-30 mg at night. can cause weight gain.

B. Muscle Relaxants?

Tizanidine: Alpha-2 agonist. Evidence exists but side effects (drowsiness/hypotension) limit long-term use.
Benzodiazepines: Avoid. High risk of dependence and Medication Overuse Headache (MOH). [3]

C. Botulinum Toxin

TTH Status: Unlike Chronic Migraine (where specific protocols work), Botox is generally NOT recommended for Pure TTH. The evidence is conflicting/negative.

15. The "Cervicogenic" Interface

The neck and head are neurologically fused. [19]

A. The Trigeminocervical Complex (TCC)

Anatomy: The Trigeminal Nucleus Caudalis (Brainstem) descends to the C1-C3 spinal cord segments. [10]
Mechanism: Pain afferents from the Upper Neck (C1-C3) synapse in the SAME place as forehead pain fibers (Trigeminal V1). [10,19]
Result: Referred Pain. Neck pathology feels like a "Frontal Headache". [19]

B. TTH vs Cervicogenic Headache (CGH)

TTH: Bilateral. Pressing. "Featureless". Neck tenderness is secondary. [1]
CGH: Unilateral (usually). Locked neck movements. Provoked by neck pressure. [19]
Overlap: Many Chronic TTH patients have significant neck driver. Treating the neck (Physio) often helps the head. [19]

16. Integrated Care: Biofeedback & Lifestyle

Non-drug options are as potent as drugs for TTH. [6]

A. Biofeedback (EMG)

Concept: Patient watches a screen showing their own Trapezius/Frontalis muscle tension (via surface electrodes). [6]
Goal: Learn to "voluntarily decrease" tone.
Evidence: Level A evidence. Efficacy is comparable to Amitriptyline, with ZERO side effects. [6]

B. Cognitive Behavioral Therapy (CBT)

Target: "Catastrophising" and Stress response. [6]
Outcome: Reduces "Suffering" even if pain frequency persists. [6]

C. The "Water Myth"

Myth: "Dehydration causes all headaches."
Fact: While severe dehydration triggers headache, chronic TTH is rarely cured by just "drinking more water". Sleep and Stress are far bigger drivers. [18]

TTH is the "Forgotten" Headache in terms of research funding, but the "Giant" in terms of economic loss. [17]

Presenteeism: Migraineurs stay home (Absenteeism). TTH sufferers go to work but function at 50% (Presenteeism). This is harder to measure but costs economies billions. [17,18]
Disability: WHO ranks TTH as a major cause of global disability (YLDs). [9,17]
Stigma: "It's just a stress headache." Minimization leads to undertreatment.

Last Reviewed: 2026-01-11 | MedVellum Editorial Team

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and current guidelines.

Clinical board

Urgent signals

Editorial and exam context

Tension-Type Headache

1. Clinical Overview

Summary

Key Facts

Clinical Pearls

Why This Matters Clinically

2. Epidemiology

Incidence & Prevalence

Demographics

Global Burden

Risk Factors and Associations

3. Pathophysiology

Overview

Mechanism (Stepwise)

Pathophysiology Diagram

Classification (ICHD-3)

4. Clinical Presentation

Symptoms - Detailed Analysis

Temporal Pattern

Impact and Disability

Red Flags (Detailed Analysis)

5. Clinical Examination

Structured Approach

Pericranial Muscle Palpation (Key Examination)

Cervical Spine Examination

TMJ Examination

Special Tests

6. Investigations

First-Line (Bedside)

When to Investigate (Red Flags)

ICHD-3 Diagnostic Criteria

7. Management

Management Algorithm

General Principles

Acute Treatment

Prophylactic Treatment

Non-Pharmacological Management (Essential)

Medication Overuse Headache (MOH)

Referral Criteria

8. Complications

Overview

Immediate Complications

Short-Term Complications (Days-Weeks)

Long-Term Complications (Months-Years)

Medication Overuse Headache - Detailed

9. Prognosis & Outcomes

Natural History

Outcomes with Treatment

Long-Term Outcomes

Disability Impact

Prognostic Factors

Mortality

10. Evidence & Guidelines

Key Guidelines

Landmark Trials/Evidence

Evidence Strength

11. Patient/Layperson Explanation

What is Tension-Type Headache?

Why Does It Happen?

Types of Tension-Type Headache

How is it Different from Migraine?

How is it Treated?

Self-Help Strategies

Medication Overuse Headache – Important Warning

When to See a Doctor

Frequently Asked Questions

Support Resources

12. References

Primary Guidelines

Landmark Trials

Systematic Reviews

Additional References

13. Examination Focus

Common Exam Questions

Viva Points

Common Mistakes

Examiner Follow-Up Questions