Tension-type headache

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 7 Aug 2025

Last updated: 01 Apr 2025

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.

Nondrug therapies include acupuncture, relaxation, electromyographic biofeedback, cognitive behavioral therapy, and physical therapy.

Definition

TTHs can be either episodic or chronic. They are the most common type of headache, but are rarely disabling and are typically associated with little or no photophobia, phonophobia, or nausea; thus patients do not usually seek medical care and usually successfully self-treat. The attacks are bilateral and generalized throughout the head with a predilection for the frontal and occipital regions. The pain is typically described as being a "tight band" around the head. It does not worsen with routine physical activity.

History and exam

Key diagnostic factors

generalized head pain
frontal or occipital head pain
nonpulsatile head pain
constricting pain
normal neurologic examination

Full details

Other diagnostic factors

pericranial tenderness
sternocleidomastoid muscle tenderness
trapezius muscle tenderness
temporalis muscle tenderness
lateral pterygoid muscle tenderness
masseter muscle tenderness
photophobia or phonophobia
nausea
regular analgesic use
anxiety and depression
somatization

Full details

Risk factors

mental tension
stress
missing meals
fatigue
lack of sleep
somatization
female sex
age 20-39 years
lower socioeconomic status
analgesic overuse

Full details

Diagnostic investigations

1st investigations to order

clinical diagnosis

Full details

Investigations to consider

CT sinus
MRI brain
lumbar puncture
polysomnography

Full details

Treatment algorithm

ACUTE

acute attack

ONGOING

chronic symptoms (>7-9 headache days/month)

Contributors

Authors

Mark W. Green, MD, FAAN

Professor of Neurology, Anesthesiology and Rehabilitation Medicine

Emeritus Director of Headache and Pain Medicine

Icahn School of Medicine at Mount Sinai

New York

Disclosures

MWG declares that he has no competing interests.

Rachel Colman, MD

Assistant Professor of Neurology

Icahn School of Medicine at Mount Sinai

New York

Disclosures

RC declares that she has no competing interests.

Peer reviewers

Sait Ashina, MD

Assistant Professor of Neurology and Anesthesia

Harvard Medical School

Director of Comprehensive Headache Center

Beth Israel Deaconess Medical Centre

Boston

Disclosures

SA has received honoraria from and is a consultant for Abbvie/Allergan, Eli Lilly, Linpharma, Lundbeck, Satsuma, Teva, Theranica, Percept, and Impel NeuroPharma. SA is an author of one of the references in this topic.

Giles Elrington, MBBS (Hons), MD, FRCP

Consultant Neurologist

Barts Health NHS Trust

London

Disclosures

GE is involved in a number of clinical trials on multiple sclerosis sponsored by Genzyme, Roche, Teva, Novartis, Biogen, as well as one funded by the MRC. He is also involved in clinical trials sponsored by Allergan, NMT Medical, GlaxoSmithKline (GSK), Bristol-Myers, the UK's Parkinson's Disease Research Group, and Pharmacia. In addition, he has attended lectures, conferences, and symposia with the following companies: GSK, AstraZeneca, MSD, Almirall, Pfizer, Menarini, Allergan, Biogen, Teva, Conference Plus, Infomed, BMJ.

Paul Davies, MA, MD, FRCP

Consultant Neurologist

Northampton General Hospital

Northampton

Disclosures

PD declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

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.Full text Abstract

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.Full text Abstract

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;(4):CD007587.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Chronic migraine
- Medication overuse headache
- Sphenoid sinusitis
More Differentials
Guidelines
- Headaches in pregnancy and postpartum: ACOG clinical practice guideline No. 3
- ACR Appropriateness Criteria: headache
More Guidelines
Patient information
Tension-type headache
More Patient information
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Tension-type headache

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acute attack

chronic symptoms (>7-9 headache days/month)

Contributors

Authors

Mark W. Green, MD, FAAN

Disclosures

Rachel Colman, MD

Disclosures

Peer reviewers

Sait Ashina, MD

Disclosures

Giles Elrington, MBBS (Hons), MD, FRCP

Disclosures

Paul Davies, MA, MD, FRCP

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice