Tension-type headache

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

Last reviewed: 27 Jun 2024

Last updated: 13 Dec 2023

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 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.

BMJ talk medicine: tension headache Opens in new window

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 tests

1st tests to order

clinical diagnosis

Full details

Tests 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.

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

1st tests to order

Tests 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

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

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