Tension-type headache

Last reviewed: 1 Nov 2023

Last updated: 08 Sep 2022

Tension-type headaches can be either episodic or chronic.

Stress and mental tension are common triggers.

Symptoms include dull, nonpulsatile, bilateral, constricting pain (not severe); pericranial tenderness is common.

Unlike migraine, there is no significant nausea, no vomiting, and a lack of aggravation by routine physical activity.

Usually responds to simple analgesics; preventive treatments have less evidence for their effectiveness.

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

Definition

Tension-type headaches can be either episodic or chronic. They are rarely disabling or associated with any significant autonomic phenomena, thus patients do not usually seek medical care and usually successfully self-treat. The attacks are generalized throughout the head with a predilection for involving the frontal and occipital regions. The pain is typically expressed as being a "tight band" around the head. It does not worsen with routine physical activity.

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History and exam

Key diagnostic factors

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

More key diagnostic factors

Other diagnostic factors

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

Other diagnostic factors

Risk factors

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

More risk factors

Diagnostic investigations

1st investigations to order

clinical diagnosis

More 1st investigations to order

Investigations to consider

CT sinus
MRI brain
lumbar puncture

More investigations to consider

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

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

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.

Marc S. Husid, MD

Director

Walton Headache Center

Augusta

Disclosures

MSH declares that he has no competing interests.

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
- Headaches in pregnancy and postpartum: ACOG clinical practice guideline No. 3
- ACR Appropriateness Criteria: headache
More Guidelines
Patient leaflets
Tension-type headache
More Patient leaflets
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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

Giles Elrington, MBBS (Hons), MD, FRCP

Disclosures

Marc S. Husid, MD

Disclosures

Paul Davies, MA, MD, FRCP

Disclosures

Differentials

Guidelines

Patient leaflets

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