When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Tension-type headache

Last reviewed: 5 Apr 2025
Last updated: 01 Apr 2025

Summary

Definition

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
Mark W. Green

Professor of Neurology, Anesthesiology and Rehabilitation Medicine

Emeritus Director of Headache and Pain Medicine

Icahn School of Medicine at Mount Sinai

New York

NY

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

NY

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

MA

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

UK

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

UK

Disclosures

PD declares that he has no competing interests.

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
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer