Tension-Type Headache

Tension-type headache (TTH) is the commonest headache. It has a very high incidence with most people experiencing a tension-type headache at some point in their lives. There are many subtypes of Tension-type headache. The commonest one is the infrequent episode variant which tends to be mild and self-limiting. However, other people may experience more frequent or chronic tension-type headache and this can be severe. These variants can lead to decreased quality of life and disability.


  • Formerly known as: Tension headache, ordinary headache, muscle contraction headache, stress headache, essential headache, idiopathic headache, psychogenic headache, psychomyogenic headache

Clinical features:

  • The headaches are typically bilateral, have a tension (pressure or tightening) character and may last from minutes to days.
  • The headache is non-pusating and not aggravated by routine physical activity such
    as walking or climbing stairs. There is no vomiting with the headaches. Usually there is no nausea but in severe cases mild nausea may occur. Photophobia or phonophobia may occur but not both.
  • There are no auras or focal neurological signs.
  • Increased pericranial tenderness may occur in tension-type headache. This is often present even when the patient is not experiencing a headache. The pericranial tenderness occurs in the following muscles:  frontalis, temporalis, masseter, pterygoid, sternocleidomastoid, splenius and trapezius.
  • The neurological examination is normal.


International Headache Society IHS criteria:

At least 10 previous headache episodes fulfilling criteria below:

  • Number of days with such headache is < 180/yr (< 15/mo)
  • Headache lasting from 30 min to 7 days
  • At least two of the following pain characteristics:
    • Pressing or tightening (nonpulsating) quality
    • Mild or moderate intensity (may inhibit but does not prohibit activities)
    • Bilateral location
    • No aggravation by walking stairs or similar routine activity
  • Both of the following:
    • No nausea or vomiting (anorexia may occur)
    • Photophobia and phonophobia are absent, or one but not the other is present
  • No evidence of another illness that can explain the headache

Other notes:

Migraine without aura is the commonest differential diagnosis


Treatment is usually with simple analegics like acetaminophen and education to avoid medication over-use headache. In some cases, especially more frequent or chronic variants, other medications may be indicated.

  • Medications in selected patients with frequent headaches:
    • Amitriptyline
    • Mirtazapine and venlafaxine
    • Some consider: SSRI (sertraline, fluoxetine), Propranolol
  • Acupuncture for prophyaxis, at least 6 sessions [good evidence, by multiple RCTs, and 2014 Cochrane systematic review]
  • Address psycho-social stressors
  • Cognitive behavioural therapy and relaxation techniques training for selected patients
  • Electromyography (EMG) biofeedback in selected patients

Related articles:


  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808. doi: 10.1177/0333102413485658. PMID: 23771276
  2. Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, Vickers A, White AR. Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD007587. DOI: 10.1002/14651858.CD007587.pub2. PMID: 27092807
  3. Bendtsen L1, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J; EFNS. EFNS guideline on the treatment of tension-type headache – report of an EFNS task force. Eur J Neurol. 2010 Nov;17(11):1318-25. doi: 10.1111/j.1468-1331.2010.03070.x PMID: 20482606