Tension-Type Headache
Most common primary headache; bilateral pressing/tightening, mild-moderate, no nausea.
Also known as: TTH, tension headache, muscle contraction headache, stress headache
Overview
Primary headache disorder characterized by bilateral, pressing or tightening (non-pulsating), mild-to-moderate intensity pain lasting 30 minutes to 7 days, without nausea/vomiting and with at most one of photophobia or phonophobia. Subclassified by frequency: infrequent episodic (<1 day/month), frequent episodic (1-14 days/month), and chronic (≥15 days/month for >3 months).
Epidemiology
Lifetime prevalence 30-78% — the most common primary headache disorder. Slight female predominance. Onset typically in teens through 30s.
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Risk factors
- Stress, anxiety, depression
- Poor posture, prolonged static positions (computer work)
- Sleep disturbance
- Skipped meals, dehydration
- Muscle tension in pericranial and cervical muscles
- Caffeine overuse / withdrawal
- Medication overuse (>15 days/month of analgesics)
Pathophysiology
Peripheral mechanisms include increased pericranial muscle tenderness from local nociceptor activation. Central mechanisms predominate in chronic forms: central sensitization at the level of the trigeminocervical complex amplifies pain perception. Genetic factors play a smaller role than in migraine.
Clinical presentation
Symptoms
- Bilateral 'band-like' pressing or tightening pain
- Mild to moderate intensity (does not preclude activities)
- Duration 30 min to 7 days
- NO nausea/vomiting
- At most one of photophobia or phonophobia
- Not aggravated by routine physical activity (unlike migraine)
Signs / physical exam
- Generally normal neurologic exam
- Pericranial tenderness on palpation (temporalis, frontalis, occipitalis, trapezius)
- Possible cervical paraspinal tenderness, limited cervical ROM
Classic findings
Bilateral, non-throbbing, mild-moderate, without autonomic or migrainous features.
Differential diagnosis
- Migraine — Unilateral, pulsating, moderate-severe, with nausea/photo/phonophobia, worse with activity
- Cluster headache — Severe unilateral periorbital, autonomic features, episodic timing, restlessness
- Medication overuse headache — Daily/near-daily headache with frequent acute medication use
- Cervicogenic headache — Mechanical neck pain reproducing the headache; unilateral; limited cervical ROM
- Sinus headache — Facial pressure with nasal congestion/discharge, worse bending forward, fever; though true 'sinus headache' is over-diagnosed and many cases are migraine
- Temporomandibular disorder — Jaw pain, clicking, bruxism; tenderness over TMJ
- Secondary causes (mass, IIH, GCA) — Atypical features, focal deficit, age >50 with new headache, papilledema
Diagnostic workup
Diagnostic criteria
ICHD-3: ≥10 episodes lasting 30 min-7 days, with ≥2 of [bilateral, pressing/tightening, mild-moderate, not aggravated by activity] AND no nausea/vomiting AND ≤1 of [photophobia, phonophobia].
Labs
- Not routinely indicated
- ESR/CRP if temporal arteritis suspected (age >50)
Imaging
- Not indicated for typical TTH with normal exam
- MRI brain only if red flags (SNOOP — systemic, neurologic, onset, older age, pattern change)
Diagnostic algorithm
| Feature | Tension-Type | Migraine |
|---|---|---|
| Location | Bilateral, band-like | Unilateral (60%) |
| Quality | Pressing, tightening (non-pulsatile) | Throbbing, pulsating |
| Intensity | Mild to moderate | Moderate to severe |
| Duration | 30 min to 7 days | 4-72 hours |
| Aggravation by activity | No | Yes |
| Nausea / vomiting | Absent | Present |
| Photo / phonophobia | 0 or 1 of them | Both common |
| First-line acute Rx | NSAID, acetaminophen | NSAID, triptan, gepant |
| First-line prevention | Amitriptyline | Propranolol, topiramate, CGRP mAb |
Treatment
First-line
- NSAIDs — ibuprofen 400-800 mg, naproxen 500 mg — first-line for acute treatment
- Acetaminophen 1000 mg — alternative; less effective than NSAIDs
- Aspirin 650-1000 mg
- Combination analgesics (acetaminophen-aspirin-caffeine) — effective but increase risk of medication overuse headache
- Limit acute medications to <2 days/week to prevent medication overuse headache
Second-line / adjunct
- Prophylaxis indicated for chronic TTH (≥15 days/month) or frequent episodic TTH that interferes with QOL
- Tricyclic antidepressant — amitriptyline 10-75 mg at bedtime (first-line for chronic TTH) — start low, titrate
- Mirtazapine 15-30 mg or venlafaxine 75-150 mg — alternatives
- Non-pharmacologic: relaxation training, biofeedback, cognitive-behavioral therapy, physical therapy with stretching, posture training, acupuncture
- Trigger management: stress reduction, regular sleep, hydration, regular meals, ergonomic workspace
- Address comorbid depression/anxiety
Complications
- Chronic transformation (episodic → chronic TTH)
- Medication overuse headache
- Reduced quality of life, work productivity loss
- Comorbid depression and anxiety
- Overlap with migraine (mixed headache disorder)
PANCE pearls
- If the patient describes a headache severe enough to keep them from work or causes nausea, it is probably migraine — not TTH.
- Tricyclic antidepressants (amitriptyline) are the most effective preventive medication for chronic TTH.
- Non-pharmacologic therapies (relaxation, CBT, PT) have strong evidence and should be offered to all chronic TTH patients.
- Frequent use of acute medications (>2 days/week, especially combination analgesics with caffeine) drives medication overuse headache.
- Always reconsider the diagnosis if 'TTH' worsens, becomes unilateral, or develops new features — could be evolving migraine or secondary cause.
References
- AAN/AHS — Evidence-based Guideline Update: Pharmacologic Treatment for Episodic Migraine Prevention in Adults (Silberstein et al., Neurology 2012) — chronic TTH treatment evidence reviewed concurrently
- ICHD-3 — International Classification of Headache Disorders, 3rd edition (HCC of IHS, Cephalalgia 2018)
- EFNS Guideline — EFNS Guideline on the Treatment of Tension-Type Headache (Bendtsen et al., Eur J Neurol 2010)
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