What is on the differential diagnosis for Tension-Type Headache?

Key differentials include Migraine, Cluster headache, Medication overuse headache, Cervicogenic headache, Sinus headache, Temporomandibular disorder, Secondary causes (mass, IIH, GCA).

What are the high-yield PANCE pearls for Tension-Type Headache?

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.

Neurology · PANCE / PANRE

Tension-Type Headache

Written & clinically reviewed by Ryan Busch, PA-C · Updated October 2026 · Report an error

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.

Try a board-style Tension-Type Headache question

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Question 1NeurologyMedium

A 28-year-old woman presents with a 6-month history of bilateral, band-like, pressing (non-pulsatile) headaches occurring 2-3 times per week and lasting 4-6 hours. The pain is mild to moderate, is not worsened by routine activity, and is not associated with nausea, vomiting, photophobia, or phonophobia. Neurologic exam is normal. She has not previously tried any therapy. Which of the following is the most appropriate first-line treatment for her acute headaches?

AOral tizanidine
BOral ibuprofen
COral butalbital
DOral sumatriptan
EOral verapamil

Reveal answer & full explanation

Correct answer: B — Oral ibuprofen

AOral tizanidine
BOral ibuprofen✓
COral butalbital
DOral sumatriptan
EOral verapamil

Why oral ibuprofen is correct

Episodic tension-type headache is the most common primary headache disorder: bilateral, pressing or tightening (non-pulsatile) pain of mild to moderate intensity, not aggravated by routine physical activity, and without nausea or significant photophobia/phonophobia
First-line acute therapy is a simple analgesic — NSAIDs (ibuprofen, naproxen) or acetaminophen — with NSAIDs generally preferred for efficacy, per current AAFP and international headache society guidance
Patients should be counseled to limit use to fewer than 10–15 days/month to avoid medication-overuse headache

Why the others are wrong

Oral sumatriptan — 5-HT1B/1D agonist for acute migraine; triptans are not effective for tension-type headache. Trap: buzzword-matching recurrent headache to migraine despite the stem excluding every migraine feature (pulsatile quality, nausea, photophobia/phonophobia, activity aggravation)
Oral verapamil — calcium channel blocker used for cluster headache prophylaxis; it is neither an acute therapy nor a tension-type headache drug. Trap: right-drug-wrong-disease plus prophylaxis-versus-acute confusion
Oral butalbital — butalbital-containing combination analgesics are specifically discouraged for tension-type headache because of sedation, dependence, and a high rate of medication-overuse headache; they are never the opening move in a patient who has tried no therapy. Trap: escalating to a sedative combination pill before a simple analgesic has been tried
Oral tizanidine — centrally acting alpha-2 agonist muscle relaxant that appeals to the idea that tension-type headache is a disorder of tight muscles; muscle relaxants are not supported by good evidence for acute tension-type headache and add sedation and hypotension. Trap: treating the name of the headache instead of choosing the simple analgesic the evidence supports

Additional high-yield points

For frequent or chronic tension-type headache, amitriptyline is first-line prophylaxis

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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

Tension-type headache vs. migraine — key distinguishing features.

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

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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