Neurology · PANCE / PANRE

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

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

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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