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Tension headache

Tension-type headache is the most common type of primary headache.A tension-type headache (TTH) is generally a mild to moderate pain that’s often described as feeling like a tight band around the head. A tension-type headache is the most common type of headache, yet its causes aren’t well understood.

Treatments for tension-type headaches are available. Managing a tension-type headache is often a balance between practicing healthy habits, finding effective nondrug treatments and using medications appropriately.


For most of the population, the first onset of TTH is before the second decade of life. The peak prevalence appears to be between 30- 39 years of age. The lifetime prevalence ranges between 30%- 78%. It is seen in both sexes with female preponderance. The studies show that there is slight decrease in the occurrence with advancing age.



Signs and symptoms of a tension-type headache include:

  • Dull, aching head pain
  • Sensation of tightness or pressure across the forehead or on the sides and back of the head
  • Tenderness in the scalp, neck and shoulder muscles

Tension-type headaches are divided into two main categories — episodic and chronic.


  • Episodic TTH (ETTH):- Infrequent episodic, Frequent episodic
  • Chronic TTH (CTTH)
  • Associated with peri cranial tenderness
  • Not associated with peri cranial tenderness


Episodic tension-type headaches

Episodic tension-type headaches can last from 30 minutes to a week. Frequent episodic tension-type headaches occur less than 15 days a month for at least three months. Frequent episodic tension-type headaches may become chronic.


Chronic tension-type headaches

This type of tension-type headache lasts hours and may be continuous. If your headaches occur 15 or more days a month for at least three months, they’re considered chronic.

Tension-type headaches versus migraines

Tension-type headaches can be difficult to distinguish from migraines. Plus, if you have frequent episodic tension-type headaches, you can also have migraines.

Unlike some forms of migraine, tension-type headaches usually aren’t associated with visual disturbances, nausea or vomiting. Although physical activity typically aggravates migraine pain, it doesn’t make tension-type headache pain worse. An increased sensitivity to either light or sound can occur with a tension-type headache, but this symptom isn’t common.


When to see a doctor

Make an appointment with your doctor

If tension-type headaches disrupt your life or you need to take medication for your headaches more than twice a week, see your doctor.

Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different. Occasionally, headaches may indicate a serious medical condition, such as a brain tumor or rupture of a weakened blood vessel (aneurysm).

When to seek emergency help

If you have any of these signs or symptoms, seek emergency care:

  • Abrupt, severe headache
  • Headache with a fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or speaking difficulties
  • Headache after a head injury, especially if the headache gets worse


The cause of tension-type headaches is not known. Experts used to think tension-type headaches stemmed from muscle contractions in the face, neck and scalp, perhaps as a result of heightened emotions, tension or stress. But research suggests that muscle contraction isn’t the cause.

The most common theory supports a heightened sensitivity to pain in people who have tension-type headaches. Increased muscle tenderness, a common symptom of tension-type headaches, may result from a sensitized pain system.


Diagnostic criteria
Number of days of headache TTH type
<1 / month Infrequent episodic
1-14 / month Frequent episodic
≥15/ month Chronic


 Diagnosis of TTH is confirmed if there are 10 episodes of any of the above headaches fulfilling the following criteria:

  1. Headache lasting for 30 minutes to 7 days
  2. At least two of the following pain characteristics are present
  • Pressing or tightening quality
  • Mild or moderate intensity
  • Bilateral location
  • No aggravation by walking stairs or similar routine physical activity
  1. Both of the following
  • No nausea or vomiting
  • Photophobia and phonophobia are absent or one but not the may be present
  1. Not attributed to another disorder.
  • Pericranial tenderness by manual palpation.
  • Electromyogram and pressure algometry have limited clinical diagnostic value.

Differential diagnosis

  • Medication overuse headache
  • Chronic post traumatic headache
  • Sinusitis/ eye disease
  • Temporomandibular joint disorder
  • Idiopathic intracranial hypertension
  • Brain tumor
  • Psychiatric disorder
  • Musculoskeletal disorders (fibromyalgia, arthritis)
  • Migraine without aura


  1. Nonpharmacologic techniques

Rarely evidence based. Physical therapy is the most common form which includes relaxation and exercise programs, improvement of posture, hot and cold packs, ultrasound and electrical stimulation. Spinal manipulation is also extensively used. Patients with frequent attacks of TTH are often referred for acupuncture.

Cognitive behaviour therapy significantly improves the patients on measures of headaches, depression, anxiety and quality of life.

Oromandibular treatment with occlusal splints is an attractive option but lacks scientific data.

Biofeedback and relaxation training can be done to reduce the emotional and physiologic arousal that can trigger and exacerbate headache. Isometric strength training of the neck flexors correlates with decrease in pressure pain scores in patients with CTTH.

  1. Pharmacologic treatment

Acute treatment:

Simple analgesics like aspirin, acetaminophen are used.

Sometimes combination analgesics including caffeine can be more effective, but with frequent use side effects such as rebound headache may emerge.

Acute treatments to be limited to no more than twice per week as they can produce medication overuse headache and undesirable effects on liver, kidneys, GIT and other organs.

  1. Preventive treatment:

Tricyclic antidepressant amitriptyline is the mainstay in treatment of patients with CTTH.

Mirtazapine a tetracyclic antidepressant is reported to be effective in chronic TTH.

Centrally acting muscle relaxant tizanidine.

Botulinum type A toxin is sometimes used in patients with CTTH.

  1. Future therapies:

Calcitonin Gene Related Peptide receptor antagonism.

Antagonism of substance P and nitric oxide pathways.



Stress is the most commonly reported trigger for tension-type headaches.


Because tension-type headaches are so common, their effect on job productivity and overall quality of life is considerable, particularly if they’re chronic. The frequent pain may render you unable to attend activities. You might need to stay home from work, or if you do go to your job, your ability to function may be impaired.


In addition to regular exercise, techniques such as biofeedback training and relaxation therapy can help reduce stress.

  • Biofeedback training.

     This technique teaches you to control certain body responses that help reduce pain. During a biofeedback session, you’re connected to devices that monitor and give you feedback on body functions such as muscle tension, heart rate and blood pressure. You then learn how to reduce muscle tension and slow your heart rate and breathing yourself.

Cognitive behavioral therapy. This type of talk therapy may help you learn to manage stress and may help reduce the frequency and severity of your headaches.