Tension-type headache

1. OVERVIEW

Tension-type headache is the most common primary headache disorder worldwide. The term “tension” reflects the involvement of muscle tension in the head and neck region, as well as psychological stress, in its pathophysiology.

According to the International Classification of Headache Disorders, 3rd edition (ICHD-3), a typical tension-type headache has the following clinical characteristics:

• Location: Pain is usually bilateral and commonly involves the forehead, temples, occipital region, or neck.
• Pain quality: The pain is typically pressing or tightening, often described as a band-like sensation around the head, and is non-pulsating.
• Intensity: Pain is usually mild to moderate and is not aggravated by routine physical activity.
• Duration: Headache episodes may last from 30 minutes to 7 days. In chronic cases, the pain may be prolonged or almost continuous.

Classification of tension-type headache according to ICHD-3

Episodic tension-type headache

This is the most common form, characterized by intermittent headache episodes lasting from 30 minutes to 7 days. It is divided into two subtypes:

• Infrequent episodic tension-type headache: Headache occurs on fewer than 1 day per month, or fewer than 12 days per year.
• Frequent episodic tension-type headache: Headache occurs on 1–14 days per month for at least 3 consecutive months.

Chronic tension-type headache

Chronic tension-type headache is defined as headache occurring on 15 or more days per month for at least 3 months. The pain may last for hours, days, or may be continuous. This form has the greatest impact on quality of life and work performance and contributes substantially to the overall disease burden.

Probable tension-type headache

Probable tension-type headache is diagnosed when the clinical features resemble tension-type headache but do not fully meet one of the diagnostic criteria. It may be classified as probable infrequent episodic, probable frequent episodic, or probable chronic tension-type headache.

2. EPIDEMIOLOGY

Global prevalence

Tension-type headache is the most common primary headache disorder worldwide, affecting approximately 26% of the adult population, equivalent to more than 2 billion people globally. Lifetime prevalence is estimated to range from approximately 30% to 80%.

Distribution by sex and age

Tension-type headache occurs in both men and women, although it is slightly more common in women, with a female-to-male ratio of approximately 1.2:1.

The condition can occur at any age. In children and adolescents, prevalence gradually increases with age, while the chronic form remains uncommon. Among adults, prevalence generally peaks between 30 and 50 years of age, particularly affecting people of working age. After the age of 60, prevalence tends to decline.

Disease burden

Although individual episodes of tension-type headache are generally less disabling than migraine attacks, the very high prevalence of the condition results in a substantial public health burden. It can negatively affect quality of life, work productivity, and healthcare costs.

3. PATHOPHYSIOLOGY

The pathophysiology of tension-type headache is complex and involves interactions between peripheral and central pain mechanisms, together with genetic factors, neurotransmitter activity, and psychological stress. Current understanding has shifted away from the traditional view that muscle contraction is the primary mechanism and increasingly emphasizes the role of central nervous system sensitization, particularly in the progression to chronic disease.

Peripheral mechanisms

Peripheral mechanisms play an important role, particularly in episodic tension-type headache. Prolonged tension in the muscles of the head, neck, shoulders, and upper back may lead to the formation of myofascial trigger points and the release of pain-related mediators such as substance P and inflammatory cytokines. These substances stimulate nociceptive sensory fibers and increase local pain sensitivity.

Central mechanisms

In patients with persistent tension-type headache, repeated peripheral nociceptive input may lead to central sensitization. The nervous system becomes excessively responsive, reducing the pain threshold and resulting in hyperalgesia or pain in response to stimuli that would normally not be painful.

Role of genetics and neurotransmitters

Tension-type headache may have a genetic component, particularly in chronic cases. Variations in genes involved in pain regulation, including 5-HTTLPR (5-HTT gene-linked polymorphic region), COMT (catechol-O-methyltransferase), and NOS1 (nitric oxide synthase 1), may contribute to an increased susceptibility to the disorder.

In addition, an imbalance between excitatory neurotransmission, such as glutamate activity, and inhibitory pain-modulating systems involving GABA, serotonin, and norepinephrine may impair the nervous system’s ability to regulate pain.

Effects of stress and changes in brain function

Psychological stress is one of the most common triggers of tension-type headache. Prolonged stress activates the hypothalamic–pituitary–adrenal axis, increasing the release of stress hormones such as cortisol. This may promote both peripheral and central pain sensitization.

4. CLINICAL MANIFESTATIONS

The clinical manifestations of tension-type headache primarily include the characteristic features of the headache itself, associated symptoms, and findings related to muscle tension in the head and neck region. These features are important for differentiating tension-type headache from migraine.

Characteristics of the headache

• Location: Pain is usually bilateral and commonly affects the forehead, temples, occipital region, or may extend into the neck.
• Pain quality: Patients commonly describe a pressing, tightening, or heavy sensation, often likened to a tight band around the head. Unlike migraine, the pain is not pulsating or throbbing.
• Pain intensity: Pain is typically mild to moderate, and patients are often able to continue their normal daily activities.
• Effect of physical activity: Pain is not aggravated by routine physical activity such as walking or climbing stairs.
• Duration: In episodic tension-type headache, episodes may last from 30 minutes to 7 days. In chronic tension-type headache, pain may persist for many hours or days or may be almost continuous.

Associated symptoms

Nausea and vomiting: These are usually absent. In chronic tension-type headache, mild nausea may occasionally occur, but vomiting or moderate-to-severe nausea is not typical.

Photophobia and phonophobia: These symptoms may be absent, or only one of the two may be present. The simultaneous presence of both is more characteristic of migraine.

These features are important in distinguishing tension-type headache from migraine.

Manifestations involving the head and neck muscles

Muscle tension and increased pericranial tenderness are common findings, particularly in patients with chronic headache.

Pericranial muscle tenderness: On palpation of the muscles of the head, neck, shoulders, and upper back, patients may experience pain or discomfort. The degree of tenderness generally increases with the frequency and severity of headache episodes.

Myofascial trigger points: Tense or painful muscle nodules are commonly found in the temporal, masseter, trapezius, and cervical muscles. Stimulation of these trigger points may produce referred pain in the head.

Muscle stiffness and impaired muscle function: Some patients, particularly those with persistent headache, may develop increased stiffness of the head and neck muscles or reduced strength of the cervical extensor muscles.

Clinical features in different patient groups

Children and adolescents: Symptoms may sometimes be difficult to distinguish from migraine. Some children may experience unilateral headache, photophobia, phonophobia, or pain that worsens with physical activity.

Women: Women may experience greater pain intensity, longer-lasting episodes, and a higher risk of progression to chronic headache. They may also have a greater number of tender myofascial trigger points.

Older adults: Symptoms may sometimes be atypical, and pain intensity may be milder. Changes in headache pattern or progression to a chronic form should be carefully evaluated.

5. DIAGNOSTIC CRITERIA

ICHD-3 diagnostic criteria for tension-type headache

Diagnosis is primarily based on the patient’s medical history and the clinical characteristics of the headache, while other causes of headache should be excluded.

Typical headache characteristics

According to ICHD-3, the headache should meet at least two of the following four criteria:

• Bilateral location.
• Pressing or tightening, non-pulsating quality.
• Mild to moderate intensity.
• Not aggravated by routine physical activity.

Associated symptoms

For episodic tension-type headache, there is no nausea or vomiting. Photophobia or phonophobia may be absent, or only one of these symptoms may be present.

For chronic tension-type headache, no more than one of the following mild symptoms may be present: photophobia, phonophobia, or mild nausea. Moderate-to-severe nausea and vomiting should not occur.

The headache should not be better accounted for by another headache disorder.

Classification according to headache frequency

a. Infrequent episodic tension-type headache

• At least 10 headache episodes.
• Headache occurs on fewer than 1 day per month, or fewer than 12 days per year.
• Each episode lasts from 30 minutes to 7 days.

b. Frequent episodic tension-type headache

• Headache occurs on 1–14 days per month for at least 3 months.
• Each episode lasts from 30 minutes to 7 days.

c. Chronic tension-type headache

• Headache occurs on 15 or more days per month for at least 3 months.
• The headache may last for hours, days, or may be continuous.

Chronic tension-type headache has the greatest impact on quality of life and work capacity.

6. TREATMENT

Non-pharmacological treatment

Non-pharmacological measures include maintaining adequate sleep and consistent sleeping and waking times; drinking sufficient fluids; eating regular meals and avoiding fasting or skipping meals; limiting potential triggers such as excessive caffeine, monosodium glutamate, and artificial sweeteners; practicing relaxation techniques, meditation, or yoga; and performing moderate-intensity aerobic exercise, for example 30–40 minutes several times per week.

Patient education is also important. Patients should understand the generally benign nature of tension-type headache, learn to identify potential triggers, and adopt self-care techniques such as muscle stretching and applying heat.

Keeping a headache diary may help monitor headache frequency, severity, and associated factors and can support adjustments to the treatment plan.

Nutritional supplementation may also be considered. Certain nutrients, including magnesium, B vitamins, and supplements that may support serotonergic function, may help improve neurological function and reduce headache frequency in some patients.

Pharmacological treatment

Pharmacological treatment of tension-type headache is generally divided into two categories: acute treatment, which aims to relieve pain during an attack, and preventive treatment, which aims to reduce headache frequency, severity, and recurrence, particularly in patients with frequent or chronic headache.

Acute treatment

The primary goal of acute treatment is to achieve rapid relief when a headache begins. Conventional analgesics are generally considered first-line therapy.

NSAIDs and paracetamol

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, diclofenac, and ketoprofen, are commonly preferred because several studies have shown them to provide better pain relief than paracetamol.

Paracetamol is an alternative, particularly in patients who cannot take NSAIDs or who are at increased risk of gastrointestinal complications.

Combination analgesics containing caffeine

Combining caffeine with paracetamol or ibuprofen may enhance analgesic efficacy. However, use should generally be limited to fewer than 10 days per month to reduce the risk of medication-overuse headache.

Medications that are not recommended

Opioids, muscle relaxants, and migraine-specific medications such as triptans, ergot derivatives, and anti-CGRP therapies have not been shown to be effective for uncomplicated tension-type headache and are generally not recommended unless the patient also has migraine.

Preventive treatment

The goals of preventive therapy are to reduce the number of headache days, decrease headache intensity, and reduce the need for acute analgesic medications.

Amitriptyline

Amitriptyline has the strongest evidence for the prevention of tension-type headache and is generally considered the first-line preventive medication.

Mechanism of action: Amitriptyline increases serotonergic and noradrenergic activity, helping regulate pain pathways and reduce central sensitization.

Treatment is usually initiated at a low dose, approximately 2.5–10 mg at bedtime, and gradually increased according to clinical response and tolerability.

Common adverse effects include drowsiness, dry mouth, constipation, and weight gain. Caution is required in patients at risk of glaucoma, urinary retention, or cardiovascular disorders.

If treatment is effective and the patient remains stable, gradual dose reduction and discontinuation may be considered after approximately 3–6 months.

Alternative preventive medications

Mirtazapine: Some studies suggest efficacy comparable to amitriptyline, with potentially better tolerability in some patients. However, it may cause drowsiness and weight gain.

Venlafaxine: An SNRI that may provide benefit, although the supporting evidence is less robust.

Other medications, including clomipramine, maprotiline, and mianserin, may be considered in selected patients.

Several other medications have potential benefit but are not currently considered standard first-line options:

Topiramate, valproate, and buspirone: These may be considered in patients who do not respond to or cannot tolerate first-line treatment.

Memantine: May help reduce headache severity in some patients.

Tizanidine: A muscle relaxant, although its effectiveness for tension-type headache has not been clearly established.

Vitamin D: May have a supportive role, particularly when used in combination with other preventive therapies.

REFERENCES

1. Pan, Li-Ling Hope, et al. “Hallmarks of primary headache: part 2–Tension-type headache.” The Journal of Headache and Pain 26.1 (2025): 164. https://doi.org/10.1186/s10194-025-02098-w
2. Lee, Hye Jeong, et al. “Update on tension-type headache.” Headache and Pain Research 26.1 (2024): 38–47. https://doi.org/10.62087/hpr.2024.0025
3. Cathcart, Stuart, et al. “Stress and tension-type headache mechanisms.” Cephalalgia 30.10 (2010): 1250–1267. DOI: 10.1177/0333102410362927
4. International Classification of Headache Disorders, 3rd edition (ICHD-3). https://ichd-3.org/2-tension-type-headache/

MSc. Kim Ngoc Son

MSc. Tran Khanh