Tension Headaches


Tension-type headaches (TTH) are the most common type benign headache. They can affect all aspects of one’s life including work, school, and home life [1].TTH may result in disability, missed workdays, and decreased quality of life [2]. They are characterized by how often an individual experience them in a given month. If an individual experiences tension-type headaches 14 or less days out of a month then it is considered episodic. If they experience these headaches 15 or more days out of a month for 3 consecutive months, then they are considered to be chronic. The etiology behind these headaches is still unknown. It is believed that changes in levels of neurotransmitters may be a contributing factor.


Episodic tension type headaches (TTH) are the most prevalent type of headache. Research has found that approximately 38% of individual’s experience TTHs in a given year [1][2][3] In Denmark, it was found that 78% of the population experienced TTHs at some point in their lifetime[4]. Approximately 24% to 37% of individual’s experience TTHs multiple times a month[4]. According to Schwartz study in 1998, women are more likely to experience TTHs in every race, age group, and educational level. Tension-type headaches usually begin in an individual’s teenage years, and those between the age of 30 and 39 are at the highest risk[1]. Schwartz found that 40.1% of Caucasian men and 46.8% of Caucasian women experienced TTHs in a single year. In the African American population, the prevalence of TTHs in a year was 22.8% in men and 30.9% in women. There is a positive correlation between educational levels and prevalence of TTHs with graduate students being most at risk.

Characteristics/Clinical Presentation

There are two types of tension-type headaches: episodic and chronic. Episodic TTHs are characterized by occurring less than 15 days out of a month[5]. They can last anywhere from a few hours to several days. Patients usually report feeling symptoms such as a tight band or pressure around their head and/or neck. These headaches are most often bilateral but can be unilateral. They range from mild to moderate in intensity and do not have any of the associated symptoms which are found in migraines.

TTHs are characterized as chronic when their symptoms persist for 15 or more days within a month for three consecutive months. Because of the moderate to severe intensity of chronic TTHs, this type of headache is more debilitating than the episodic TTHs. In addition to feeling pressure around the head and/or neck, patients with chronic TTHs may experience mild nausea.

Associated Co-morbidities

Generalized anxiety disorder [6][7], major depression disorder[8], impairment in quality of life and functional abilities [7], suicidal ideation[9] , dementia.[10]


A review of the literature shows that there are several medications which are taken for TTH[11] . Medication is much more effective in patients with episodic TTH than chronic TTH. Acutely, individuals will use over-the-counter analgesics such as Ibuprofen (400-800mg), Acetylsalicylic acid (600-1000 mg), and Paracetamol (1000mg) when they experience pain one or two days out of the week. Ibuprofen and Acetylsalicylic acid have been found to be much more effective than Paracetamol at treating the pain. Individuals experiencing these headaches should stay away from the use of opioids such as dextropropoxyphene, codeine, and dihydrocodeine. Barbiturates should not be used to treat TTHs.

If an individual experiences episodic TTHs more than twice a week, then their acute intervention should be replaced with prophylactic interventions[11]. These individuals are often prescribed 10-100 mg of Amitriptyline at night. Amitriptyline is also used to treat chronic TTHs. Nortriptyline is less effective at treating these headaches than Amitriptyline but also produces less anticholinergic side-effects. With the use of pain inhibiting drugs comes the increased risk for medication overuse headaches. A psychological approach is often needed to treat patients with chronic TTHs.

Diagnostic Tests/Lab Tests/Lab Values

If an individual is experiencing frequent headaches, then a medical professional may perform physical and neurological exams to try to determine what is causing them.[12] Taking a thorough history may be the most important diagnostic tool in determining a TTH[5]. It is important to understand how long an individual has been experiencing these headaches, how long they last, their intensity, and if there are any associated symptoms that accompany the headache. For example, auras are associated with migraines and one can rule out TTH if these symptoms are described. A medical professional may also ask if there are any known triggers and what, if anything, can be done to eliminate the symptoms. A physician may also choose to order a computed tomography (CT) scan, magnetic resonance imaging (MRI), X-Ray, or electroencephalogram (EEG) to rule out other possible causes of the headaches. The HALT index, or headache-attributed lost time index, is a patient reported outcome measure used to determine how headaches are affecting the individual's life. This outcome measurement can help steer decisions in medical treatment. After medical intervention, the Headache and Assessment of Response to Treatment (HART) is used to assess the effectiveness of the treatment. Lastly, individuals are given pamphlets of information describing what a TTH is, the symptoms, and possible treatment options.


It is unclear as to what causes tension type headaches. It was once believed that these headaches could be due to either psychological stress factors or muscular contractions of the shoulder, neck, scalp, and jaw but these theories have since been rejected[2]. It is now believed that TTH are a result of neurotransmitter (including serotonin) imbalances. Researchers are still trying to determine what could cause the fluctuation in neurotransmitters, but they hypothesize that the imbalances are triggering pain pathways in the brain. There may be an association between tight muscles and changes in neurotransmitters but it is still undetermined if tight muscles are causing the fluctuation in neurotransmitters or vise versa[13].

The following list of possible triggers for TTH was taken from University of Maryland Medical Center:

  • Stress
  • Depression
  • Anxiety
  • Holding your head in one position for a long time
  • Sleeping in an awkward position or in a cold room
  • Eye strain
  • Drugs or alcohol
  • Over-exertion
  • Skipping meals
  • Head and neck injury, even years after the injury
  • Clenching your jaw or grinding your teeth (bruxism)
  • Medications, including some headache medications (leading to rebound headaches)
  • Arthritis
  • Hormonal changes (primarily among women)

Systemic Involvement

Gastrointestinal (GI) involvement is a common side effect of the drugs which are most often used to treat tension-type headaches[14]. These side effects include: GI ulcers, abdominal pain, upset stomach, cramping, nausea, diarrhea, heartburn, bleeding, bloating, constipation, and gas. Another possible side effect of these drugs is symptoms of the headache can worsen. This is most often seen when headaches are severe and an individual overuses the drug. If an individual experience these or any other symptoms after taking medication for a tension-type headache, then they should seek medical attention.

Medical Management (current best evidence)

After appropriately diagnosing TTHs, medical professionals must then determine what the most effective treatment is for these headaches. Due to the lack of knowledge of concerning the etiology of TTHs, they are very difficult to treat. Medical professionals try to incorporate patient education, lifestyle modifications, and cost-effective medications into their treatments[11]. An example of a lifestyle modification would be discussing smoking cessation with one’s patient. There is a strong positive correlation between how many cigarettes are smoked and how many days out of the week patients experience headaches. Research has also found a positive correlation between high volumes of nicotine and higher anger, anxiety, and depression. Although drug therapy is finite in its ability to treat the underlying cause of TTHs, it has still been found to be effective in relieving symptoms of pain many patients.

Physical Therapy Management (current best evidence)

  • Research suggests that biofeedback may be a potentially useful option when drug treatments must be avoided.[5][11]
  • The RCT by Chaibi suggests that physical therapy can have significant effects on frequency and intensity at post treatment and six-month follow-up when managing of chronic TTH. [15] Multiple research studies had been performed to identify whether providing skilled and individualized therapy, patient education for proper posture, appropriate home exercise program, passive manipulation of cervical spine facet joints, and cryotherapy are viable treatment options for decreasing frequency of the headache and increasing psychological well-being in patients with tension-type headache.[11][15][16]
  • A review of literature suggests acupuncture treatment for TTH headaches had superior outcomes, compared with patients in the control group.[5][11][17][18]According to Linde, clinically significance was found in number of headaches and pain intensity for up to 3 months.[18] However, according to Mcdermaid, acupuncture does not appear to be more effective treatment approach than a course of physical therapy interventions[2]
  • According to Mcdermaid and Boline, spinal manipulative treatment appears to be as effective as amitriptyline in producing short-term (4-6-week) benefit for TTH.[19]
  • Myofascial Trigger point massage therapy in key cervical musculature was efficacious for reducing headache frequency in a mixed population with of episodic or chronic TTH who participated in the six-week program. Although, no statistical difference between massage and placebo was found for headache frequency, self-report of perceived greater improvement.[20]
  • Research addresses cold packs (cryotherapy) having positive effects on relieving pain or discomfort in some patients.[5]
  • Education about headaches, signs/symptoms, appropriate treatment options.

Differential Diagnosi

1.    Medication-overuse headaches[5] that are diagnosed by clinical diagnosis. [21]

2.    Subarachnoid hemorrhage that is frequently described as “thunderclap headache.”[5]

3.    Temporal arteritis that is a new headache in a patient that are older than 50 years.[5]

4.    Intracranial tumor that is a new headache in a patient older than 50 years.[21][5]

5.    Intracranial space-occupying lesion that is a progressive headache that is worsening over weeks or longer.

6.    Meningitis that is unexplained pyrexia associated with headache[5]

7.    Secondary headache.[5]

8.    Chronic migraine that is confirmed by clinical diagnosis test. [21]

9.    Sphenoid sinuses are diagnosed by CT scan of an acute or chronic symptoms.[21]

10.    Giant cell arteritis can be confirmed by elevated levels of ERS and/or CRP.[21]

11.    Temporomandibular disorder.[21]

12     Pituitary tumor can be confirmed by MRI.[21]

13.    Chronic subdural hematoma can be confirmed by MRI. [21]

14.    Pseudotumor cerebri is an idiopathic intracranial hypertension that presents with elevated spinal fluid pressure and can cause headaches.[21]

15.    Cervical pathology can be ruled out by MRI for disk herniations and soft tissue masses.[21]



  1. 1.0 1.1 1.2 Schwartz BS. Epidemiology of Tension-Type Headache. Jama. 1998;279(5):381. doi:10.1001/jama.279.5.381.
  2. 2.0 2.1 2.2 2.3 Mcdermaid C, Hagino C, Vernon H. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. Complementary Therapies in Medicine. 1999;7(3):142-155. doi:10.1016/s0965-2299(99)80122-8.
  3. 3.Crystal SC, Robbins MS. Epidemiology of tension-type headache. Curr Pain Headache Rep. 2010;14:449–54
  4. 4.0 4.1 Chowdhury D. Tension type headache. Annals of Indian Academy of Neurology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444224/. Published August 2012. Accessed April 3, 2017.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Headache disorders. World Health Organization. http://www.who.int/mediacentre/factsheets/fs277/en/. Accessed April 3, 2017. 
  6. Juang, K.D., Wang, S.J., Fuh, J.L. et al. Comorbidity of depressive and anxiety disorders in chronic daily headache and its subtypes. Headache. 2000; 40: 818–823 
  7. 7.0 7.1 Heckman BD, Holroyd KA. Tension-type headache and psychiatric comorbidity. Current Pain and Headache Reports. 2006;10(6):439-447. doi:10.1007/s11916-006-0075-2.
  8. Bera S, Goyal V, Khandelwal S, Sood M. A comparative study of psychiatric comorbidity, quality of life and disability in patients with migraine and tension type headache. Neurology India. 2014;62(5):516. doi:10.4103/0028-3886.144445. 
  9. Da Silva, A. Jr, Costa, E.C., Gomes, J.B. et al. Chronic headache and comorbidities: a two-phase, population-based, cross-sectional study. Headache. 2010; 50: 1306–1312
  10. Yang F-C, Lin T-Y, Chen H-J, Lee J-T, Lin C-C, Kao C-H. Increased Risk of Dementia in Patients with Tension-Type Headache: A Nationwide Retrospective Population-Based Cohort Study. Plos One. 2016;11(6). doi:10.1371/journal.pone.0156097. 
  11. 11.0 11.1 11.2 11.3 11.4 11.5 Brodie PJMCJJ. Tension-Type Headache. Tension-Type Headache - American Family Physician. http://www.aafp.org/afp/2002/0901/p797.html. Published September 1, 2002. Accessed April 3, 2017. 
  12. Mayo Clinic Staff Print. Overview. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/tension-headache/home/ovc-20211413. Published June 30, 2016. Accessed April 5, 2017. 
  13. Tension headache. University of Maryland Medical CenterTension headache. University of Maryland Medical Center. http://umm.edu/health/medical/altmed/condition/tension-headache. Accessed April 5, 2017. 
  14. RxList - The Internet Drug Index for prescription drugs, medications and pill identifier. RxList - The Internet Drug Index for prescription drugs, medications and pill identifier. http://www.rxlist.com/script/main/hp.asp. Accessed April 5, 2017 
  15. 15.0 15.1 Chaibi A, Russell M. Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials. The Journal of Headache and Pain. 2014;15(1):67. doi:10.1186/1129-2377-15-67.
  16. Hammill JM, Cook TM, Rosecrance JC. Effectiveness of a Physical Therapy Regimen in the Treatment of Tension-Type Headache. Headache: The Journal of Head and Face Pain. 1996;36(3):149-153. doi:10.1046/j.1526-4610.1996.3603149.x. 
  17. Melchart D, Linde K, Fischer P, et al. Acupuncture for recurrent headaches: a systematic review of randomized controlled trials. Cephalalgia. 1999;19(9):779-786. doi:10.1046/j.1468-2982.1999.1909779.
  18. 18.0 18.1 Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tension-type headache (n=270). Acupuncture in Medicine. 2005;23(3):148-149. doi:10.1136/aim.23.3.148.
  19. Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. Journal of manipulative and physiological therapeutics. https://www.ncbi.nlm.nih.gov/pubmed/7790794. Accessed April 3, 2017
  20. Moraska AF, Stenerson L, Butryn N, Krutsch JP, Schmiege SJ, Mann JD. Myofascial Trigger Point-focused Head and Neck Massage for Recurrent Tension-type Headache. The Clinical Journal of Pain. 2015;31(2):159-168. doi:10.1097/ajp.0000000000000091.
  21. 21.0 21.1 21.2 21.3 21.4 21.5 21.6 21.7 21.8 21.9 Ryan B. Epocrates Rx Drug reference app Epocrates Rx Drug reference app Free. Nursing Standard. 2013;28(13):31-31. doi:10.7748/ns2013.