Tension Headache

Tension-Type Headache (TTH)

Tension-type headache is the most prevalent primary headache disorder worldwide (lifetime prevalence 30–78%), characterized by bilateral, pressing/tightening, mild-to-moderate intensity pain that is not aggravated by routine physical activity.[1-3] Despite its high prevalence, TTH is frequently overdiagnosed in the ED — one study found only 5 of 211 patients discharged with a TTH diagnosis actually fulfilled ICHD-3 criteria, with 6.1% ultimately having a life-threatening disorder.[4]

• Quality: Bilateral, pressing or tightening ("band-like"), non-pulsating
• Intensity: Mild to moderate (not severe)
• Duration: 30 minutes to 7 days per episode
• Aggravating factors: Not worsened by routine physical activity (walking, climbing stairs) — this is a key distinguishing feature from migraine[5]
• Associated symptoms: No nausea or vomiting; may have photophobia OR phonophobia but not both[5-6]

Frequency classification

• Infrequent episodic: <1 day/month (<12 days/year)
• Frequent episodic: 1–14 days/month for >3 months
• Chronic: ≥15 days/month for >3 months[5]
• Key HPI questions: Onset timing, prior similar episodes, recent stressors, sleep changes, medication use (frequency of OTC analgesics), caffeine intake, trauma history
• Important negatives: No thunderclap onset, no fever, no focal neurologic symptoms, no visual changes, no neck stiffness, no weight loss

• Red flags warranting urgent workup (use the SNNOOP10 mnemonic):[7]
• Thunderclap onset (peak intensity in seconds) → SAH
• Fever + meningismus → meningitis/encephalitis
• Focal neurologic deficits → stroke, mass lesion, vascular malformation
• Papilledema → intracranial hypertension, mass lesion
• New headache in age >50 → giant cell arteritis, neoplasm
• Progressive or changing pattern → mass lesion, medication overuse headache
• Positional component → intracranial hypo-/hypertension
• Immunosuppression → opportunistic infection
• Impaired consciousness or seizure
• First or worst headache of life
• A single or first-time headache should always prompt evaluation for secondary causes[6]

Acute treatment

• Ibuprofen 400 mg or acetaminophen 1,000 mg — first-line for acute episodes. Lower doses of acetaminophen are not effective.[3][6][8]
• Aspirin and combination analgesics with caffeine are also effective[3]
• Triptans are NOT effective for TTH unless the patient also has migraine[3]
• Preventive treatment (for frequent episodic or chronic TTH):
• Amitriptyline 10–25 mg nightly — first-line preventive; benefits seen after 3 months[3][8]
• Mirtazapine 15–30 mg at bedtime — second-line[2-3]
• Venlafaxine up to 150 mg daily — third-line[2-3]
• OnabotulinumtoxinA is NOT effective for TTH (unlike chronic migraine)[8]

Medication cautions

• Limit OTC analgesic use to ≤2 days per week (or ≤10 days/month) to prevent medication overuse headache (MOH)[6][9]
• NSAIDs: monitor for GI, renal, and cardiac risks with chronic use[6]
• Chronic TTH is associated with acute medication overuse[3]

• No specific dietary triggers are well-established for TTH (unlike migraine)
• Regular meals — skipping meals may contribute to headache[9]
• Adequate hydration — dehydration is a common headache precipitant
• Caffeine: moderate intake may help acutely (included in some combination analgesics), but excessive use or withdrawal can trigger headache
• Alcohol is a recognized precipitant in some patients[10]

• Neurologic: Visual changes, focal weakness, numbness, speech difficulty, gait disturbance (to rule out secondary causes)
• Psychiatric: Anxiety, depression, sleep disturbance — strongly associated with chronic TTH[3][11-12]
• Musculoskeletal: Neck pain, jaw clenching, TMJ symptoms
• Ophthalmologic: Vision changes, eye pain (rule out glaucoma, refractive error)
• Constitutional: Fever, weight loss, night sweats (rule out infection, malignancy)
• ENT: Sinus pressure, nasal congestion (rule out sinusitis)

• Prior headache diagnoses and treatments tried
• Family history of migraine (TTH and migraine frequently coexist; migraine has a stronger genetic component)[5]
• Occupational and psychosocial stressors — stress and mental tension are the most common precipitating factors[10][12]
• Screen for domestic violence, substance use, and workplace ergonomics
• Medication history from pharmacy records (to assess for MOH)

• Stress and mental tension — most conspicuous precipitating factor[10][12-13]
• Poor sleep quality/insomnia — particularly associated with chronic TTH[14-16]
• Anxiety and depression — strongly comorbid with chronic TTH[3][11-12]
• Sedentary lifestyle — higher prevalence of TTH in men with exclusively sedentary activity[10]
• Medication overuse — risk factor for chronification[3][5]
• Age 30–39 years — peak prevalence[3]
• Sex: TTH is slightly more common in men than women (unlike migraine)[3]

Cannot-miss diagnoses

• Subarachnoid hemorrhage — thunderclap onset, worst headache of life
• Meningitis/encephalitis — fever, neck stiffness, altered mental status
• Intracranial mass/neoplasm — 23.5% of patients with intracranial malignancy present with TTH-like symptoms[3]
• Cerebral venous thrombosis — progressive headache, especially postpartum or with hypercoagulable state
• Cervical artery dissection — neck pain, Horner syndrome, focal deficits
• Giant cell arteritis (age >50) — jaw claudication, visual symptoms, elevated ESR/CRP[7]
• Idiopathic intracranial hypertension — obesity, visual obscurations, papilledema[3]

Common mimics

• Migraine without aura — the most common diagnostic difficulty; distinguished by pulsating quality, moderate-severe intensity, aggravation by activity, nausea/vomiting, and both photophobia AND phonophobia[5]
• Medication overuse headache — headache ≥15 days/month with regular overuse of acute headache medications for >3 months[5]
• Cervicogenic headache — unilateral, associated with neck movement
• Sinusitis — facial pressure, purulent discharge, fever
• TMJ dysfunction — jaw pain, clicking, tenderness over TMJ
• Refractive error/eye strain

• Prior headache types and frequency (headache diary is valuable)[5][9]
• History of head/neck trauma
• Depression, anxiety, or other psychiatric conditions
• Sleep disorders (insomnia, OSA)
• Fibromyalgia (shares pathophysiological features with chronic TTH)[12]
• Prior neuroimaging results
• Medication list with focus on analgesic frequency

• Vital signs: Blood pressure (hypertensive emergency can cause headache), temperature (fever → secondary cause)
• Neurologic exam: Must be normal in TTH — cranial nerves, motor, sensory, reflexes, coordination, gait. Any focal deficit mandates further workup[3][7]
• Fundoscopy: Assess for papilledema (intracranial hypertension)[3]
• Pericranial tenderness: The most significant abnormal finding in TTH — palpate frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius, and trapezius muscles bilaterally using small rotating movements with firm pressure. Score 0–3 per muscle to generate a total tenderness score. Tenderness increases with headache frequency and intensity.[5][12]
• Cervical spine: Range of motion, paraspinal tenderness
• TMJ: Palpation, range of motion, clicking
• Temporal arteries: Tenderness, reduced pulsation (if age >50)

• No routine labs are needed for typical TTH with normal neurologic exam[7]

If red flags present

• ESR and CRP — if age >50 (giant cell arteritis)[7]
• CBC — infection, anemia
• BMP — metabolic derangement
• Blood cultures — if febrile
• Coagulation studies — if hemorrhage suspected
• Pregnancy test — reproductive-age women (changes differential and treatment)
• TSH — if chronic/atypical headache
• LP with opening pressure — if SAH suspected after negative CT, or if meningitis/IIH suspected[7][17]

• Primary headache disorders without red flags or abnormal exam findings do NOT need neuroimaging[7]

When indicated

• Non-contrast CT head — first-line for emergent evaluation (thunderclap headache, suspected hemorrhage, mass effect)[7][17]
• MRI brain with/without contrast — preferred for less urgent concerning features (progressive headache, new neurologic symptoms, suspected neoplasm, infection, IIH)[3][7]
• CTA or MRA — if vascular pathology suspected (dissection, aneurysm, CVT)
• Consider MRI in patients >50 with new-onset TTH-like headache given risk of intracranial malignancy mimicking TTH[3]
• The following figure outlines a systematic approach to headache evaluation:
• View full figure Figure 1. Evaluation of headache. Acute Headache in Adults: A Diagnostic Approach. Am Fam Physician. August 31, 2022.

• SNNOOP10 mnemonic — systematic screening tool for secondary headache red flags[7]
• ID Migraine screener — 3-question validated tool to distinguish migraine from TTH (disability, nausea, photophobia)[7]
• Total Tenderness Score (TTS) — manual palpation of pericranial muscles; recommended by ICHD-3 for subclassifying TTH[5][18]
• Headache diary — essential for tracking frequency, severity, medication use, and triggers; helps distinguish TTH from migraine and identify MOH[5][9]

• ECG is not routinely indicated for tension-type headache

Consider ECG if

• Hypertensive emergency with headache
• Syncope or presyncope associated with headache
• Concern for cardiac etiology (e.g., exertional headache with chest pain)
• Pre-treatment screening if starting medications with cardiac effects (e.g., amitriptyline — QT prolongation risk)

• TTH is a clinical diagnosis based on ICHD-3 criteria — requires ≥10 episodes with characteristic features and absence of migraine-defining symptoms[5-6]
• The primary clinical challenge is distinguishing TTH from mild migraine without aura, as these frequently coexist[5]
• Chronic TTH (≥15 days/month) causes significant disability — average 27 missed workdays per year[3]
• Peripheral mechanisms (myofascial pain, trigger points) likely drive episodic TTH, while central sensitization contributes to chronification[2][11]
• Always consider secondary causes when headache is new-onset, changing in pattern, or accompanied by any red flag features[3-4]

Acute management

• Ibuprofen 400 mg PO or acetaminophen 1,000 mg PO[6][8]
• Combination analgesics with caffeine are an alternative[3]
• Limit acute medication use to ≤2 days/week to prevent MOH[6]

Non-pharmacologic (all patients)

• Stress management, regular sleep hygiene, regular meals, regular physical activity[9][19]
• Manual therapy/physical therapy — modestly reduces TTH frequency[8]
• CBT, biofeedback, relaxation therapy — evidence-based adjuncts, especially for chronic TTH[3][9][19]
• Acupuncture — may be helpful[3]
• Preventive pharmacotherapy (initiate when ≥10 attacks/month, significant disability, or chronic TTH):
• Amitriptyline 10–25 mg nightly (titrate as tolerated) — first-line; expect benefit after ~3 months[3][8]
• Mirtazapine 15–30 mg at bedtime — second-line[3]
• Venlafaxine up to 150 mg daily — third-line[3]

Discharge criteria (vast majority of TTH patients)

• Normal neurologic exam
• No red flag features
• Pain adequately controlled
• Able to tolerate PO

Admission/observation criteria

• Abnormal neurologic exam or red flag features requiring workup
• Intractable headache not responding to ED treatment
• Concern for secondary headache disorder pending imaging/LP results
• New neurologic findings

Specialist consultation triggers

• Chronic daily headache refractory to first-line preventive therapy
• Diagnostic uncertainty (TTH vs. migraine vs. secondary cause)
• Medication overuse headache requiring structured withdrawal
• Abnormal neuroimaging findings → neurology or neurosurgery

Follow-up timing

• Episodic TTH managed with OTC analgesics: follow up with PCP if headaches increase in frequency or severity
• Chronic TTH started on preventive therapy: follow up in 4–6 weeks to assess tolerability, then at 3 months to evaluate efficacy[8]
• Headache diary should be maintained between visits[5][9]
• Return precautions — instruct patients to return immediately for:
• Sudden severe "worst headache of life"
• Fever with stiff neck
• New weakness, numbness, vision changes, speech difficulty, or confusion
• Headache after head trauma
• Headache that is progressively worsening despite treatment
• Seizure

Expected recovery

• Episodic TTH is self-limiting; most episodes resolve within hours with simple analgesics[20]
• Chronic TTH may require months of multimodal therapy before significant improvement[8][19]
• Educate patients that overuse of acute medications can paradoxically worsen headache frequency[6][9]

1. Global, Regional, and National Burden of Headache Disorders, 1990-2023: A Systematic Analysis for the Global Burden of Disease Study 2023. — GBD 2023 Headache Collaborators. The Lancet. Neurology. 2025.

2. Tension-Type Headache. — Ashina S, Mitsikostas DD, Lee MJ, et al. Nature Reviews. Disease Primers. 2021.

3. Diagnosis and Management of Headache: A Review. — Robbins MS. The Journal of the American Medical Association. 2021.

4. Tension-Type Headache in the Emergency Department Diagnosis and Misdiagnosis: The TEDDi Study. — García-Azorín D, Farid-Zahran M, Gutiérrez-Sánchez M, et al. Scientific Reports. 2020.

5. Management of Headache (2023). — Jane Abanes PhD DNP MSN/Ed PMHCNS PMHNP-BC RN, Natasha M. Antonovich PharmD BCPS, Andrew C. Buelt DO, et al Department of Veterans Affairs. 2023.

6. Acute Headache in Adults: A Diagnostic Approach. — Viera AJ, Antono B. American Family Physician. 2022.

7. Outpatient Primary Care Management of Headaches: Guidelines From the VA/­DoD. — Ford B, Dore M, Harris E. American Family Physician. 2021.

8. Educational and Supportive Self-Management Program for the Treatment of Chronic Headache. — Preston J. Neurology. 2023.

9. Migraine and Tension-Type Headache in a General Population: Precipitating Factors, Female Hormones, Sleep Pattern and Relation to Lifestyle. — Rasmussen BK. Pain. 1993.

10. Hallmarks of Primary Headache: Part 2- Tension-Type Headache. — Pan LH, Ling YH, Wang SJ, et al. The Journal of Headache and Pain. 2025.

11. Tension-Type Headache: Current Research and Clinical Management. — Fumal A, Schoenen J. The Lancet. Neurology. 2008.

12. Cognitive or Daily Stress Association With Headache and Pain Induction in Migraine and Tension-Type Headache Patients: A Systematic Review. — Viero FT, Rodrigues P, Trevisan G. Expert Review of Neurotherapeutics. 2022.

13. Pathofysiological and Clinical Correlates of Sleep in Primary Headache Disorders: A Narrative Review. — van Liefland M, Munday V, van Tilborg P, et al. Sleep Medicine. 2026.

14. Sleep and Tension-Type Headache. — Cho SJ, Song TJ, Chu MK. Current Neurology and Neuroscience Reports. 2019.

15. Stress and Sleep Duration Predict Headache Severity in Chronic Headache Sufferers. — Houle TT, Butschek RA, Turner DP, et al. Pain. 2012.

16. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. — Godwin SA, Cherkas DS, Panagos PD, et al. Annals of Emergency Medicine. 2019.

17. Pericranial Total Tenderness Score in Patients With Tension-Type Headache and Migraine. A Systematic Review and Meta-Analysis. — Castien R, Duineveld M, Maaskant J, De Hertogh W, Scholten-Peeters G. Pain Physician. 2021.

18. Assessment and Management of Tension-Type Headaches. — Steelquist J, Pham A, Vu K, Eapen BC. Physical Medicine and Rehabilitation Clinics of North America. 2025.

19. Tension-Type Headache in Childhood and Adolescence. — Anttila P. The Lancet. Neurology. 2006.