Tension-type headache (TTH) is the most common primary headache disorder worldwide, yet it is often overlooked in clinical practice. While usually considered less disabling than migraines, TTH still imposes a significant burden on daily functioning, productivity, and overall quality of life. Its gradual onset and mild to moderate symptoms contribute to underdiagnosis and undertreatment. 

TTH is defined as a bilateral, pressing or tightening pain of mild to moderate intensity without severe nausea or vomiting. It often presents as a band-like or vice-like discomfort around the head and may last for hours to days. Understanding this condition is crucial for improving recognition, management, and long-term outcomes. 

Tension-type headache is characterized by its distinctive features that separate it from migraine and other headache disorders. It is a non-pulsatile, bilateral headache of mild to moderate intensity that does not worsen with routine physical activity. Unlike migraine, it is rarely associated with nausea or simultaneous photophobia and phonophobia. 

Types of TTH are classified by frequency: 

• Infrequent episodic TTH: less than 1 day per month (≤12 days per year) 

• Frequent episodic TTH: 1–14 days per month 

• Chronic TTH: 15 or more days per month for over 3 months 

Key features of TTH include: 

• Bilateral location (frontal, temporal, occipital, or generalized) 

• Pressing or tightening quality, often described as a “band” around the head 

• Mild to moderate intensity 

• Duration lasting 30 minutes to 7 days in episodic forms 

• Possible mild photophobia or phonophobia, but not both simultaneously 

Tension-type headache is the most prevalent form of headache globally, affecting approximately 30% to 80% of people at some point in life. Women are more frequently affected than men, with a female-to-male ratio of about 1.5:1. The peak incidence occurs in individuals aged 30 to 39 years. 

Key prevalence statistics: 

• Lifetime prevalence: 70–80% 

• One-year prevalence: 30–40% in adults 

• Chronic TTH: 2–3% globally 

The impact of TTH extends beyond pain, contributing significantly to disability and lost productivity. This makes it an important public health concern despite its often mild clinical presentation.

The causes of tension-type headache are multifactorial, involving both peripheral and central mechanisms. Understanding these contributors is important for developing effective prevention and treatment strategies. 

Peripheral factors: 

• Muscle tenderness in the scalp, neck, and shoulders 

• Sustained muscle contraction and ischemia 

• Trigger points and myofascial pain 

Central factors: 

• Sensitization of central pain pathways, particularly in chronic TTH 

• Impaired descending inhibitory pain mechanisms 

• Heightened pain sensitivity and hyperalgesia 

Risk factors: 

• Stress and anxiety 

• Poor posture and long periods of screen use 

• Sleep disturbances 

• Depression and psychological comorbidities 

• Bruxism or jaw clenching 

• Cervical spine dysfunction 

These factors can act alone or together, leading to episodic TTH that may become chronic if persistent. 

The pathophysiology of TTH involves complex interactions between peripheral and central mechanisms. Episodic TTH is typically driven by peripheral muscle tension, while chronic TTH is more strongly linked to central sensitization. 

Peripheral mechanisms: 

• Pericranial muscle contraction activates nociceptors 

• Nociceptive signals travel to the trigeminocervical complex 

Central mechanisms: 

• Repeated peripheral input causes central sensitization 

• Reduced inhibition in descending serotonergic and noradrenergic pathways 

• Altered neurotransmitter function, including serotonin and endorphins 

These changes result in heightened pain perception and persistent headache patterns.

Tension-type headache presents with a characteristic symptom pattern that aids in diagnosis. It typically develops gradually and is often described as a tight band around the head. Many patients also report a sense of heaviness or pressure in the scalp and temples, which may worsen throughout the day. Recognizing these consistent features is essential for distinguishing TTH from other headache types. 

Common symptoms: 

• Bilateral, non-throbbing pain 

• Pressing or tightening quality 

• Mild to moderate intensity 

• Not worsened by physical activity 

• Mild photophobia or phonophobia (but not both) 

• Rare nausea and no vomiting 

Duration: 

• Episodic TTH lasts 30 minutes to 7 days 

• Chronic TTH occurs 15 or more days per month, lasting hours or continuously 

Aggravating factors: 

• Stress and emotional strain 

• Sleep deprivation 

• Poor posture or prolonged concentration 

Relieving factors: 

• Rest and relaxation 

• Gentle exercise or massage 

• Stress management strategies

TTH is diagnosed clinically using the International Classification of Headache Disorders, 3rd edition (ICHD-3). Diagnosis relies on patient history and symptom criteria rather than imaging or laboratory tests. Careful attention to a patient’s description of headache onset, frequency, and associated symptoms is crucial, and clinicians may also use headache diaries to better capture the clinical picture. 

Diagnostic criteria for episodic TTH: 

• At least 10 episodes lasting 30 minutes to 7 days 

• At least two of the following: bilateral location, pressing/tightening quality, mild to moderate intensity, not aggravated by activity 

• No nausea or vomiting 

• No more than one of photophobia or phonophobia 

Diagnostic criteria for chronic TTH: 

• Headaches on 15 or more days per month for more than 3 months 

• Same core features as episodic TTH 

• No more than one of photophobia, phonophobia, or mild nausea 

Clinical assessment may include: 

• Headache diary to record frequency, triggers, and medication use 

• Palpation of pericranial muscles to detect tenderness 

• Neurological examination to exclude secondary causes

It is essential to distinguish TTH from other primary and secondary headaches to avoid misdiagnosis. Careful evaluation of headache features such as location, quality, intensity, and associated symptoms helps differentiate it from migraine or other conditions. Clinicians should also assess risk factors, headache frequency, and medication history when making a diagnosis. 

Conditions to consider: 

• Migraine: unilateral, throbbing, moderate to severe pain with nausea and photophobia/phonophobia 

• Medication overuse headache: daily or near-daily headache in patients using painkillers excessively 

• Cervicogenic headache: headache linked to neck pain and restricted movement 

• Cluster headache: severe unilateral headache with autonomic symptoms 

• Secondary headaches: caused by tumors, vascular disorders, or systemic illness 

Red flag features (SNOOP): 

• Systemic symptoms such as fever or weight loss 

• Neurological signs 

• Sudden onset (thunderclap headache) 

• Onset after age 50 

• Pattern change or progressive worsening

The management of TTH combines medication with non-pharmacological strategies. A patient-centered, multimodal approach is essential for effective control. 

Acute treatment: 

• Simple analgesics such as acetaminophen 500–1000 mg 

• NSAIDs such as ibuprofen 200–400 mg or naproxen 250–500 mg 

• Avoid opioids and frequent analgesic use to prevent medication overuse headache 

Preventive treatment: 

• Tricyclic antidepressants such as amitriptyline (10–75 mg at bedtime) 

• Nortriptyline as an alternative 

• Mirtazapine or venlafaxine for refractory cases 

• SSRIs generally not effective for prevention 

Non-pharmacologic approaches: 

• Stress management and relaxation training 

• Cognitive behavioral therapy 

• Physical therapy including posture correction and stretching 

• Biofeedback and EMG training 

• Acupuncture in selected cases 

• Sleep hygiene to improve rest quality 

Lifestyle modifications: 

• Regular exercise 

• Adequate hydration 

• Limiting caffeine 

• Ergonomic workspace adjustments 

• Consistent sleep schedule 

• Stress reduction practices like yoga or mindfulness 

Although TTH is not life-threatening, it can lead to complications if untreated or poorly managed. These complications can worsen quality of life and increase healthcare needs. 

Short-term complications: 

• Reduced concentration and productivity 

• Absenteeism from work or school 

• Overuse of acute medications 

Long-term complications: 

• Progression from episodic to chronic TTH 

• Medication overuse headache 

• Anxiety and depression 

• Sleep disturbances 

• Persistent reduction in quality of life 

Preventive strategies play an important role in reducing TTH frequency and severity. These focus on identifying triggers and adopting healthy lifestyle habits. 

Key preventive measures: 

• Identifying and modifying personal triggers 

• Avoiding medication overuse 

• Stress management and relaxation techniques 

• Maintaining good posture and ergonomics 

• Regular aerobic exercise 

• Adequate hydration and balanced nutrition 

• Consistent sleep hygiene 

The prognosis of TTH is generally favorable, although chronic forms may be more difficult to manage. With appropriate treatment and lifestyle adjustments, most patients achieve good symptom control. 

Prognostic considerations: 

• Many individuals experience episodic TTH with long periods of remission 

• Chronic TTH can improve with preventive treatment and lifestyle modifications 

• Long-term outcomes are typically positive with appropriate management

Tension-type headache is the most prevalent primary headache disorder and a major cause of global disability. Despite its often mild symptoms, its high prevalence and impact make it a significant public health issue. 

Effective management requires a comprehensive approach that combines acute and preventive treatments with lifestyle and behavioral strategies. Early recognition and consistent intervention are key to preventing chronic forms and improving long-term outcomes. Ongoing research will further enhance understanding and provide new treatment options for this widespread condition. 

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