What Is Tension-Type Headache?
Tension-type headache (TTH) is the most common type of primary headache, affecting up to 80% of the population at some point in life. It is characterized by bilateral, pressing or tightening pain, of mild to moderate intensity, without the typical associated symptoms of migraine (nausea, severe vomiting, marked photophobia).
Despite its high prevalence, tension-type headache is frequently underestimated by both patients and healthcare professionals. When it becomes chronic (15 or more days per month), it can be as disabling as migraine, generating a significant impact on productivity and quality of life.
The name "tension-type" reflects the old belief that the pain resulted exclusively from muscular tension. Today we know that the mechanisms are more complex, involving sensitization of peripheral and central nociceptive pathways, in addition to myofascial factors.
Most Common
Tension-type headache accounts for up to 90% of all primary headaches, affecting both sexes in a relatively balanced way.
Mixed Mechanism
It involves peripheral myofascial sensitization and dysfunction in central pain processing, not just "muscular tension".
Episodic or Chronic
When it exceeds 15 days per month, it becomes chronic tension-type headache and requires a differentiated therapeutic approach.
Pathophysiology
The pathophysiology of tension-type headache involves an interaction between peripheral (myofascial) and central (sensitization of the nervous system) mechanisms. In the episodic form, peripheral mechanisms predominate; in the chronic form, central sensitization assumes a dominant role.
Peripheral Component
Increased sensitivity of pericranial muscles (frontalis, temporalis, masseter, pterygoids, sternocleidomastoid, and trapezius) is the most consistent finding in tension-type headache. Myofascial trigger points in these regions generate referred pain to the head, mimicking the headache.
Increased peripheral nociception arises from sensitization of muscle nociceptors, possibly from accumulation of algogenic substances (bradykinin, serotonin, prostaglandins) in myofascial tissues. Inadequate posture, bruxism, and stress contribute to the maintenance of this sensitization.
Central Component
In chronic tension-type headache, central sensitization occurs — neurons of the trigeminal nucleus caudalis and of the dorsal horn at C1-C3 become hyperexcitable, amplifying the perception of normal peripheral stimuli. The descending inhibitory mechanisms of pain (serotonin, norepinephrine) are also impaired.
The role of stress is mediated by the hypothalamic-pituitary-adrenal axis and the autonomic nervous system, which increase muscle tension and reduce the pain threshold. Psychological factors (anxiety, depression) are not the cause of tension-type headache but contribute to its chronification.
Symptoms
Typical tension-type headache presents a clinical profile distinct from migraine. Correct identification of the pain features is fundamental for the differential diagnosis and the choice of appropriate treatment.
Symptoms of Tension-Type Headache
- 01
Bilateral pressing or tightening pain
Sensation of "a band tightening around the head" or "weight on the head". Different from the pulsating character of migraine.
- 02
Mild to moderate intensity
The pain does not prevent routine activities, although it reduces productivity. In the chronic form it may be moderate.
- 03
Duration of 30 minutes to 7 days
Episodes typically last hours, but in the chronic form pain may be continuous for weeks.
- 04
Does not worsen with routine physical activity
Unlike migraine, walking or climbing stairs does not intensify the pain.
- 05
Absence of significant nausea
Nausea and vomiting are absent or minimal, distinguishing it from migraine.
- 06
Pericranial tenderness
Pain on palpation of the muscles of the skull, neck, and shoulders — the most reproducible finding in tension-type headache.
- 07
Mild photophobia or phonophobia
There may be mild sensitivity to light OR sound (not both simultaneously), less intense than in migraine.
TENSION-TYPE HEADACHE VS. MIGRAINE
| FEATURE | TENSION-TYPE HEADACHE | MIGRAINE |
|---|---|---|
| Location | Bilateral | Generally unilateral |
| Character | Pressure/tightening | Pulsating |
| Intensity | Mild to moderate | Moderate to severe |
| Duration | 30 min to 7 days | 4 to 72 hours |
| Nausea/vomiting | Absent or mild | Frequent |
| Photophobia/phonophobia | Mild (one or the other) | Marked (both) |
| Worsens with activity | No | Yes |
| Pericranial tenderness | Frequent | Variable |
Diagnosis
As with migraine, the diagnosis of tension-type headache is clinical, based on history and physical examination. There is no complementary test that confirms the diagnosis. The ICHD-3 criteria (International Classification of Headache Disorders) are used for classification.
🏥ICHD-3 Criteria for Frequent Episodic Tension-Type Headache
- 1.At least 10 episodes occurring on average 1-14 days/month for at least 3 months
- 2.Headache lasting from 30 minutes to 7 days
- 3.At least 2 of: bilateral, pressing/tightening (not pulsating), mild/moderate intensity, not aggravated by physical activity
- 4.Absence of nausea or vomiting
- 5.At most photophobia OR phonophobia (not both)
- 6.Not attributed to another condition
Differential Diagnosis
Tension-type headache must be differentiated from other types of primary headache and from treatable secondary causes. Correct diagnosis guides treatment and avoids the use of inappropriate medications.
DIAGNÓSTICO DIFERENCIAL
Diagnóstico Diferencial
Migraine without Aura
Leia mais →- Unilateral, pulsating
- Nausea/vomiting
- Worsens with activity
- Lasts 4-72h
Testes Diagnósticos
- ICHD-3 criteria
- Headache diary
Cervicogenic Headache
- Pain originating in the neck
- Unilateral
- Worsens with cervical movements
Testes Diagnósticos
- Diagnostic cervical block
- Cervical physical examination
Medication-Overuse Headache
- Headache present >15 days/month
- Use of analgesics >10 days/month
- Worsens on attempted withdrawal
Testes Diagnósticos
- Medication history
- Headache diary
Systemic Arterial Hypertension
- BP >180/110 mmHg
- Occipital morning headache
- Cardiovascular risk factors
Testes Diagnósticos
- BP measurement
- Cardiovascular evaluation
Temporomandibular Disorder
Leia mais →- Pain in masticatory muscles
- Clicking in the TMJ
- Bruxism
Testes Diagnósticos
- TMJ examination
- Dental panoramic radiograph
Tension-Type Headache vs. Migraine: The Central Differential Diagnosis
Differentiating between tension-type headache and migraine is the most frequent challenge in clinical practice. Bilateral pressing character, mild to moderate intensity, and absence of nausea or vomiting point to tension-type headache. Unilateral pulsating pain, with nausea and worsening with movement, characterizes migraine. The headache diary is indispensable for documenting the features of each episode and guides both the diagnosis and the response to treatment.
A frequently overlooked point is that tension-type headache and migraine can coexist in the same patient — called "mixed headache". In this situation, the patient has attacks of two different types that must be recognized and treated separately. The medical acupuncturist should explore the detailed history of each type of attack to guide the correct therapeutic approach.
Medication-Overuse Headache
Medication-overuse headache (MOH) is one of the most underestimated and most important conditions in the differential diagnosis of chronic tension-type headache. When simple analgesics are used on more than 15 days per month (or triptans/combinations on more than 10 days/month), the medication itself begins to perpetuate and intensify the headache.
MOH frequently overlaps with preexisting tension-type headache, transforming it from episodic to chronic. The patient describes an almost daily headache, present on waking, that improves temporarily with analgesics but returns rapidly. Supervised withdrawal of the analgesics in excess, although associated with initial worsening, is essential for restoring the normal response pattern.
Secondary Causes That Should Not Be Missed
Although tension-type headache is benign, some secondary headaches present a similar pattern and should not be missed. Very high arterial hypertension can cause occipital headache, especially in the morning. Untreated hypothyroidism generates chronic low-intensity headaches. Obstructive sleep apnea is an underdiagnosed cause of persistent morning headache, frequently confused with tension-type headache.
Abrupt change in headache pattern, onset after age 50, association with systemic symptoms (fever, weight loss) or neurological symptoms (diplopia, ataxia, personality change) are alarm signs that demand investigation to exclude serious secondary causes, even in patients with a known history of tension-type headache.
Treatment
Treatment of tension-type headache depends on attack frequency. In the infrequent episodic form, simple analgesics suffice. In the frequent episodic or chronic form, preventive treatment and a multimodal approach are necessary.
Acute Treatment
Simple analgesics such as acetaminophen (1,000 mg) and ibuprofen (400 mg) are effective for most episodes. Ibuprofen tends to be more effective than acetaminophen. Aspirin (500-1,000 mg) is also a valid option. Triptans are not effective for isolated tension-type headache.
The main risk of acute treatment is excessive use of analgesics. Limit use to a maximum of 10-15 days per month. Combination analgesics (with caffeine or codeine) carry a greater risk of rebound headache and should be avoided.
Preventive Treatment
Amitriptyline (10-75 mg/day) is the first-choice drug in the prevention of chronic tension-type headache. Its mechanism involves modulation of descending inhibitory pain pathways (serotonin and norepinephrine), a central analgesic effect independent of the antidepressant effect, and improvement in sleep quality. The effective dose is usually lower than the antidepressant dose.
Other preventive options include mirtazapine, venlafaxine, and tizanidine. Non-pharmacologic approaches such as electromyographic biofeedback, cognitive-behavioral therapy, and cervical physical therapy have evidence of efficacy and are recommended as part of multimodal treatment.
Acupuncture as Treatment
Acupuncture is a complementary therapeutic option with growing evidence in tension-type headache. The Cochrane systematic review (Linde et al., 2016) concluded that acupuncture can be a useful complement to conventional treatment, particularly for patients seeking to reduce medication burden, with moderate quality of evidence.
The proposed mechanisms are particularly relevant for tension-type headache: deactivation of myofascial trigger points in the pericranial muscles, reduction of central sensitization via activation of descending inhibitory pathways, release of endorphins, and modulation of muscle tone via the autonomic nervous system.
Typical treatment involves 10-12 sessions over 5-8 weeks. The response is generally gradual, with progressive improvement in the frequency and intensity of episodes. Acupuncture can be combined with preventive medications and physical therapy.
Prognosis
Episodic tension-type headache has a generally favorable prognosis. Most patients achieve adequate control with simple measures. The chronic form, although more challenging, also responds well to appropriate multimodal treatment.
Factors that influence prognosis include the duration of chronification, presence of psychiatric comorbidities (anxiety, depression), excessive use of analgesics, and untreated perpetuating factors (bruxism, inadequate posture, sleep disturbances). Addressing comorbidities and perpetuating factors is as important as treating the headache itself.
Myths and Facts
Myth vs. Fact
Tension-type headache is caused only by stress
Although stress is a frequent trigger, tension-type headache involves complex neurobiological mechanisms including peripheral and central sensitization. Postural, muscular, and sleep factors are equally important.
It is a "trivial" headache that does not deserve medical attention
The chronic form of tension-type headache can be as disabling as migraine and accounts for an enormous socioeconomic cost. It deserves appropriate diagnosis and treatment.
Taking analgesics every day is the solution
Frequent use of analgesics can chronify the headache. Preventive treatment, physical therapy, and lifestyle changes are fundamental for the chronic form.
Tension-type headache and migraine are the same thing
They are distinct entities with different pathophysiology, symptoms, and treatments, although they may coexist in the same patient.
When to Seek Help
Frequently Asked Questions
Frequently Asked Questions
Yes. Tension-type headache is classified as episodic (infrequent or frequent) or chronic, when it occurs on 15 or more days per month for at least 3 months. Chronification is favored by excessive use of analgesics, sleep disturbances, anxiety, depression, inadequate posture, and untreated bruxism. Treatment of the chronic form is more complex and requires a multimodal approach with pharmacologic prevention, psychotherapy, and physical therapy.
For episodic attacks, acetaminophen (1,000 mg) or ibuprofen (400-600 mg) are effective in most cases. Ibuprofen tends to be slightly superior to acetaminophen. Aspirin (500-1,000 mg) is also a valid option. Triptans are not effective for tension-type headache. The critical point is to limit use to a maximum of 10-15 days per month to avoid rebound headache. For the chronic form, low-dose amitriptyline is the first-line preventive.
Inadequate posture — especially when using computers and smartphones for long periods — is an important perpetuating factor in tension-type headache. It generates chronic tension in the pericranial and cervical muscles, maintaining peripheral sensitization. Postural correction, regular work breaks, ergonomic adjustment of the workstation, and cervical stretching exercises are relevant complementary measures, especially for patients who work seated for many hours.
Yes. The Cochrane review (Linde et al., 2016) on acupuncture in tension-type headache concludes that acupuncture can reduce episode frequency and represent a useful complement to conventional treatment in the prevention of the chronic form, with moderate quality of evidence. The mechanisms are particularly suitable for tension-type headache: deactivation of myofascial trigger points in the pericranial muscles, reduction of muscle tension, and modulation of central pain pathways. The medical acupuncturist can combine local and distal points according to the individual pattern of the patient.
Yes, there is a bidirectional relationship between bruxism and tension-type headache. Bruxism (grinding or clenching of teeth, generally during sleep) generates hyperactivity of the masticatory and temporal muscles, contributing directly to peripheral sensitization and headaches. Conversely, stress — an important factor in tension-type headache — also worsens bruxism. Treatment of bruxism with an occlusal splint can improve headaches in patients in whom this association is identified.
Stress is a frequent trigger but not the only cause. Tension-type headache has its own neurobiological mechanisms — peripheral and central sensitization — that can persist even when stress is controlled. In addition, the relationship is bidirectional: frequent headaches generate more stress, creating a cycle. Stress management techniques (mindfulness, biofeedback, cognitive-behavioral therapy) are useful adjuncts but should be integrated into appropriate medical treatment.
By the definition of the ICHD-3 criteria, tension-type headache should not be accompanied by nausea or vomiting. The presence of nausea shifts the diagnosis toward migraine. However, patients with intense pain of any type may feel malaise or mild nausea as a nonspecific response. If nausea is prominent, the diagnosis of tension-type headache should be reassessed, and the possibility of migraine or mixed headache should be considered.
Sleep has a central role in tension-type headache. Both deprivation and excess sleep can trigger attacks. Sleep disturbances — insomnia, obstructive sleep apnea, restless legs syndrome — are frequent comorbidities that perpetuate and aggravate chronic tension-type headache. Treatment of sleep disturbances is an important therapeutic strategy that frequently improves headache frequency independently of medications specific to headache.
Tension-type headache has a smaller genetic component than migraine. Twin studies show heritability of about 25-40% for the chronic form, suggesting that environmental and behavioral factors are more determinant than in migraine. Families with a history of tension-type headache may share patterns of stress response, postural and sleep habits that contribute to the familial transmission of the condition, even without necessarily having a strong genetic basis.
Although benign, tension-type headache can mask serious conditions. Seek immediate care if: the headache is the most intense you have ever felt ("thunderclap headache"), it began suddenly during physical or sexual exertion, it is accompanied by fever, neck stiffness, mental confusion, or neurological deficit, it worsens progressively over days, it began after head trauma, or it is a new headache in a person over 50. Any abrupt change in the usual pattern also deserves medical evaluation.
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