Tension Headaches

Tension headache is the most common of the primary primary headache disorders and one of the most common disorders presenting for medical evaluation worldwide. Tension headaches are generally described as bilateral, nonthrobbing, and of mild to moderate severity. There is no aura or other associated features. The diagnosis is clinical, often self-diagnosed by the patient or in the primary care setting. Management consists of abortive analgesics, such as NSAIDs and aspirin for isolated attacks, and preventative measures, such as behavioral changes, biofeedback, and preventative administration of medication for more chronic attacks.

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A headache attack is defined by the following features:

  • Mild to moderate intensity
  • Bilateral
  • Nonthrobbing 
  • With or without pericranial muscle tenderness
  • Generally without other associated symptoms
    • No aura
    • No focal neurologic symptoms
    • No photophobia
    • No phonophobia
    • No nausea or vomiting


Three primary headache disorders:

  1. Migraine headache
  2. Cluster headache
  3. Tension headache

Three tension headache subtypes:

  1. Infrequent episodic tension headache: ≤ 1 headache day per month
  2. Frequent episodic tension headache: 2–14 headache days per month
  3. Chronic tension headache: ≥ 15 headache days per month


  • Most prevalent headache in the general population 
  • Major cause of lost work productivity
  • Prevalence: affects about 75% of the population at some point
  • Women > men
  • Most common subtype: infrequent episodic


The pathophysiology of tension headache is multifactorial, but the precise mechanisms are largely unknown. Pain mechanisms are dynamic and vary from 1 individual to another.

Peripheral activation

Activation of myofascial nociceptors due to exposure to noxious environmental stimuli:

  • Most likely mechanism in infrequent episodic tension headache
  • Environmental stimuli may include (but are not limited to):
    • Stress
    • Mental/emotional tension
    • Bright light
    • Loud noises
    • Smells
    • Hunger
    • Ambient temperature extremes
    • Caps/headbands/ponytails
    • Suboptimal/improper vision correction
    • Pericranial muscle tension

Peripheral sensitization

Sensitization of myofascial nociceptors:

  • Due to persistent exposure to noxious environmental stimuli
  • Lower pain threshold to normally noxious stimuli
  • Development of latent trigger points in pericranial musculature
  • Likely mechanism in frequent episodic tension headache
  • Stepping stone to the development of chronic tension headache

Central sensitization

Sensitization of pain pathways in the central nervous system:

  • Likely mechanism in chronic tension headache
  • Due to prolonged nociceptive stimuli from peripherally sensitized pericranial myofascial tissues
  • Lower pain threshold to normally noxious stimuli (hypersensitivity)
  • Normally innocuous stimuli are misinterpreted as pain (allodynia):
    • Increased facilitation of pain transmission at the spinal dorsal horn/trigeminal nucleus
    • Decreased inhibition of pain transmission at the spinal dorsal horn/trigeminal nucleus
    • Increased pericranial muscle activity

Genetic factors

Genetic factors have been shown to play a role in the pathogenesis of chronic tension headache.

  • 1st-degree relatives of individuals with chronic tension headache have > 3-fold risk of chronic tension headache.
  • Multifactorial inheritance pattern proposed but not proven

Clinical Presentation

Tension headache may present with wide variation in frequency and intensity between individuals, in the same individual over time, and from 1 attack to another in the same individual.


  • Classic pain descriptors:
    • Dull
    • Pressure
    • Head fullness
    • Head feels large
    • Like a tight cap
    • Band-like
    • Heavy weight on head or shoulders
  • Features:
    • Typically bilateral
    • Duration from 30 minutes to several days
    • Not worsened by physical activity
    • Pericranial muscle tension
    • Presence of myofascial trigger points

Physical exam

  • Pericranial muscle tenderness:
    • Frontalis
    • Temporalis
    • Orbicularis oculi
  • Extracranial muscle tenderness:
    • Masseter
    • Pterygoid
    • Sternocleidomastoid
    • Splenius
    • Trapezius
  • Presence of myofascial trigger points (pericranial or extracranial)


Diagnostic criteria

  • At least 2 of the following:
    • Bilateral location
    • Pressing or tightening (nonpulsating) quality
    • Mild or moderate intensity
    • Not aggravated by routine physical activity (walking, climbing stairs)
  • Exclusions:
    • No nausea or vomiting
    • No more than 1 of:
      • Photophobia
      • Phonophobia
  • Classification by chronicity:
    • Infrequent episodic tension headache: ≤ 1 headache day per month
    • Frequent episodic tension headache: 2–14 headache days per month
    • Chronic tension headache: ≥ 15 headache days per month

Laboratory evaluation

Laboratory evaluation is indicated only in the following cases:

  • Suspected infectious process
  • Suspected organ dysfunction
  • Suspected volume depletion/overload
  • Suspected electrolyte disturbance

Laboratory testing should be specific to suspected underlying cause(s):

  • Suspected infectious process:
    • CBC
    • CSF studies
  • Suspected organ dysfunction:
    • Cardiac biomarkers
    • BUN, creatinine (renal function)
    • AST/ALT (hepatic function)
  • Suspected volume depletion/overload:
    • BUN/creatinine (renal function)
    • AST/ALT (hepatic function)
    • BNP (indicates heart failure)
    • Thyroid studies
  • Suspected electrolyte disturbance: chemistry panel or electrolyte panel


Imaging is indicated only in the following cases:

  • Red-flag headache symptoms
  • Focal neurologic findings 
  • Headache does not classify as any of the primary headache disorders.

Imaging modalities:

  • MRI of the brain with and without contrast is the test of choice. 
  • CT is faster for triage of suspected acute intracranial hemorrhage.


Treatment of tension headache is usually self-directed by sufferers using over-the-counter analgesics without seeking any medical attention or direction. The primary care physician should be able to diagnose and manage tension headache without the need for specialist consultation.

Abortive therapy

  • 1st-line medication: simple analgesics (single ingredient, nonopioid, nonbarbiturate):
    • Aspirin
    • Acetaminophen
    • NSAIDs (ibuprofen, naproxen) 
  • 2nd-line medication:
    • Compound analgesics (1 or more ingredients, most commonly caffeine, butalbital, or a weak opioid):
      • Simple analgesics + caffeine 
      • Simple analgesics + codeine 
      • Simple analgesics + butalbital 
    • Chlorpromazine
    • Metoclopramide
    • Ketorolac (NSAID)
    • Triptans
  • Most effective if administered soon after symptom onset
  • Frequency of dosing should be limited to avoid medication overuse headache (rebound effect), especially for combination drugs containing:
    • Caffeine
    • Codeine
    • Butalbital

Preventative therapy

  • Considered in management as frequency of attacks increases
  • Indicated for:
    • Chronic tension headache 
    • Selected cases of frequent tension headache 
    • Acute therapy failure/intolerance
    • Prevention/treatment of medication overuse headache
  • Pharmacologic therapy:
    • Antidepressants
      • Tricyclics 
      • Mirtazapine
      • Venlafaxine
    • Anticonvulsants
      • Topiramate
      • Gabapentin
    • Botulinum toxin (headache protocol)
  • Nonpharmacologic therapies:
    • Neuromodulation (low-frequency electrical stimulation) 
    • Trigger point injections
    • Acupuncture
  • Behavioral approaches:
    • Lifestyle modifications
      • Regular sleep
      • Exercise
      • Diet
    • CBT
    • Relaxation
    • Biofeedback

Differential Diagnosis

  • Cluster headache: primary headache that is severe and unilateral, often around the eye, with a duration of minutes up to 3 hours. More common in men. Patients typically present with accompanying autonomic symptoms, such as nasal congestion and swelling or watering of the eye. Diagnosis is clinical based on the typical symptoms. Management includes administration of oxygen and triptans and avoiding triggers, such as smoking and alcohol.
  • Migraine headache: type of primary headache that is severe, generally described as unilateral and throbbing, and associated with neurological symptoms, such as nausea and/or light and sound sensitivity. Migraine attacks last between 4 and 72 hours and are more common in women. Patients may experience an aura before the onset of the headache, such as visual phenomena, tingling of the skin, or difficulty speaking. Diagnosis is clinical based on the typical symptoms. Management includes avoiding loud noises and light and the administration of simple analgesics and/or triptans.
  • Medication overuse headache: also called rebound headache. A type of secondary headache in patients who have frequent or daily headaches despite, or because of, the regular use of headache medications. Medication overuse headache is usually preceded by an episodic primary headache disorder that has been treated with excessive amounts of abortive medications, especially combination drugs with caffeine and codeine. Management includes a gradual reduction of the dose.
  • Cervicogenic headache: headache caused by referred pain from the upper cervical joints. Typically unilateral, moderate to severe intensity, increased by movement of the head, with radiation from occipital to frontal regions. Diagnosis is clinical based on typical symptoms. Management includes simple analgesics, physical therapy, nerve blocks, or spinal manipulation. 
  • Sinus headache: headache that occurs in the setting of acute or chronic sinusitis. The pain is typically described as constant and deep around the cheeks, forehead, or bridge of the nose. Sinus headache is associated with symptoms including a runny nose, swelling or tearing of the eyes, and fever. Management includes decongestants, antihistamines in case of allergy, and antibiotics in the presence of a bacterial infection.


  1. Taylor F. (2020). Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis. Retrieved July 18, 2021, from https://www.uptodate.com/contents/tension-type-headache-in-adults-pathophysiology-clinical-features-and-diagnosis
  2. Taylor F. (2020). Tension-type headache in adults: Acute treatment. Retrieved July 18, 2021, from https://www.uptodate.com/contents/tension-type-headache-in-adults-acute-treatment
  3. Taylor F. (2020). Tension-type headache in adults: Preventive treatment. Retrieved July 18, 2021, from https://www.uptodate.com/contents/tension-type-headache-in-adults-preventive-treatment
  4. American Migraine Foundation. Tension-type headache. Retrieved July 19, 2021, from https://americanmigrainefoundation.org/resource-library/tension-type-headache/ 

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