Tension type headaches (TTHs) are recurring headaches that can last for anything from a few minutes to several weeks1. They are one of the most common types of headache2.

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What is a tension headache?

In the past, this type of headache was known by other names, such as “stress headache” and “muscle contraction headache”, but it’s been officially dubbed “tension-type headache” since 19881.

Many people, however, simply refer to TTHs as “normal headaches” and just take over-the-counter painkillers instead of seeing their healthcare provider3. However, taking painkillers more than twice a week can put you at risk for developing chronic daily medication overuse headaches1.

TTH can be divided into two main types, episodic and chronic, which share similar symptoms but differ in frequency1

Episodic

Can further be divided into infrequent and frequent1. Infrequent episodic TTH last from 30 minutes to 7 days5. Headache episodes occur less than 1 day a month on average or less than 12 days a year5. With frequent episodic TTHs, headache episodes occur on 1 to 14 days a month on average for more than 3 months or between 12 and 180 days a year5.

Chronic

Is when you have a TT headache most days of the month1.

Symptoms of TTHs are the same, whether you’re a chronic sufferer or get episodic headaches1.

Signs of TTHs include:

  • Dull, pressing sensation that feels like a tight band wrapping around your head2.
  • Neck muscles at the base of your skull may feel painful or tender2.
  • Scalp muscles may feel tender1.
  • Pain increases slowly, then remains constant1.
  • Symptoms are mild-to-moderate and less severe than with a migraine4.
  • No throbbing pain, nausea, aura or sensitivity to light and noise that you’d have with a migraine1,4.

Tension Triggers

Despite the high impact of TTHs and the existence of well-established diagnostic criteria, knowledge about this disorder is still quite limited3. Infrequent episodic TTH is primarily caused by environmental factors, while frequent episodic and chronic TTH is caused partly by genetic factors7.

Precipitating factors

Many people have reported mental tension, smoking and weather changes as precipitating a headache7. Other reported triggers for episodic TTHs include1:

  • Lack of sleep
  • Not eating on time
  • Alcohol
  • Menstruation

Genetics

Frequent episodic and chronic TTHs are caused by a combination of genetic factors7.

Stress

This is the most common trigger reported by people who suffer from TTHs8.

Get Diagnosed

Anyone who gets headaches often or very badly should consult their healthcare provider to rule out the possibility that there’s a serious underlying condition4.

A big part of the diagnostic process is ruling out other possible causes for the headache1,2. With this in mind, your healthcare provider will likely take a detailed history1:

Do a physical exam – examine the scalp for trigger (causes you to feel pain elsewhere in the body) or tender points (feels sore to the touch).
Ask about precipitating factors – stress, lack of sleep and not eating on time are among the most common headache-preceding factors reported by both TTH and migraine sufferers.
Ask about any variations during the day – TTH tends to start at some point during the day and then remain, often unchanging, for the rest of the day, although some people have said their headaches get worse by late evening.

Neuroimaging

Creating images of the nervous system using techniques such as magnetic resonance imaging (MRI), computed tomography (CT), functional MRI (fMRI) or positron emission tomography (PET) scans – should not be necessary unless your healthcare provider picks up something concerning during the initial examination4,9.

Treating tension headaches

A combination of medical and non-medical treatment options can be used for acute treatment or prevention1.

Treatment for tension headaches include:

Episodic tension-type headache

Simple painkillers, such as aspirin and paracetamol, and non-steroidal anti-inflammatory drugs (NSAIDs) are usually the primary treatment1,8.

You can also use medication that contains a combination of different active ingredients – painkillers combined with butalbital or an opiate such as codeine. This is often used to treat TTH, although a risk exists of developing chronic daily headache4.

Anti-emetics (used to treat nausea and vomiting) or sedating antihistamines (used to treat allergies) can increase the effects of the painkillers4.

Chronic tension-type headache

If you are overusing pain medication, the first thing you need to do is stop1. If you’re suffering from depression and anxiety, these conditions need to be evaluated and managed in their own right1. Medical, behavioural and physical treatments used in combination achieve optimum results1.

The tricyclic antidepressant, amitriptyline has been shown to be effective in treating chronic TTH1. The use of amitriptyline is continue for 6 months followed by a withdrawal attempt– some people remain headache-free during this period, while others find their headaches return without the medication and need a long-term treatment1.

Non-medical treatments

Other common treatments for TTHs include:

  • Biofeedback – trains you to control body responses that cause pain8
  • Relaxation training8
  • Self-hypnosis4
  • Cognitive therapy – can help manage stress8
  • Physiotherapy2
  • Massage2
  • Acupuncture2

Preventing tension headaches

Episodic tension-type headache

If you know what your triggers are, it’s important to avoid them1. Do not overuse pain medication as this can render the medication less effective1. Relaxation therapy and biofeedback can work well when administered by a trained professional1.

Chronic tension-type headache

Tricyclic antidepressants and biofeedback-assisted relaxation techniques are the most effective for prevention3,10.

Keeping a headache diary may be beneficial

Note any details of the headache episode, including severity, duration and any medication taken. This can provide helpful insight for your healthcare provider, who may be able to pick up triggers or whether you’re experiencing symptoms of medication overuse1.

Migraine or TTH?

If you experience migraines and TTH, it’s important to learn the difference between the two so you can take the right medication1.

Symptoms of migraine5

  • Headache lasts 4 – 72 hours
  • Pain is on one side
  • Pulsating pain
  • Pain intensity is moderate to severe
  • Normal physical activity makes it worse
  • Light sensitivity
  • Noise sensitivity
  • Possible aura

Symptoms of TTH5

  • Headache lasts between 30 minutes and 7 days
  • Pain is on both sides
  • Pressing or tightening pain – not pulsating
  • Pain intensity is mild to moderate
  • Physical activity has no impact on it
  • No nausea
  • Possible light sensitivity
  • Possible noise sensitivity
  • No aura

References

  1. Chowdhury, D. Tension-type headache. Annals of Indian Academy of Neurology. 15, 1. 83-8. (2012)
  2. Trkanjec, Z. & Aleksić-Shihabi, A. Glavobolje tenzijskog tipa [Tension-type headaches]. Acta Med Croatica. 62, 2. 205-10. (2008)
  3. Speciali, J.G., et al. Tension-type Headache. Expert Rev Neurother. 8, 5.839-53. (2008)
  4. Millea, P.J. & Brodie, J.J. Tension-type Headache. Am Fam Physician. 66, 5.797-804. (2002)
  5. IHS Staff. The International Classification of Headache Disorders, 3rd Edition. Cephalgia. 38, 1. 1-211. (2018)
  6. Fumal, A., & Schoenen, J. Céphalées de tension [Tension-type headache]. Revue neurologique161, 6-7. 720–722. (2005)
  7. Russell, M.B. Genetics of Tension-type Headache. J Headache Pain 8, 71–76. (2007)
  8. Bendtsen, L. Drug and Nondrug Treatment in Tension-type Headache. TAND. 2. 155-61. (2009)
  9. Powers, W.J. & Derdeyn, C.P. Neuroimaging, Overview. Editor(s): Michael J. Aminoff, Robert B. Daroff. Encyclopedia of the Neurological Sciences (Second Edition). Academic Press. 398-399. (2014)
  10. Loder, E. & Rizzoli, P. Tension-type headache. BMJ. 336, 88. (2008)

Learn more about other areas of pain.

Learn more about other areas of pain.