Tension-Type Headache: Diagnosis & Clinical Features
Tension-type headache (TTH) is the most prevalent primary headache disorder worldwide, yet it is underdiagnosed and undertreated because patients often self-manage and rarely seek specialty care. TTH is defined by what it is not — it lacks the defining features of migraine (pulsating quality, nausea, photophobia and phonophobia together, worsening with activity). The ICHD-3 classifies TTH into infrequent episodic, frequent episodic, and chronic forms, with the chronic form being the most disabling and the most likely to present to a neurologist.
Bottom Line
- Lifetime prevalence: 30-78% depending on the study — the most common primary headache
- Character: Bilateral, pressing/tightening ("band-like"), mild-to-moderate intensity, not worsened by routine physical activity
- Key distinction from migraine: No nausea/vomiting, no more than one of photophobia or phonophobia (not both), not pulsating, not aggravated by walking or climbing stairs
- Subtypes: Infrequent episodic (<1 day/month), frequent episodic (1-14 days/month), chronic (≥15 days/month for >3 months)
- Pericranial tenderness: The most significant physical finding — present in most patients and correlates with headache frequency and severity
- Overlap with migraine is common: Many patients have both TTH and migraine. When attacks have any migrainous features, they should be classified as migraine.
ICHD-3 Diagnostic Criteria
| Subtype | Frequency | Features (All Subtypes) |
|---|---|---|
| Infrequent episodic TTH (2.1) | <1 day/month (<12 days/year) |
A. At least 10 episodes fulfilling criteria B-D B. Lasting 30 minutes to 7 days C. At least 2 of the following: • Bilateral location • Pressing or tightening (non-pulsating) quality • Mild or moderate intensity • Not aggravated by routine physical activity D. Both of the following: • No nausea or vomiting • No more than one of photophobia or phonophobia |
| Frequent episodic TTH (2.2) | 1-14 days/month for >3 months (≥12 and <180 days/year) | |
| Chronic TTH (2.3) | ≥15 days/month for >3 months (≥180 days/year) |
Note on chronic TTH: Mild nausea is permitted (but not moderate/severe nausea or vomiting). This is the only feature that differs from episodic TTH criteria. Chronic TTH also permits only one of photophobia or phonophobia, not both.
With or Without Pericranial Tenderness
Each subtype is further specified as:
- Associated with pericranial tenderness (2.X.1) — increased tenderness on manual palpation of pericranial muscles (temporalis, masseter, pterygoid, SCM, splenius, trapezius)
- Not associated with pericranial tenderness (2.X.2)
This subclassification has mechanistic implications: pericranial tenderness suggests a peripheral myofascial component, while its absence suggests predominantly central sensitization.
Clinical Features
Typical Presentation
- Location: Bilateral — classically described as a "band" or "cap" around the head. Frontal, temporal, or occipital predominance is common but always bilateral.
- Quality: Pressing, tightening, or squeezing. Patients say "like a vice" or "like wearing a tight hat." Explicitly non-pulsating.
- Intensity: Mild to moderate. Patients can usually continue daily activities (unlike migraine, where activity worsening is a defining feature).
- Duration: 30 minutes to 7 days per episode. Chronic TTH may be continuous for weeks.
- Timing: Often builds throughout the day ("end-of-day headache"). May be related to sustained posture, stress, or fatigue. Less commonly present upon waking (unlike migraine).
- Associated features: Absent or minimal. One of photophobia or phonophobia (not both) is permitted. No nausea, no vomiting, no aura.
Physical Examination
Examining for Pericranial Tenderness
- Technique: Firm rotary pressure with the second and third fingers on the following muscles bilaterally: frontalis, temporalis, masseter, pterygoid (intraoral or external), SCM, splenius, trapezius, and suboccipital insertions
- Scoring: Tenderness is graded 0-3 at each site. A Total Tenderness Score (TTS) can be calculated. Higher TTS correlates with increased headache frequency.
- Clinical significance: Pericranial tenderness is the most consistent objective finding in TTH. It increases with headache frequency (most prominent in chronic TTH) and may reflect peripheral sensitization of myofascial nociceptors.
- Neurologic exam: Must be normal. Any focal findings, papilledema, or signs of increased ICP warrant imaging and further evaluation.
Differentiating TTH from Migraine
| Feature | TTH | Migraine |
|---|---|---|
| Location | Bilateral | Unilateral (60%) or bilateral |
| Quality | Pressing/tightening | Pulsating/throbbing |
| Intensity | Mild to moderate | Moderate to severe |
| Activity worsening | No | Yes (walking, climbing stairs) |
| Nausea | Absent (mild nausea allowed in chronic TTH only) | Common |
| Photo + phonophobia | At most one, not both | Both typically present |
| Aura | Never | 25-30% |
| Disability | Mild (usually can continue activities) | Moderate-severe (often needs to stop activities) |
| Triptan response | No | Yes |
The Overlap Problem
- Many patients have both migraine and TTH. The two disorders coexist in up to 30-50% of headache patients.
- An individual attack should be classified by its features: if any attack has nausea, or has both photophobia and phonophobia, or is aggravated by activity — it is migraine, even if other attacks in the same patient are TTH.
- "Mild migraine" is commonly misdiagnosed as TTH. Studies show that up to 50% of self-diagnosed "sinus headache" and "tension headache" actually meet criteria for migraine.
- If in doubt, a triptan trial can help differentiate: a clear response to triptans supports migraine, not TTH.
Pathophysiology
Episodic TTH: Peripheral Mechanisms
- Myofascial nociception: Increased sensitivity and activation of peripheral pain receptors in pericranial muscles (temporalis, trapezius, SCM, suboccipital)
- Sustained muscle contraction is likely not the cause (EMG studies show no consistent increase in muscle activity during TTH). The older term "muscle contraction headache" is misleading.
- Peripheral sensitization: Myofascial trigger points release sensitizing substances (substance P, CGRP, bradykinin) that lower the activation threshold of muscle nociceptors
- Contributing factors: Postural strain, jaw clenching/bruxism, stress-related muscle guarding, poor ergonomics
Chronic TTH: Central Sensitization
- As TTH becomes chronic, central sensitization develops — the trigeminal nucleus caudalis and supraspinal pain-processing centers become hyperexcitable
- Impaired descending inhibition: Endogenous pain-modulating systems (periaqueductal gray, rostral ventromedial medulla) become dysfunctional
- Widespread pressure pain thresholds decrease (not just in pericranial region) — indicating generalized central sensitization
- This shift from peripheral to central mechanisms explains why chronic TTH is harder to treat and why pericranial-focused therapies (massage, trigger points) become less sufficient
Secondary Headache Mimics
TTH is a diagnosis of exclusion in certain situations. Consider secondary causes when:
- New-onset daily headache in a patient >50 years — evaluate for GCA, intracranial lesion
- Progressive worsening over weeks to months despite treatment
- Positional component (worse lying down or worse standing) — suggests CSF pressure disorder
- Associated systemic symptoms (fever, weight loss, jaw claudication)
- Cervicogenic headache: Can closely mimic TTH but is strictly unilateral and provoked by neck movement or sustained neck posture. Tenderness is over cervical facet joints, not pericranial muscles.
- Medication overuse headache: Chronic daily headache in a patient using acute analgesics ≥15 days/month (simple analgesics) or ≥10 days/month (combination analgesics, triptans)
References
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
- Bendtsen L, Jensen R. Tension-type headache: the most common, but also the most neglected, headache disorder. Curr Opin Neurol. 2006;19(3):305-309.
- Jensen R. Pathophysiological mechanisms of tension-type headache: a review of epidemiological and experimental studies. Cephalalgia. 1999;19(6):602-621.
- Lyngberg AC, et al. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survey. Eur J Epidemiol. 2005;20(3):243-249.
- Fernandez-de-Las-Penas C, et al. Myofascial trigger points in subjects presenting with mechanical neck pain: a blinded, controlled study. Man Ther. 2007;12(1):29-33.