Tension Headache: Symptoms, Types, Causes and Treatment

Tension-type headache (TTH) is the most common kind of headache worldwide, affecting millions of people of all ages. While often described as a mild or moderate discomfort, TTH can significantly impact quality of life and productivity, especially for those with frequent or chronic episodes. Understanding what makes tension headaches unique—their symptoms, types, underlying causes, and the latest evidence-based treatments—empowers individuals to manage and seek help for this prevalent, yet often misunderstood, condition.

Symptoms of Tension Headache

Tension headaches can be deceptively simple in their presentation—sometimes mistaken for "just stress" or "normal head pain." However, recognizing the classic features of TTH is essential for distinguishing it from other headache types and for ensuring effective management.

Symptom	Description	Distinction	Source
Pain Quality	Pressing or tightening (non-pulsating)	Not throbbing; steady	3 4
Intensity	Mild to moderate	Rarely severe	3 4 5
Location	Bilateral (both sides of head)	Diffuse, "band-like"	3 4 10
Physical Activity	Not aggravated by routine activity	Contrasts with migraine	3
Associated Symptoms	No nausea/vomiting; may have photophobia or phonophobia, but not both	Lacks migraine features	3

Table 1: Key Symptoms

Typical Features of Tension Headache

Tension headaches are typically described as a dull, aching pain or a sensation of tightness or pressure encircling the head—often likened to a tight band. The discomfort is usually felt on both sides, rather than being localized to one spot. Unlike migraines, TTH does not worsen with everyday physical movement such as walking or climbing stairs 3 4.

Duration and Frequency

• Duration: Lasts from 30 minutes to several days.
• Frequency: Can be infrequent, frequent, or chronic (see Types section).

Associated Symptoms

Tension headaches rarely cause nausea or vomiting. Some people might experience either light sensitivity (photophobia) or sound sensitivity (phonophobia), but not both at the same time—a key difference from migraines 3.

When to Seek Medical Attention

While tension headaches are not typically dangerous, sudden severe headaches, neurological symptoms (like weakness or confusion), or headaches that change pattern or worsen over time warrant prompt evaluation.

Types of Tension Headache

Tension headaches are not all alike. They are classified based on how often they occur and how long they last. This distinction is crucial for guiding treatment strategies and understanding prognosis.

Type	Frequency/Duration	Features	Source
Infrequent Episodic (IETTH)	<12 days/year	Short, isolated attacks	3 5 10
Frequent Episodic (FETTH)	1–14 days/month (≥12/year)	More regular, but not daily	3 5
Chronic (CTTH)	≥15 days/month for >3 months	May be daily, disabling	1 3 5

Table 2: Types of Tension Headache

Infrequent Episodic Tension-Type Headache (IETTH)

This is the most common form, characterized by fewer than 12 headache days per year. Episodes are isolated, with normal periods in between 3.

Frequent Episodic Tension-Type Headache (FETTH)

These headaches occur more regularly—between 1 and 14 days per month, for at least three months in a row. They can be more disruptive to daily life, but are not as persistent as the chronic form 3 5.

Chronic Tension-Type Headache (CTTH)

CTTH is defined as headaches present on 15 or more days per month, lasting for at least three months. This type is the most disabling and often the hardest to treat. Individuals with CTTH may experience continuous or near-continuous head pain, which can lead to significant impairment and reduced quality of life 1 3 5.

Progression and Overlap

• Progression: Some people with frequent episodic TTH may develop chronic TTH, especially if risk factors are not addressed 5 10.
• Overlap: The clinical features of these subtypes are similar, but their frequency and impact differ.

Causes of Tension Headache

The exact cause of tension-type headache remains elusive, but research points to a complex interplay of biological, psychological, and environmental factors. Understanding these can help in both prevention and management.

Factor	Mechanism/Contribution	Role in TTH	Source
Peripheral mechanisms	Myofascial pain, muscle nociception	Initiates pain (episodic)	1 3 5 10
Central sensitization	Increased CNS pain sensitivity	Key in chronic type	1 3 5 7
Stress/Emotional factors	Triggers or worsens headaches	Important contributor	5 7 9
Sleep disturbances	Poor sleep quality, insomnia	Increases frequency	9
Musculoskeletal factors	Neck/jaw muscle tension, posture	May provoke attacks	10

Table 3: Main Causes and Mechanisms

Peripheral vs. Central Mechanisms

• Peripheral Mechanisms: In episodic TTH, pain often arises from increased sensitivity of pain receptors in the muscles of the head, neck, and shoulders (myofascial nociception). Factors like sustained muscle contraction, poor posture, or local tenderness may be involved 1 3 5 10.
• Central Sensitization: In chronic TTH, changes in the way the brain and spinal cord process pain—making the nervous system more sensitive—play a dominant role. This is called central sensitization and helps explain why CTTH can persist even without obvious muscle tension 1 3 5 7.

Role of Stress and Emotional Factors

Stress is a well-established trigger for tension headaches. Episodes often coincide with periods of psychological tension, anxiety, or depression 5 7 9. Stress can heighten pain processing in the central nervous system and lower the threshold for headache onset.

Sleep Disturbances

Insomnia and poor sleep quality are strongly linked to higher frequency and intensity of TTH. The relationship is bidirectional—headaches can disrupt sleep, and sleep disturbances can trigger headaches. Addressing sleep can have a significant impact on headache management 9.

Musculoskeletal Contributions

While once thought that muscle tension was the sole cause, studies show that muscle activity is not always elevated in TTH sufferers. However, musculoskeletal factors—such as neck or jaw tension and poor posture—can still act as triggers or perpetuate pain in susceptible individuals 6 10.

Other Theories and Controversies

The traditional "muscle contraction theory" of tension headache has been challenged by recent research, which points toward a more nuanced understanding involving both physical and psychological mechanisms 8. Genetics may also play a role in susceptibility, especially in the progression from episodic to chronic TTH 5.

Treatment of Tension Headache

Managing tension headaches involves a combination of acute symptom relief and, for frequent or chronic cases, preventive strategies. Evidence-based treatments span medications, behavioral therapies, and physical interventions, often tailored to the individual's headache pattern and contributing factors.

Approach	Example/Details	Best for	Source
Simple Analgesics	Acetaminophen, NSAIDs	Acute episodes	3
Preventive Medication	Amitriptyline (TCA), others	Chronic/frequent	1 3 13
Non-Drug Therapies	Relaxation, CBT, biofeedback	All types (esp. chronic)	1 6 11
Physical Therapies	Physiotherapy, manual therapy, acupuncture	Adjunct for some	1 12 14

Table 4: Evidence-Based Treatments

Acute (Symptomatic) Treatments

For most people with episodic TTH, simple over-the-counter pain relievers such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) are effective and safe when used as needed. Overuse should be avoided, as frequent use can lead to medication overuse headache or diminish effectiveness over time 3.

Preventive (Prophylactic) Treatments

• Indications: Considered for individuals with frequent or chronic TTH, or when acute medications are ineffective, poorly tolerated, or contraindicated 1 3.
• First-line: Tricyclic antidepressants (TCAs) such as amitriptyline have the best evidence for reducing headache frequency and severity in chronic cases. TCAs are superior to placebo and more effective than SSRIs for prevention 1 13.
• Other medications: Some evidence supports venlafaxine and mirtazapine, though data are less robust 3. Tetracyclic antidepressants appear less effective 13.

Non-Pharmacological Therapies

• Cognitive Behavioral Therapy (CBT), relaxation training, and electromyographic (EMG) biofeedback are effective, especially for chronic TTH and in those with prominent stress or psychological triggers 1 6 11.
• Stress management: Learning coping skills and stress reduction techniques can reduce the frequency and severity of headaches 1 7 11.

Physical and Manual Therapies

• Manual therapy (such as massage or soft tissue techniques) and dry needling may help reduce pain intensity and frequency, but evidence is mixed and more research is needed 14.
• Physiotherapy and posture correction can be beneficial, especially when musculoskeletal factors are prominent 1 14.
• Acupuncture: Moderately effective for reducing frequency in frequent or chronic TTH, with some studies suggesting benefit over routine care or placebo. However, the effect size varies, and more research is required to confirm long-term benefits 12.

Lifestyle and Supportive Strategies

• Sleep hygiene: Improving sleep quality can reduce headache burden 9.
• Regular exercise and hydration may help, though evidence is limited.
• Identifying and avoiding personal triggers (such as stress, poor posture, or specific foods) can be useful for some individuals.

Treatment Considerations

• Combination approaches combining medication and non-drug therapies are often most effective, especially for chronic TTH 1.
• Individualization: Treatment should be tailored to headache pattern, severity, comorbidities (such as depression or anxiety), and patient preference.

Conclusion

Tension-type headache is a common, yet often under-recognized, neurological disorder with a significant impact on individuals' daily functioning and well-being. By understanding its symptoms, types, underlying causes, and evidence-based treatments, individuals and healthcare providers can work together to reduce the burden of TTH and improve quality of life.

Key Takeaways:

• Tension-type headache is the most prevalent headache disorder, typically presenting as a bilateral, pressing pain that is mild to moderate in intensity and not worsened by routine activity 3 4.
• There are three main types—episodic (infrequent or frequent) and chronic—distinguished by how often headaches occur 3 5.
• The causes are multifactorial, involving peripheral muscle or nerve mechanisms, central nervous system sensitization, stress, sleep disturbances, and musculoskeletal factors 1 3 5 7 9 10.
• Acute management relies on simple analgesics, while chronic or frequent cases benefit from preventive medications (especially TCAs), behavioral therapies, and selected physical treatments 1 3 11 13 14.
• Non-drug interventions such as CBT, relaxation, manual therapy, and acupuncture can play a valuable role, particularly for those with chronic tension-type headache or when medications are insufficient 1 6 11 12 14.
• Personalizing treatment—addressing triggers, stress, and sleep—is crucial for long-term success.

If you or someone you know struggles with frequent or chronic headaches, seeking evaluation from a healthcare professional can help clarify the diagnosis and build a treatment plan tailored to your needs.