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Tension-Type Headache

by Stephen D. Silberstein, MD

Tension-type headache causes mild generalized pain without the incapacity, nausea, or photophobia associated with migraine.

Tension-type headaches may be episodic or chronic. Episodic tension-type headaches occur < 15 days/mo. Episodic tension-type headache is very common; most patients obtain relief with OTC analgesics and do not seek medical attention. Tension-type headaches that occur 15 days/mo are considered chronic.

Symptoms and Signs

The pain is usually mild to moderate and often described as viselike. These headaches originate in the occipital or frontal region bilaterally and spread over the entire head. Unlike migraine headaches, tension-type headaches are not accompanied by nausea and vomiting and are not made worse by physical activity, light, sounds, or smells. Potential triggers for chronic tension-type headache include sleep disturbances, stress, temporomandibular joint dysfunction, neck pain, and eyestrain.

Episodic headaches may last 30 min to several days. They typically start several hours after waking and worsen as the day progresses. They rarely awaken patients from sleep.

Chronic headaches may vary in intensity throughout the day but are almost always present.


  • Clinical evaluation

Diagnosis is based on characteristic symptoms and a normal physical examination, which includes a neurologic examination. Potential triggers for chronic tension-type headache should be identified and treated.

Tension-type headache should be distinguished from a forme fruste of migraine, which many patients with migraine have; these headaches have only some features of migraine and resemble tension-type headache, but they are mild and respond to migraine-specific drugs.

If severe headaches are thought to be tension-type headaches, the diagnosis should be reconsidered because severe tension-type headaches are rare.

Pearls & Pitfalls

  • Reconsider the diagnosis of tension-type headache if headache is severe.


  • Analgesics

  • Sometimes behavioral and psychologic interventions

Some drugs used to prevent migraine, particularly amitriptyline, can help prevent chronic tension-type headache.

For most mild to moderate tension-type headaches, OTC analgesics (eg, aspirin, acetaminophen) can provide relief. Massaging the affected area may help.

Behavioral and psychologic interventions (eg, relaxation and stress management techniques) are often used and are effective, especially when combined with drug treatment.

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