Headache, Tension



  • A bilateral mild to moderate, nonthrobbing head pain or pressure, without other associated symptoms. Three types of tension-type headache (TTH):
    • Infrequent episodic TTH: <1 day per month
    • Frequent episodic TTH: ≥1 but <15 days per month
    • Chronic TTH: ≥15 days per month for >3 months
  • TTHs replaced older terms: muscle contraction headache, stress or tension headache, and psychogenic headache.


The most common type of primary headache, and the second-most prevalent disorder in the world


  • Peak age of prevalence in the United States: the 4th decade
  • Lifetime prevalence: men (69%); women (88%)
  • Prevalence of episodic TTH decreases with age, whereas the prevalence of chronic TTH increases with age.

Etiology and Pathophysiology

  • Multifactorial: peripheral and/or central mechanisms
  • Activation of peripheral nociceptors leads to myofascial pain in episodic TTH.
  • Prolonged stimulation of nociceptors sensitizes the central pain pathways leading to chronic TTH.
  • Nitric oxide may play an important role in TTH.

Risk Factors

Associated with triggers/precipitating factors:

  • Stress (mental or physical): the most common
  • Change in sleep regimen
  • Skipping meals
  • Certain foods (caffeine, alcohol, chocolate)
  • Dehydration
  • Physical exertion
  • Environmental factors (sun glare, odors, smoke, noise, lighting)
  • Poor or sustained posture
  • Female hormonal changes
  • Medications (e.g., nitrates, SSRIs, antihypertensives)
  • Overuse of abortive headache medication

General Prevention

  • Identify and avoid triggers/precipitating factors.
  • Minimize physical and emotional stress.
  • Relaxation techniques: biofeedback, relaxation therapy, and physical therapy

Commonly Associated Conditions

  • 83% of patients with migraine headaches also suffer from TTHs.
  • Debatable: increased prevalence of comorbid anxiety and depression

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