> Table of Contents > Headache, Tension
Headache, Tension
Kaelen C. Dunican, PharmD
Brandi Hoag, DO
image BASICS
  • Typically characterized by bilateral mild to moderate pain and pressure; may be associated with pericranial tenderness at the base of the occiput
  • Two types
    • Episodic tension-type headache (ETTH) divided into
      • Infrequent: <1 day per month
      • Frequent: ≥1 but <15 days per month
    • Chronic tension-type headache (CTTH): ≥15 days per month for ≥3 months
  • Synonym(s): muscle contraction headache; stress headache
Most common type of primary headache
  • Global prevalence in adults is 42% (1).
  • Lifetime prevalence is 79%.
  • More prevalent among women
  • Prevalence of CTTH is 3%.
  • Prevalence of ETTH decreases with age, whereas the prevalence of CTTH increases with age.
  • Debatable: peripheral and/or central mechanisms
  • Activation of peripheral nociceptors leads to muscle tenderness in ETTH.
  • Central sensitization is associated with CTTH:
    • Nitric oxide may play an important role in central sensitization.
    • Debatable: low-platelet serotonin
  • Peripheral: may provoke the central mechanism leading from ETTH to CTTH
  • Stress is the most frequently reported precipitating factor.
An increased genetic risk has been suggested by studies, particularly for CTTH.
Associated with triggers/precipitating factors
  • Stress (mental or physical)
  • 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
  • Identify and avoid triggers/precipitating factors.
  • Minimize emotional stress.
  • Encourage relaxation techniques:
    • Biofeedback, relaxation therapy, and physical therapy
    • Consider counseling/psychotherapy.
  • 83% of patients with migraine headaches also suffer from tension-type headaches.
  • Debatable: increased prevalence of comorbid anxiety and depression
  • General physical exam: vital signs, funduscopic and cardiovascular assessment, palpation of the head and neck
  • Neurologic exam: mental status, pupillary responses, motor-strength testing, deep tendon reflexes, sensation, cerebellar function, gait testing, signs of meningeal irritation
  • Migraine headache
  • Cluster headache
  • Head trauma
  • Subarachnoid hemorrhage
  • Subdural hematoma
  • Unruptured vascular malformation
  • Ischemic cerebrovascular disease
  • Temporal arteritis
  • Arterial hypertension (HTN)
  • Cerebral venous thrombosis
  • Benign intracranial HTN
  • Intracranial neoplasm, infection, or meningitis
  • Low CSF pressure
  • Medication (nonprescription analgesic dependency, nitrates)
  • Caffeine dependency
  • Metabolic disorders (hypoxia, hypercapnia, hypoglycemia)
  • Toxic effects from drugs or fumes
  • Temporomandibular joint syndrome
  • Eyes: glaucoma, refractive errors
  • Sinusitis or middle ear infection
  • Cervical spondylosis
  • Severe anemia or polycythemia
  • Uremia and hepatic disorders
  • Paget disease of bone
Labs and neuroimaging (CT or MRI) are only necessary when a secondary cause is suspected:
  • Atypical pattern of headache (does not fit specific category such as migraine, cluster, or tension)
  • Rapid increase in frequency (2)[C]
  • Focal neurologic findings
  • New onset after age 40 years
  • Sudden onset or worsening with exertion CT scan, with and without contrast, is as sensitive as MRI and is the test of choice.
  • Use MRI when lesions of the posterior fossa or an aneurysm is suspected.
  • NSAIDs, acetaminophen (APAP), and aspirin (ASA) are effective for short-term pain relief of ETTH (3,4)[B].
  • Amitriptyline should be considered first line for prophylaxis of CTTH (3,4)[B].
Relief measures: relaxation routines; rest in quiet, dark room; hot bath or shower; massage of back of neck and temples
Choice of simple analgesic is based on patient-specific parameters:
  • NSAIDs may be more effective than APAP for ETTH (3)[C]:
    • Ibuprofen and naproxen may be preferred due to better GI tolerability.
  • APAP should be considered for patients taking warfarin, unable to tolerate NSAIDs, or allergic to ASA or NSAIDs.
First Line
  • For acute attack (ETTH): NSAIDs, APAP, or ASA:
    • NSAIDs:
      • Ibuprofen (Motrin, Advil): 400 to 800 mg; may repeat q8h PRN (max 3.2 g/day)
      • Naproxen (Naprosyn): 375 to 500 mg or naproxen sodium (Aleve, Anaprox) 440 to 550 mg; may repeat q8-12h PRN (max 1,250 mg base/day)
      • Ketoprofen (Orudis): 12.5 to 50 mg; may repeat q6-8h PRN (max 300 mg/day)
      • Diclofenac (Voltaren, Cataflam): 50 to 100 mg; may repeat q8h PRN (max 150 mg/day)
      • Contraindications: ASA or NSAID allergy or bronchospasm, renal disease, bleeding disorders, increased risk of cardiovascular events (myocardial infarction [MI], stroke, new onset, or worsening of HTN)
      • Drug interactions: antihypertensives, anticoagulants, antiplatelet drugs, ASA, lithium, methotrexate
      • Adverse effects: epigastric distress, peptic ulcer
    • P.443

    • APAP (Tylenol): 1,000 mg; may repeat q6h PRN (max 4 g/day):
      • Adverse effects (rare): rash, pancytopenia, liver damage
      • Precaution: hepatic impairment, consumption of ≥3/day alcoholic beverages
  • Aspirin: 500 to 1,000 mg; may repeat q6h PRN (max 4 g/day):
    • Contraindication: ASA or NSAID allergy or bronchospasm, bleeding disorders
    • Drug interactions: anticoagulants, antiplatelet drugs, ACE inhibitors, &bgr;-blockers, corticosteroids, NSAIDs, sulfonylureas
    • Adverse effects: GI irritation/bleeding, thrombocytopenia
  • Prophylaxis for CTTH: tricyclic antidepressants (TCAs) (amitriptyline [Elavil]) 10 to 75 mg/day:
    • Not FDA approved for CTTH
    • Contraindications: acute recovery phase of MI, use of monamine oxidase inhibitors (MAOIs) within 14 days
    • Drug interactions: clonidine, MAOIs, quinolone antibiotics, SSRIs, sympathomimetics, azole antifungals, valproic acid
    • Adverse effects: drowsiness, dry mouth, tachycardia, heart block, blurred vision, urinary retention, seizure
Second Line
  • For acute attack (ETTH):
    • Caffeine combinations: 130 mg caffeine with 500 mg APAP and/or 500 mg ASA q6h PRN (3)[C]
    • Narcotic analgesics (rarely indicated; consider secondary causes of headache or secondary gain such as drug-seeking behavior for personal use or diversion/sale)
    • Ketorolac: 60 mg IM, single dose
  • For CTTH prophylaxis:
    • Mirtazapine: 15 to 30 mg/day (not FDA approved for CTTH) (3,4)[B]
    • Venlafaxine XR (Effexor XR): 37.5 to 300 mg/day (not FDA approved for CTTH) (3,4)[B]
Pediatric Considerations
ASA and antidepressants are contraindicated.
  • The combination of stress management therapy and a TCA (amitriptyline) may be most effective for CTTH.
  • Maprotiline: 75 mg/day (not FDA approved for CTTH) (3)[C]
  • Topiramate: 100 mg/day (limited clinical evidence for prevention of CTTH; not FDA approved for CTTH)
  • Alternative TCAs (although limited evidence of benefit, all are widely used for prophylaxis) (5)[B]
    • Desipramine (Norpramin): 50 to 100 mg/day
    • Imipramine (Tofranil): 50 to 100 mg/day
    • Nortriptyline (Pamelor): 25 to 50 mg/day
    • Protriptyline (Vivactil): 25 mg/day
  • Drugs with conflicting clinical evidence for CTTH (not FDA approved for CTTH):
    • Tizanidine: 2 to 6 mg TID
    • Memantine: 20 to 40 mg/day
  • Botulinum toxin type A is not likely to be effective for ETTH or CTTH (6)[A).
  • Electromyographic (EMG) biofeedback may be effective and is enhanced when combined with relaxation therapy (3,7)[C].
  • Cognitive-behavioral therapy may be helpful (3,7)[C].
  • Physical therapy, including positioning, ergonomic instruction, massage, transcutaneous electrical nerve simulation, and application of heat/cold may help.
  • Alternative agents (not FDA approved for TTH)
    • Tiger Balm or peppermint oil applied topically to the forehead may be effective for ETTH.
    • Limited evidence for use of acupuncture and physical therapy (7)[B]
  • Chiropractic spinal manipulation cannot be recommended for the management of ETTH; recommendations cannot be made for CTTH (8)[B].
Admission Criteria/Initial Stabilization
Outpatient treatment
  • Regulate sleep schedule.
  • Regular exercise
  • Identify and avoid dietary triggers.
  • Regulate meal schedule.
For additional information, contact:
  • National Headache Foundation: http://www.headaches.org
  • American Council for Headache Education: http://www.achenet.org
  • Usually follows a chronic course when life stressors are not changed
  • Most cases are intermittent.
1. Ferrante T, Manzoni GC, Russo M, et al. Prevalence of tension-type headache in adult general population: the PACE study and review of the literature. Neurol Sci. 2013;34(Suppl 1):S137-S138.
2. Freitag F. Managing and treating tension-type headache. Med Clin North Am. 2013;97(2):281-292.
3. Bendtsen L, Jensen R. Treating tension-type headache—an expert opinion. Expert Opin Pharmacother. 2011;12(7):1099-1109.
4. Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache—report of an EFNS task force. Eur J Neurol. 2010;17(11):1318-1325.
5. Verhagen AP, Damen L, Berger MY, et al. Lack of benefit for prophylactic drugs of tension-type headache in adults: a systematic review. Fam Pract. 2010;27(2):151-165.
6. Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA. 2012;307(16):1736-1745.
7. Sun-Edelstein C, Mauskop A. Complementary and alternative approaches to the treatment of tension-type headache. Curr Pain Headache Rep. 2012;16(6):539-544.
8. Bryans R, Descarreaux M, Duranleau M, et al. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther. 2011;34(5):274-289.
See Also
Algorithm: Headache, Chronic
  • G44.209 Tension-type headache, unspecified, not intractable
  • G44.219 Episodic tension-type headache, not intractable
  • G44.229 Chronic tension-type headache, not intractable
Clinical Pearls
  • Tension-type headache may be difficult to distinguish from migraine without aura. A tension-type headache is typically described as bilateral, mild to moderate, and dull pain, whereas a migraine is typically pulsating, unilateral, and associated with nausea, vomiting, and photophobia or phonophobia.
  • Evidence suggests that NSAIDs may be more effective than APAP for ETTH. Consider APAP for patients who cannot tolerate, or have a contraindication, to NSAIDs. Initial dose of APAP should be 1,000 mg (500 mg may not be as effective).
  • CTTH is difficult to treat, and these patients are more likely to develop medication-overuse headache. Clinical evidence supports the use of amitriptyline + stress-management therapy for CTTH.
  • Medication-overuse headaches must be avoided by limiting use of abortive agents to no more than 2 days/week.
  • A headache diary may be useful to identify triggers, response to treatment, and medication-overuse headaches.