Signs and Symptoms of Tension-Type Headache
Tension-type headache presents with bilateral, mild to moderate pain that has a pressing or tightening quality, is not aggravated by routine physical activity, and notably lacks the accompanying symptoms characteristic of migraine (such as nausea, photophobia, or phonophobia). 1
Core Clinical Features
The pain characteristics are highly distinctive:
- Pain Quality: Dull, pressing, or tightening sensation—often described as a band-like tightness around the head 2, 3, 4
- Pain Location: Bilateral distribution, typically radiating from forehead to occiput in a band-like fashion, often extending to neck muscles 4
- Pain Intensity: Mild to moderate severity (not severe) 2, 3
- Duration: Episodes can last from 30 minutes to several days 5
Key Distinguishing Features (What TTH Does NOT Have)
This is critical for differential diagnosis from migraine:
- No throbbing or pulsating quality 2
- No aggravation with routine physical activity 1, 3—patients can continue daily activities
- No nausea or vomiting (though anorexia may occasionally occur) 2
- No photophobia AND phonophobia together (may have one or the other, but not both) 2
- No aura or prodromal symptoms 6
- No autonomic symptoms (no tearing, nasal congestion, or other cranial autonomic features) 6
Physical Examination Findings
- Increased tenderness of pericranial muscles on palpation 6
- Myofascial trigger points may be present 7
- Normal neurological examination—no focal deficits 4
Clinical Subtypes
The presentation varies by frequency:
- Episodic TTH: Most common form, with lifetime prevalence of approximately 78% 5
- Chronic TTH: Headache occurring ≥15 days per month, affecting 1-3% of population and causing considerable disability 5
Common Pitfalls to Avoid
Do not confuse with migraine: The absence of migraine-associated features is the key diagnostic criterion. If nausea, photophobia AND phonophobia, or aggravation with physical activity are present, reconsider the diagnosis 1.
Recognize psychological factors: Stress and psychological comorbidities (anxiety, depression) are commonly associated with TTH and should be assessed 6, 7.
Watch for medication overuse: Patients using analgesics more than twice weekly are at risk for progression to chronic daily headache 4.
The diagnosis is purely clinical, based on headache history and exclusion of secondary causes 3. Neuroimaging is not indicated unless red flags are present in the history or examination 4.