Characteristic Features of Tension-Type Headache
Tension-type headache presents with bilateral, pressing or tightening (non-pulsatile) pain of mild to moderate intensity that is not aggravated by routine physical activity and lacks the associated symptoms typical of migraine. 1, 2
Pain Characteristics
The headache quality is distinctly pressing, tightening, or band-like rather than throbbing or pulsatile. 1, 2 The intensity ranges from mild to moderate—severe pain should prompt consideration of alternative diagnoses. 1, 3
- Location: Bilateral involvement affecting both sides of the head is the rule, not unilateral. 1, 2
- Duration: Episodes can last from 30 minutes to 7 days in episodic forms. 3
- Quality: Patients often describe a sensation of a tight band or pressure around the head. 4
Key Distinguishing Features
The absence of certain features is as diagnostically important as what is present:
- No aggravation with routine physical activity (walking, climbing stairs)—this distinguishes it from migraine where movement worsens pain. 1, 2
- No nausea or vomiting (though anorexia may occur). 1, 2
- No photophobia AND phonophobia together (may have one or the other, but not both). 1, 2
- No autonomic symptoms such as lacrimation, nasal congestion, or ptosis that characterize cluster headache. 5
Diagnostic Requirements
According to the International Headache Society criteria, diagnosis requires at least two of the following features: 1
- Pressing, tightening, or nonpulsatile character
- Mild to moderate intensity
- Bilateral location
- No aggravation with routine activity
AND both of the following: 1
- No nausea or vomiting (anorexia acceptable)
- Absence of both photophobia and phonophobia (one is permissible)
Clinical Subtypes
Three recognized subtypes exist based on frequency: 4
- Infrequent episodic: <1 day per month
- Frequent episodic: 1-14 days per month
- Chronic: ≥15 days per month for >3 months
Common Pitfalls in Diagnosis
Coexistence with migraine is extremely common in clinical populations and can complicate diagnosis—many patients have both conditions requiring separate recognition and treatment. 6 Do not assume a single diagnosis explains all headache episodes. 6
Red flags requiring neuroimaging or further workup include: 2
- Sudden onset or "thunderclap" presentation
- Fever or systemic symptoms
- Focal neurological symptoms or abnormal examination
- Onset after age 50
- Progressive worsening pattern
Routine neuroimaging is not indicated for typical tension-type headache with normal examination and no concerning historical features. 2
Pathophysiology Context
Peripheral myofascial mechanisms predominate in episodic forms, while central sensitization and inadequate endogenous pain control become more prominent in chronic tension-type headache. 7 This explains why chronic forms are more difficult to treat and may require different therapeutic approaches than episodic forms. 7