Symptoms of Tension 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 accompanying symptoms characteristic of migraine. 1
Core Diagnostic Features
According to the International Headache Society criteria, tension headache requires at least two of the following characteristics 1:
- Pressing, tightening, or nonpulsatile character (not throbbing) 1
- Mild to moderate intensity (not severe) 1
- Bilateral location (both sides of the head) 1
- No aggravation with routine physical activity (unlike migraine) 1
Additionally, both of these features must be present 1:
- No nausea or vomiting (anorexia may occur) 1
- No photophobia AND phonophobia together (may have one or the other, but not both) 1
Pain Distribution and Quality
The pain typically radiates in a band-like fashion bilaterally from the forehead to the occiput, often described as tightness, pressure, or dull ache 2. Pain commonly extends to the neck muscles and may present in a "headband" distribution around the temporal region 2, 3, 4. The headache is characterized by slowly progressive, dull, constant pain rather than sudden onset 3.
Frequency Classification
- Episodic tension-type headache: Occurs fewer than 15 times per month 3
- Chronic tension-type headache: Occurs more than 15 times per month for at least six months 3
Key Distinguishing Features from Migraine
Tension headache lacks migraine-type features including 2:
- Unilateral location
- Throbbing/pulsatile quality
- Nausea
- Photophobia (light sensitivity)
- Phonophobia (sound sensitivity) occurring together
The absence of these features is critical for accurate diagnosis, as tension-type headache is the only other paroxysmal headache disorder prevalent in the general population besides migraine 1.
Associated Factors
Tension-type headaches are commonly associated with 5, 4:
- Young age
- Poor posture
- Sleep disturbances
- Anxiety and stress
- Muscle tension in the neck and shoulder region
Treatment Overview
Acute Treatment
Ibuprofen 400 mg or acetaminophen 1000 mg are first-line options for acute episodes, showing significant improvement in pain-free response at 2 hours 6, 7. Medications should be taken early in the headache episode and limited to less than 2 days per week to prevent medication overuse headache 6, 8.
Preventive Treatment
Amitriptyline at 50-100 mg is the first-line preventive treatment for chronic tension-type headache, significantly reducing monthly headache days 6, 7. Starting doses typically range from 10-25 mg at bedtime with gradual titration 6. Monitor for anticholinergic adverse effects, especially in older patients 7.
Non-Pharmacological Approaches
Physical therapy targeting the cervical spine, aerobic exercise, and progressive strength training are recommended as adjunctive management 6, 8. These interventions are particularly important when cervical dysfunction is present 8.
Critical Pitfalls to Avoid
- Avoid opioids and butalbital-containing compounds due to high risk of dependence and medication overuse headache 1, 7
- Do not use acute medications more than 2 days per week or more than 15 days per month to prevent progression to chronic daily headache 6, 7
- Neuroimaging is not needed if there are no red flags on examination (thunderclap headache, focal neurological symptoms, unexplained fever, impaired memory) 1, 2