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Tension Headache

  • Author: Michelle Blanda, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
Updated: May 11, 2016


The International Headache Society (IHS) began developing a classification system for headaches in 1985. Now in its third edition (beta version), this system includes a tension-type headache (TTH) category, further defined as either episodic or chronic. Headache categories also are defined by whether they are associated with pericranial muscle disorders.[1]

Episodic tension headache usually is associated with a stressful event. This headache type is of moderate intensity, self-limited, and usually responsive to nonprescription drugs.

Chronic tension headache often recurs daily and is associated with contracted muscles of the neck and scalp. This type of headache is bilateral and usually occipitofrontal.

TTH is the most common type of chronic recurring head pain. In the past, pain etiology was presumed to be the muscular contraction of pain-sensitive structures of the cranium, but the IHS intentionally abandoned the terms muscular contraction headache and tension headache because no research supports muscular contraction as the sole pain etiology.



Both muscular and psychogenic factors are believed to be associated with tension-type headache.[2] A study by Kiran et al indicated that patients with chronic tension headaches for longer than five years tend to have lower cortisol levels.[3] This was postulated to be due to hippocampus atrophy resulting from chronic stress, a cause of chronic tension headaches.



Stress may cause contraction of neck and scalp muscles, although no evidence confirms that the origin of pain is sustained muscle contraction.

  • Stress and/or anxiety
  • Poor posture
  • Depression

One study showed that patients with tension-type headache (TTH) have relatively weak neck extension muscles. According to results, these patients are 26% weaker than controls with respect to neck extension muscles, that they have a 12% smaller extension/flexion ratio, and that they have a borderline significant difference in the ability to generate muscle force over the shoulder joint.[4, 5]




Headaches account for 1-4% of all emergency department (ED) visits and are the ninth most common reason for a patient to consult a physician. Tension-type headaches (TTH) are common, with a lifetime prevalence in the general population ranging between 30% and 78% in different studies. They affect approximately 1.4 billion people or 20.8% of the population.[6, 7]

TTH onset often occurs during the teenage years and affects three women to every two men.



Tension-type headaches (TTH) may be painful, but are not harmful. Most cases are intermittent and do not interfere with work or normal life span. However, they may become chronic if life stressors are not changed.


Complications of headache may include the following:

  • Overreliance on nonprescription caffeine-containing analgesics
  • Dependence on/addiction to narcotic analgesics
  • GI bleed from use of NSAIDs
  • Risk of epilepsy 4 times greater than that of the general population
Contributor Information and Disclosures

Michelle Blanda, MD Chair Emeritus, Department of Emergency Medicine, Summa Health System Akron City/St Thomas Hospital; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

Michelle Blanda, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Lori K Sargeant, MD Consulting Staff, Summa Emergency Associates Inc

Lori K Sargeant, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Edward A Michelson, MD Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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