Tension Headache Clinical Presentation

Updated: Nov 21, 2017
  • Author: Michelle Blanda, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Pain onset in tension-type headache can have a throbbing quality and is usually more gradual than onset in migraines. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.

IHS diagnostic criteria for tension-type headaches states that two of the following characteristics must be present [1] :

  • Pressing or tightening (nonpulsatile quality)
  • Frontal-occipital location
  • Bilateral - Mild/moderate intensity
  • Not aggravated by physical activity

Tension-type headache history is as follows:

  • Duration of 30 minutes to 7 days
  • No nausea or vomiting (anorexia may occur) [11]
  • Photophobia and/or phonophobia [11]
  • Minimum of 10 previous headache episodes; [11] fewer than 180 days per year with headache to be considered "infrequent"
  • Bilateral and occipitonuchal or bifrontal pain
  • Pain described as "fullness, tightness/squeezing, pressure," or "bandlike/viselike"
  • May occur acutely under emotional distress or intense worry
  • Insomnia
  • Often present upon rising or shortly thereafter
  • Muscular tightness or stiffness in neck, occipital, and frontal regions
  • Duration of more than 5 years in 75% of patients with chronic headaches
  • Difficulty concentrating
  • No prodrome

New headache onset in elderly patients should suggest etiologies other than tension headache.


Physical Examination

The physical examination serves mainly to exclude the possibility of other headache causes.

  • Vital signs should be normal.
  • Normal neurologic examination
  • Tenderness may be elicited in the scalp or neck, but no other positive physical exam findings should be noted.
  • Pain should not be elicited over temporal arteries or positive trigger zones.
  • Some patients with occipital tension headaches may be very tender when upper cervical muscles are palpated.
  • Pain associated with neck flexion and stretching of paracervical muscles must be distinguished from nuchal rigidity associated with meningeal irritation.