Tension Headache

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