Tension-Type Headache (TTH) is one of the most common forms of primary headache. It typically causes mild to moderate, pressing or tightening pain that is often felt on both sides of the head. Many patients describe the sensation as pressure or tightness around the head. The pain may be felt across the forehead, temples, or back of the head and may be accompanied by tenderness of the muscles around the scalp and neck. Unlike migraine, tension-type headache is usually not aggravated by routine daily activities such as walking or climbing stairs. Although occasional attacks may have little impact on everyday life, frequent or chronic tension-type headaches can significantly affect quality of life and require accurate diagnosis and appropriate management.

Symptoms of Tension-Type Headache

Tension-type headache is typically characterized by:

• pain on both sides of the head
• pressing or tightening pain rather than a typical throbbing or pulsating sensation
• mild to moderate intensity
• pain that is usually not aggravated by routine physical activity
• a sensation of pressure across the forehead, temples, or back of the head
• possible tenderness of the muscles around the scalp, neck, and shoulders

In the episodic form, an attack may last from 30 minutes to 7 days. Nausea and vomiting are not typical features of episodic tension-type headache. Sensitivity to light or sound may occur, but usually not both at the same time.

Tension-Type Headache and Migraine

Distinguishing between tension-type headache and migraine is important because the two conditions require different treatment approaches. Migraine is more commonly throbbing or pulsating, may be more severe, is often aggravated by physical activity, and may be accompanied by nausea, vomiting, photophobia, or phonophobia. In contrast, tension-type headache is usually pressing or tightening, mild to moderate in intensity, and is generally not aggravated by routine physical activity. Some patients may experience both migraine and tension-type headache, making accurate recording of the different types of headache particularly useful.

 

Types of Tension-Type Headache

Depending on the frequency of episodes, tension-type headache is classified into:

Infrequent Episodic Tension-Type Headache

Attacks occur on average less than one day per month. These are usually occasional episodes with little impact on daily functioning.

Frequent Episodic Tension-Type Headache

Headaches occur on average 1 to 14 days per month for more than three months. When attacks become more frequent, they may affect work, concentration, and quality of life and may require more systematic management.

Chronic Tension-Type Headache

In the chronic form, headache occurs on average 15 or more days per month for more than three months. The pain may last for hours or may be continuous. Chronic tension-type headache is a more burdensome form of the disorder and requires careful assessment, particularly when accompanied by frequent use of analgesics.

Factors That May Be Associated With Attacks

The exact mechanisms underlying tension-type headache are not fully understood. Both peripheral pain mechanisms and changes in the way the central nervous system processes pain are thought to play a role, particularly in chronic tension-type headache.

In some patients, attacks may be associated with factors such as:

• psychological or physical stress
• insufficient or disrupted sleep
• fatigue
• prolonged work without adequate breaks
• skipping meals
• maintaining the same posture for prolonged periods
• muscle tension in the neck and shoulders
• jaw clenching or bruxism

The presence of such a factor does not necessarily mean that it is the cause of the headache. However, recognizing each patient's individual patterns may help with overall management.

Pericranial Muscle Tenderness

Increased tenderness of the muscles and soft tissues surrounding the skull is a common clinical finding in patients with tension-type headache. During the neurological examination, tenderness of specific muscle groups of the head and neck may be assessed. The International Classification of Headache Disorders also distinguishes different forms of tension-type headache according to the presence or absence of increased pericranial tenderness.

Diagnosis of Tension-Type Headache

The diagnosis is primarily clinical and is based on the patient's medical history, the characteristics and frequency of the headaches, and the neurological examination.

The assessment may include:

• age at onset of the headaches
• frequency and duration of episodes
• location and characteristics of the pain
• headache intensity
• presence of nausea, photophobia, or phonophobia
• relationship between the pain and physical activity
• presence of neck or muscular pain
• use of analgesics and other medications
• impact of the headaches on everyday life

It is particularly important to distinguish tension-type headache from migraine, cervicogenic headache, and secondary headache disorders.

The Use of Magnetic Resonance Imaging in Diagnosis

In patients with typical features of a primary headache disorder and a normal neurological examination, brain imaging is not always required. However, when the headache has atypical features, changes significantly from its previous pattern, or is accompanied by abnormal findings on neurological examination, further investigation may be necessary, including Magnetic Resonance Imaging (MRI) of the brain or other diagnostic tests.

Headache Diary

For patients with frequent headaches, keeping a headache diary can help improve diagnostic accuracy and monitor treatment.

The diary may include:

• headache days
• duration and intensity of the pain
• associated symptoms
• medications used
• response to treatment
• possible factors associated with the onset of the headache

Keeping a record can also help identify excessively frequent use of headache medications.

Treatment of Tension-Type Headache

The treatment of tension-type headache depends on the frequency and severity of the episodes and the extent to which they affect everyday life.

The treatment approach may include:

• treatment of acute episodes
• preventive treatment when headaches are frequent or chronic
• lifestyle adjustments
• management of factors that may be associated with attacks

The aim is to reduce the frequency and severity of pain, avoid excessive use of analgesics, and improve daily functioning.

Treatment of Acute Tension-Type Headache

For occasional attacks, depending on the patient's medical history and individual needs, treatment may include:

• simple analgesics
• non-steroidal anti-inflammatory drugs (NSAIDs)

The choice of medication should take into account possible contraindications, coexisting medical conditions, and frequency of use. Frequent or excessive use of analgesics can lead to Medication-Overuse Headache (MOH) and may contribute to the persistence of a chronic headache pattern.

Preventive Treatment

When tension-type headache is frequent or chronic and causes a significant burden, preventive treatment may be considered.

The choice of treatment is individualized and takes into account:

• frequency of headaches
• intensity and duration of headaches
• impact on daily functioning
• other medical conditions
• previous treatments and the response to them

In selected patients, specific preventive medications may be used, while non-pharmacological interventions and daily habits that may contribute to better headache control are also evaluated.

Lifestyle and Non-Pharmacological Management

Overall management may also include:

• maintaining a regular sleep schedule
• regular meals and adequate hydration
• regular physical activity
• appropriate breaks during prolonged periods of work
• stress management and relaxation techniques
• assessment of musculoskeletal factors when neck or shoulder symptoms are present

Interventions are selected according to the medical history and headache characteristics of each patient.

Symptoms Requiring Immediate Medical Assessment

A new or severe headache should not automatically be considered a tension-type headache.

Immediate medical assessment is particularly important when there is:

• a sudden and extremely severe headache
• a new headache accompanied by weakness, numbness, speech disturbance, or loss of consciousness
• headache associated with fever and severe neck stiffness
• headache following significant head trauma
• a new or significant change in the usual headache pattern
• a progressively worsening headache
• headache accompanied by other new or unusual neurological symptoms

In these situations, assessment is required to investigate a possible secondary cause of the headache.

Individualized Headache Management

Effective management begins with an accurate diagnosis. Frequent headaches should not automatically be attributed to stress or muscle tension. The clinical presentation should be carefully assessed to distinguish tension-type headache from migraine and other primary or secondary headache disorders. A neurological assessment helps determine the type of headache, identify possible medication overuse, and develop an individualized treatment plan aimed at achieving better long-term headache control.