Skip Navigation
Skip to contents

Headache and Pain Research : Headache and Pain Research

OPEN ACCESS
SEARCH
Search
Advanced Search
mobile menu button

Articles

Page Path
HOME > Headache Pain Res > Volume 26(1); 2025 > Article
Review Article
 Update on Tension-type Headache
Hye Jeong Lee1orcid, Soo-Jin Cho2orcid, Jong-Geun Seo3orcid, Henrik Winther Schytz4orcid
Headache and Pain Research 2025;26(1):38-47.
DOI: https://doi.org/10.62087/hpr.2024.0025
Published online: December 30, 2024

1Department of Neurology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea

2Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea

3Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea

4Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark

Correspondence: Hye Jeong Lee, M.D. Department of Neurology, Chung-Ang University Gwangmyeong Hospital, 110 Deokan-ro, Gwangmyeong 14353, Republic of Korea, Tel: +82-2-1811-7800, Fax: +82-2-2610-6624, E-mail: hjlee@cauhs.or.kr
• Received: September 7, 2024   • Revised: October 1, 2024   • Accepted: October 4, 2024

© 2025 The Korean Headache Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • 246 Views
  • 15 Download
prev next
Full Article

Download PDF Download PDF

  • Tension-type headache (TTH) is the most common type of headache, characterized by mild to moderate intensity, bilateral, with a pressing or tightening (non-pulsating) quality. Migraine and TTH can occur in the same person, and their risk factors and treatments can overlap. However, TTH receives less attention than migraine. Furthermore, despite the expanding market for migraine treatments targeting calcitonin gene-related peptide (CGRP) mechanisms, the lack of evidence regarding mechanisms related to CGRP-related mechanisms in TTH continues to be neglected. There remains a need to develop effective preventive treatments for chronic TTH, which imposes a very high burden of disease. From this perspective, this review aims to provide the latest evidence on TTH.
  • Keywords: Headache, Tension-type headache, Headache disorders, Primary, Migraine
Tension-type headache (TTH) is the most common headache disorder. It is characterized by mild to moderate intensity, bilateral, pressing, or tightening pain quality in the forehead, occiput, and neck. The term “tension” emphasizes the role of muscle contraction and emotional tension, leading to various treatments that focus on muscle relaxation and stress management.
Despite knowing the nature of how TTH and migraine can co-occur and having similar medical treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs) or amitriptyline, TTH remains less researched, poorly diagnosed and treated than migraine.1 For example, a PubMed search for the word “migraine” yields to almost 50,000 hits, compared to less than 5,000 hits for the word “tension-type headache.” It is also interesting to note that while migraine and TTH can become interchangeable over time and share similar risk factors, triggers, and comorbidities in individuals, they have distinctly different headache characteristics.2 The distinctive features of migraine, as opposed to TTH, appear to be influenced in part by the calcitonin gene-related peptide (CGRP) mechanism, which has recently received a great deal of attention. In contrast, TTH has been neglected as a research topic due to the lack of a clear biomarker and the absence of randomized controlled trial-based effective preventive medications for frequent episodic or chronic TTH.
This review aims to provide an overview of recent findings on the epidemiology, pathophysiology, diagnosis, and treatment of TTH.
The global prevalence of TTH is approximately 26% of adults, with wide variation between studies and ethnicities, but it is generally estimated that 30% to 80% of the adult population will be affected at some point in their lives.3-6
The incidence of TTH is higher in women than in men, and this gender difference may be due to hormonal factors, stress, and psychosocial influences. TTH can occur at any age, but the greatest burden in terms of years of life lived with disability is in the between 15 and 49 age group.7 The incidence of TTH tends to decrease with age, although it remains a significant health problem in the elderly population.7
Lower socioeconomic status is often associated with higher levels of stress, poorer access to healthcare, and lower levels of education, all of which may contribute to the prevalence and severity of TTH.8 Cultural attitudes toward pain and healthcare-seeking behaviors may influence how individuals report and manage their headache symptoms. In some cultures, headache may be underreported due to stigma or misconceptions about headache. In addition, infrequent episodic TTH may be under-reported in epidemiological studies.9
TTH is characterized by a diffuse, mild to moderate, bilateral headache that is often described as a tightening sensation. Unlike migraine, the headache is not typically pulsating and does not worsen with routine physical activity. Also, TTH is also not usually associated with nausea or vomiting, although mild photophobia or phonophobia may be present in some cases. The clinical presentation of TTH is highly variable between individuals, with some experiencing infrequent episodic headaches and others suffering from chronic daily headaches.10
The frequency of TTH episodes can vary widely, ranging from infrequent episodic TTH (occurring less than 1 day per month) to chronic TTH (occurring more than 15 days per month).
Factors that contribute to the chronicity of TTH include high levels of stress, co-existing migraine, fatigue, anxiety, and depression, and an inability to relax after work.11
The diagnosis of TTH is primarily clinical and based on the patient’s history and symptoms according to the criteria of the International Classification of Headache Disorders, 3rd edition (ICHD-3) (Table 1).12 However, due to the non-specific nature of TTH symptoms, diagnosis can be challenging because of overlap with other headache disorders and medical conditions. This diagnostic ambiguity can lead to misdiagnosis, inappropriate treatment, and unmet patient needs. Therefore, it is important to rule out other diseases on the basis of the headache history.
Headache diaries are the best assessment tool for diagnosis and classification. However, additional diagnostic tests such as neuroimaging, blood sampling, and lumbar puncture may be necessary if any red flags are present.13
Without strict criteria are applied, both migraine and TTH may coexist and sometimes overlap, further complicating the diagnostic process. Migraine and TTH may have some overlap in their clinical features. Photophobia and phonophobia are more common in migraine than in TTH, also nausea and vomiting are more common in migraine than in TTH, although mild nausea may be present in chronic TTH according to the ICHD-3.14,15 This can lead to clinicians misdiagnosing a patient as having migraine when they are actually have TTH, and vice versa. In children and adolescents, the transition from migraine to TTH or from TTH to migraine occurs within a few years, supporting the continuum theory of headache in this subgroup of individuals. Not only are mixed presentations and diagnostic shifts common at younger ages, but the challenges associated with distinguishing TTH from migraine in clinical practice, clinical research, and epidemiologic studies have been widely recognized.16,17 TTH with migraine comorbidity is associated with genetic factors.18 Recently, machine learning models have demonstrated high diagnostic accuracy in migraine from electronic health records or questionnaires.19-21 However, these are not yet sufficient for application to TTH.21
Premonitory or prodromal symptoms are characteristic of migraine and include yawning, mood changes, fatigue, and neck pain. These symptoms typically occur within 2–48 hours of the onset of migraine headache.22 There are no of premonitory symptoms in patients with TTH. Migraine headaches may also be associated with menstrual periods, with the drop in estrogen levels affecting the frequency of migraine headaches. Migraine attacks are common during the perimenstrual period and usually improve during pregnancy.23
And the selective 5HT1B/1D agonist is thought to relieve migraine by stimulating the 5HT1B receptor on cranial vascular smooth muscle to reduce the pain-inducing vasodilation that may be responsible for the headache.24 However, it is not effective for the treatment of TTH, except in people who also have migraine.25 The healthcare provider caring for patients with headache should be aware of these overlaps and their implications for the management of patients with headache.
The pathophysiology of TTH is complex, multifactorial, and not fully understood, involving both peripheral and central mechanisms. The peripheral mechanisms are primarily related to myofascial tissues and nociception, while the central mechanisms of chronification are related to pain processing in the central nervous system.26,27 There has been some research into the mechanisms of nitric oxide-induced TTH and drug development is currently underway, but to date there have been no significant results.20,28,29 The role of CGRP in the progression and remission of chronic TTH is becoming a subject of interest, although treatment response to anti-CGRP monoclonal antibodies is poor.14,30
1. Peripheral mechanisms
The peripheral mechanisms of TTH are mainly related to pericranial muscle tenderness during acute headache attacks and myofascial trigger points.31-33 The most common method used to assess tenderness is manual palpation of the pericranial muscles and calculation of the total tenderness score.34 And muscle hardness can be measured using the hardness meter, a quantitative method.35 Pericranial tenderness is exacerbated during the acute headache phase and increases with the severity and frequency of TTH attacks, supporting the presence of more severe tenderness in individuals with chronic TTH than in those with episodic TTH.36
Myofascial tissues, which include muscles and connective tissues, can develop localized areas of tenderness called trigger points. These trigger points can cause pain in other areas, such as the neck or shoulder, which may contribute to the headache pain experienced in TTH.37 Active myofascial trigger points are common in TTH consistent with the hypothesis that peripheral mechanisms are involved in the pathophysiology.27 However, the relationship between myofascial trigger points and the severity of TTH varies between studies.
Electromyography studies have shown increased muscle activity and tension in individuals with TTH, suggesting that sustained muscle contraction and tension play a role in the development of headache pain.38
2. Central mechanisms
Central sensitization of second-order neurons in the spinal cord or the spinal trigeminal nucleus is a key mechanism in the pathophysiology of transformation from episodic to chronic TTH.39,40 Patients with chronic TTH had higher pain sensitivity and lower tolerance to pressure stimulation of cranial and extracranial structures than patients with episodic TTH patients.26,41
Comorbidities, such as back pain, fibromyalgia, and sleep disorders, may alter pain sensitivity in patients with chronic TTH and increase central sensitization compared to patients with transient TTH, suggesting shared central mechanisms between the two groups. Anxiety and depression are in patients with TTH and are associated with worsening symptoms.42,43
Functional magnetic resonance imaging studies have provided insight into the central mechanisms of TTH by examining dynamic brain changes between pain and pain-free periods in patients with episodic TTH.44,45 These studies have shown changes in activation in pain-processing regions of the brain, including the anterior cingulate cortex, insula, and prefrontal cortex. These findings suggest that individuals with TTH have abnormal pain processing and modulation, which may contribute to the perception of headache pain.
In addition, neurotransmitters such as serotonin and norepinephrine have been found to be associated with TTH, although several studies have yielded conflicting results.
There are significant gaps in the management of TTH, and many patients are not receiving adequate treatment. A multidisciplinary approach tailored to each individual patient. For example, patients with infrequent episodes of TTH can be managed with acute medications and non-pharmacological treatments such as lifestyle modifications, while patients with frequent episodes of TTH or chronic TTH may require preventive pharmacological treatments with behavioral interventions (Figure 1).
1. Acute pharmacological treatments
Acute treatment aims to provide rapid relief of headache attacks quickly and is typically used at the onset of a headache episode. Simple analgesics have evidence-based efficacy and are widely accepted as the first-line treatment for the acute treatment of patients with TTH.46
NSAIDs and acetaminophen are commonly used for acute symptom management. Opioids, triptans, and muscle relaxants are not generally recommended for symptomatic TTH.47,48

• NSAIDs

NSAIDs inhibit the enzyme cyclooxygenase, which reduces the production of prostaglandins that which mediate inflammation and pain. Initial treatments for acute TTH include ibuprofen, ketoprofen, naproxen, and diclofenac.49,50 Side effects include gastrointestinal discomfort, ulcers, and cardiovascular risks with long-term use.

• Acetaminophen

Acetaminophen is the preferred initial therapy for patients with TTH who are intolerant of or contraindicated for NSAIDs for pregnant patients. Acetaminophen is typically used in a single oral dose of 500 to 1,000 mg. It is generally well tolerated, but overdose may cause liver toxicity.51

• Combination Analgesics

Combination of caffeine with acetaminophen, aspirin, or ibuprofen improves the efficacy for the acute treatment of TTH.52 Caffeine may enhance the analgesic effects by promoting their gastric absorption.53 However, frequent use may increase gastrointestinal discomfort and increase the risk of medication overuse headache.
2. Preventive pharmacological treatments
Preventive treatments have been shown to help reduce headache frequency and severity in patients with frequent episodic TTH (1 to 14 headache days per month) or chronic TTH (≥15 headache days per month). Preventive treatment is also indicated in patients with infrequent TTH when simple analgesics are ineffective, poorly tolerated, or contraindicated.
The goal of treatment is to reduce the frequency, severity, and duration of attacks and to improve the response to treatment of acute attacks. It is important to understand patient expectations and consider patient preferences when deciding which of the various preventive therapies to use. For patients who respond well (over 50% reduction in headache days per month), an adjunctive approach is to discontinue treatment after 3 or 6 months and monitor for headache recurrence, unless there are other comorbidities, such as depression or anxiety disorders.

• Tricyclic Antidepressants (TCAs)

TCAs have moderate to high potency for TTH, and amitriptyline controls pain through its inhibitory effects on serotonin and norepinephrine reuptake.
Amitriptyline also reduces pericranial muscle tenderness, resulting in peripheral antinociception and inhibition of central sensitization. It is common for clinicians to start amitriptyline at 2.5–10 mg nightly and increase by 5–10 mg per week to a maximum of 70–80 mg. Common side effects include sedation, weight gain, dry mouth, and constipation.

• Other Antidepressants

Mirtazapine (noradrenergic and specific serotonergic antidepressant) is comparable to amitriptyline and has a better tolerability profile than amitriptyline. Evidence for the effectiveness of venlafaxine (serotonin-norepinephrine reuptake inhibitor) in preventing TTH is weak and supports a level B rating by the EFNS-TF.46
3. Non-pharmacological treatments
Non-pharmacological treatments such as cognitive behavioral therapy (CBT), biofeedback, and relaxation therapy are often recommended as first-line interventions. In addition, integrative medicine (acupuncture and massage) and lifestyle modifications (sleep management, healthy diet, hydration, and exercise) may be considered to reduce headache triggers. However, the evidence for non-pharmacological approaches in TTH are very limited.54

• CBT

CBT is a psychological intervention that helps patients identify and modify negative thought patterns and behaviors that cause stress and muscle tension, both of which are important factors in TTH.55 CBT techniques for TTH include cognitive restructuring, behavioral activation, and relaxation techniques, among others. Stress management therapy has demonstrated efficacy in randomized and placebo-controlled trials and has been shown to be equivalent to amitriptyline in preventing chronic TTH.56 Long-term group behavioral therapy has been shown to be effective in reducing headache frequency and intensity, improving coping strategies, and improving overall mental health.57,58 CBT has been shown to improve quality of life and reduce comorbid symptoms of anxiety and depression.

• Biofeedback

Biofeedback is a technique that teaches individuals how to regulate physiological processes such as muscle tension, heart rate, and skin temperature through real-time feedback. Biofeedback helps patients become aware of and voluntarily control these processes, which can help reduce the frequency, duration, and intensity of headaches in patients with TTH.

• Physical Therapy

Physical therapy involves the use of massage, cervical spine manipulation, and exercise to improve muscle function, reduce tension, and promote relaxation.59 It is particularly useful for TTH patients with severe musculoskeletal problems, such as poor posture, muscle imbalances, and trigger points.60 However, there is no standardized protocol for treating TTH, and a combination of techniques appears to be more effective.61

• Acupuncture

The exact mechanism by which acupuncture relieves TTH is not fully understood, but it is believed to involve the modulation of pain pathways, release of endogenous opioids, and reduction of muscle tension and inflammation.62 As the efficacy of greater occipital nerve block in various headache disorders has been confirmed, attempts have been made to use it as a treatment for TTH.63-65 One systematic meta-analysis found acupuncture to be effective and safe for frequent episodic TTH and chronic TTH.66

• Lifestyle Modifications

Adopting healthy lifestyle habits can play an important role in the management and prevention of TTH. Important lifestyle changes include regular physical activity, healthy sleep patterns, a balanced diet, and effective stress management.67,68
Regular exercise, such as aerobic exercise, yoga, and stretching, has been shown to help reduce stress, improve sleep quality, and relieve muscle tension, all of which can help prevent TTH.
Strategies such as maintaining a consistent sleep schedule, avoiding caffeine and electronic devices before bedtime, and creating a comfortable sleep environment can help prevent headaches caused by sleep deprivation.
Eating a balanced diet that includes a variety of nutrients can help prevent and manage TTH.
Future research should focus on addressing the diagnostic challenges and improving our understanding and treatment of TTH. The co-occurrence of migraine and TTH may be coincidental, but more research is needed to determine whether there is a causal mechanistic relationship between the two disorders.69
One of the major challenges in diagnosing these headaches is the lack of reliable biomarkers, with diagnosis largely based on clinical criteria and patient self-report. More research is needed to improve diagnostic accuracy. While both migraine and TTH are associated with genetic factors, the specific genes responsible for the heritability of TTH remain unknown, in contrast to the multiple risk loci identified for migraine.
Pharmacological provocation studies have provided valuable insights into the pathophysiology of migraine, leading to the discovery of important therapeutic targets. However, similar studies have not been thoroughly performed for TTH. Unfortunately, in the absence of identified therapeutic targets, this approach is not currently feasible for TTH patients.
In addition, the evidence supporting the use of botulinum toxin and anti-CGRP monoclonal antibodies in the treatment of TTH is limited. We believe additional studies are needed to evaluate the utility of botulinum toxin and other emerging therapies for this common and debilitating condition.
TTH remains a common and often debilitating headache disorder. Despite its high prevalence, TTH remains under-recognized and under-treated, with significant public health implications. A comprehensive understanding of its epidemiology, pathophysiology, and clinical management is essential to improve patient outcomes. Continued research into the underlying mechanisms and public health efforts are needed to address the diagnostic and treatment gaps and ultimately improve the quality of life for individuals affected by TTH.
Figure 1.
Current treatments for tension-type headache.
hpr-2024-0025f1.jpg
Table 1.
Diagnostic criteria of tension-type headache according to the International Classification of Headache Disorders, 3rd edition (ICHD-3)1
2.1. Infrequent episodic tension-type headache 2.2. Frequent episodic tension-type headache 2.3. Chronic tension-type headache 2.4. Probable tension-type headache
2.4.1. Probable infrequent episodic tension-type headache 2.4.2. Probable frequent episodic tension-type headache 2.4.3. Probable chronic tension-type headache
A At least 10 episodes of headache occurring on <1 day/mo on average (<12 days/yr) and fulfilling criteria B–D At least 10 episodes of headache occurring on 1–14 day/mo on average for >3 months (≥12 and <180 day/yr) and fulfilling criteria B–D Headache occurring on ≥15 day/mo on average for >3 months (≥180 day/yr), fulfilling criteria B–D One or more episodes of headache fulfilling all but one of criteria A–D for 2.1. Infrequent episodic tension-type headache Episodes of headache fulfilling all but one of criteria A–D for 2.2. Frequent episodic tension-type headache Headache fulfilling all but one of criteria A–D for 2.3. Chronic episodic tension-type headache
B Lasting from 30 minutes to 7 days Lasting hours to days, or unremitting Not fulfilling ICHD-3 criteria for any other headache disorder
C At least two of the following four characteristics: Not better accounted for by another ICHD-3 diagnosis
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking or climbing stairs
D Both of the following: Both of the following:
1. no nausea or vomiting 1. no more than one of photophobia, phonophobia or mild nausea
2. no more than one of photophobia or phonophobia 2. neither moderate or severe nausea nor vomiting
E Not better accounted for by another ICHD-3 diagnosis1
  • 1. Turkdogan D, Cagirici S, Soylemez D, Sur H, Bilge C, Turk U. Characteristic and overlapping features of migraine and tension-type headache. Headache 2006;46:461-468.ArticlePubMed
  • 2. Oguz Akarsu E, Baykan B, Ertas M, et al. The persistence versus interchangeability of migraine and tension-type headaches in a 5-year population-based validated survey. Cephalalgia 2020;40:39-48.ArticlePubMedPDF
  • 3. Sahler K. Epidemiology and cultural differences in tension-type headache. Curr Pain Headache Rep 2012;16:525-532.ArticlePubMedPDF
  • 4. ; GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019;18:459-480.ArticlePubMedPMC
  • 5. Deuschl G, Beghi E, Fazekas F, et al. The burden of neurological diseases in Europe: an analysis for the Global Burden of Disease Study 2017. Lancet Public Health 2020;5:e551-e567.ArticlePubMed
  • 6. ; GBD 2017 US Neurological Disorders Collaborators; Feigin VL, Vos T, et al. Burden of neurological disorders across the US from 1990-2017: a global burden of disease study. JAMA Neurol 2021;78:165-176.ArticlePubMed
  • 7. ; GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1545-1602.ArticlePubMedPMC
  • 8. Crystal SC, Robbins MS. Epidemiology of tension-type headache. Curr Pain Headache Rep 2010;14:449-454.ArticlePubMedPDF
  • 9. Yang Y, Cao Y. Rising trends in the burden of migraine and tension-type headache among adolescents and young adults globally, 1990 to 2019. J Headache Pain 2023;24:94.ArticlePubMedPMCPDF
  • 10. Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 1993;53:65-72.ArticlePubMed
  • 11. Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Prognosis of migraine and tension-type headache: a population-based follow-up study. Neurology 2005;65:580-585.ArticlePubMed
  • 12. ; Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38:1-211.ArticlePDF
  • 13. Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology 2019;92:134-144.ArticlePubMedPMC
  • 14. Onan D, Younis S, Wellsgatnik WD, et al. Debate: differences and similarities between tension-type headache and migraine. J Headache Pain 2023;24:92.ArticlePubMedPMCPDF
  • 15. Buse DC, Reed ML, Fanning KM, et al. Comorbid and co-occurring conditions in migraine and associated risk of increasing headache pain intensity and headache frequency: results of the migraine in America symptoms and treatment (MAST) study. J Headache Pain 2020;21:23.ArticlePubMedPMCPDF
  • 16. Kaniecki RG. Migraine and tension-type headache: an assessment of challenges in diagnosis. Neurology 2002;58:S15-S20.ArticlePubMed
  • 17. Turner DP, Smitherman TA, Black AK, et al. Are migraine and tension-type headache diagnostic types or points on a severity continuum? An exploration of the latent taxometric structure of headache. Pain 2015;156:1200-1207.ArticlePubMedPMC
  • 18. Ligthart L, Huijgen A, Willemsen G, de Geus EJC, Boomsma DI. Are migraine and tension-type headache genetically related? An investigation of twin family data. Twin Res Hum Genet 2018;21:112-118.ArticlePubMed
  • 19. Torrente A, Maccora S, Prinzi F, et al. The clinical relevance of artificial intelligence in migraine. Brain Sci 2024;14:85.ArticlePubMedPMC
  • 20. Fu GJ, Wang LD, Chi XS, et al. Research progress on the experimental model and underlying mechanistic studies of tension-type headaches. Curr Pain Headache Rep 2024;28:439-451.ArticlePubMedPMCPDF
  • 21. Katsuki M, Matsumori Y, Kawamura S, et al. Developing an artificial intelligence-based diagnostic model of headaches from a dataset of clinic patients’ records. Headache 2023;63:1097-1108.ArticlePubMed
  • 22. Eigenbrodt AK, Christensen RH, Ashina H, et al. Premonitory symptoms in migraine: a systematic review and meta-analysis of observational studies reporting prevalence or relative frequency. J Headache Pain 2022;23:140.ArticlePubMedPMCPDF
  • 23. Nappi RE, Tiranini L, Sacco S, De Matteis E, De Icco R, Tassorelli C. Role of estrogens in menstrual migraine. Cells 2022;11:1355.ArticlePubMedPMC
  • 24. Cologno D, Mazzeo A, Lecce B, et al. Triptans: over the migraine. Neurol Sci 2012;33 Suppl 1:S193-S198.ArticlePubMedPDF
  • 25. Bendtsen L. Drug and nondrug treatment in tension-type headache. Ther Adv Neurol Disord 2009;2:155-161.ArticlePubMedPMCPDF
  • 26. Bezov D, Ashina S, Jensen R, Bendtsen L. Pain perception studies in tension-type headache. Headache 2011;51:262-271.ArticlePubMed
  • 27. Do TP, Heldarskard GF, Kolding LT, Hvedstrup J, Schytz HW. Myofascial trigger points in migraine and tension-type headache. J Headache Pain 2018;19:84.ArticlePubMedPMCPDF
  • 28. Ashina M, Bendtsen L, Jensen R, Olesen J. Nitric oxide-induced headache in patients with chronic tension-type headache. Brain 2000;123:1830-1837.ArticlePubMed
  • 29. Shnayder NA, Petrova MM, Moskaleva PV, Shesternya PA, Pozhilenkova EA, Nasyrova RF. The role of single-nucleotide variants of NOS1, NOS2, and NOS3 genes in the comorbidity of arterial hypertension and tension-type headache. Molecules 2021;26:1556.ArticlePubMedPMC
  • 30. Repiso-Guardeño Á, Moreno-Morales N, Labajos-Manzanares MT, Rodríguez-Martínez MC, Armenta-Peinado JA. Does tension headache have a central or peripheral origin? Current state of affairs. Curr Pain Headache Rep 2023;27:801-810.ArticlePubMedPMCPDF
  • 31. Jensen R, Rasmussen BK, Pedersen B, Olesen J. Muscle tenderness and pressure pain thresholds in headache. A population study. Pain 1993;52:193-199.ArticlePubMed
  • 32. Jensen R, Olesen J. Initiating mechanisms of experimentally induced tension-type headache. Cephalalgia 1996;16:175-139.ArticlePubMedPDF
  • 33. Aaseth K, Grande RB, Lundqvist C, Russell MB. Pericranial tenderness in chronic tension-type headache: the Akershus population-based study of chronic headache. J Headache Pain 2014;15:58.ArticlePubMedPMCPDF
  • 34. Langemark M, Jensen K, Jensen TS, Olesen J. Pressure pain thresholds and thermal nociceptive thresholds in chronic tension-type headache. Pain 1989;38:203-210.ArticlePubMed
  • 35. Ashina M, Bendtsen L, Jensen R, Sakai F, Olesen J. Muscle hardness in patients with chronic tension-type headache: relation to actual headache state. Pain 1999;79:201-205.ArticlePubMed
  • 36. Fernández-de-Las-Peñas C, Cuadrado ML, Arendt-Nielsen L, Ge HY, Pareja JA. Increased pericranial tenderness, decreased pressure pain threshold, and headache clinical parameters in chronic tension-type headache patients. Clin J Pain 2007;23:346-352.ArticlePubMed
  • 37. Del Blanco Muñiz JÁ, Sánchez Sierra A, Ladriñán Maestro A, Ucero Lozano R, Sosa-Reina MD, Martín Vera D. Cervical impairments in subjects with migraine or tension type headache: an observational study. Front Neurol 2024;15:1373912.ArticlePubMedPMC
  • 38. Bendtsen L, Fernández-de-la-Peñas C. The role of muscles in tension-type headache. Curr Pain Headache Rep 2011;15:451-458.ArticlePubMedPDF
  • 39. Jensen R. Peripheral and central mechanisms in tension-type headache: an update. Cephalalgia 2003;23 Suppl 1:49-52.ArticlePubMedPDF
  • 40. Bendtsen L. Central sensitization in tension-type headache--possible pathophysiological mechanisms. Cephalalgia 2000;20:486-508.ArticlePubMedPDF
  • 41. Chen WT, Hsiao FJ, Ko YC, et al. Comparison of somatosensory cortex excitability between migraine and “strict-criteria” tension-type headache: a magnetoencephalographic study. Pain 2018;159:793-803.ArticlePubMed
  • 42. Song TJ, Cho SJ, Kim WJ, Yang KI, Yun CH, Chu MK. Anxiety and depression in tension-type headache: a population-based study. PLoS One 2016;11:e0165316.ArticlePubMedPMC
  • 43. Lampl C, Thomas H, Tassorelli C, et al. Headache, depression and anxiety: associations in the Eurolight project. J Headache Pain 2016;17:59.ArticlePubMedPMCPDF
  • 44. Schmidt-Wilcke T, Leinisch E, Straube A, et al. Gray matter decrease in patients with chronic tension type headache. Neurology 2005;65:1483-1486.ArticlePubMed
  • 45. Chen B, He Y, Xia L, Guo LL, Zheng JL. Cortical plasticity between the pain and pain-free phases in patients with episodic tension-type headache. J Headache Pain 2016;17:105.ArticlePubMedPMCPDF
  • 46. Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache: report of an EFNS task force. Eur J Neurol 2010;17:1318-1325.ArticlePubMed
  • 47. Moore RA, Derry S, Wiffen PJ, Straube S, Bendtsen L. Evidence for efficacy of acute treatment of episodic tension-type headache: methodological critique of randomised trials for oral treatments. Pain 2014;155:2220-2228.ArticlePubMed
  • 48. Lenaerts ME. Pharmacotherapy of tension-type headache (TTH). Expert Opin Pharmacother 2009;10:1261-1271.ArticlePubMed
  • 49. Derry S, Wiffen PJ, Moore RA, Bendtsen L. Ibuprofen for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev 2015;2015:CD011474.ArticlePubMedPMC
  • 50. Veys L, Derry S, Moore RA. Ketoprofen for episodic tension-type headache in adults. Cochrane Database Syst Rev 2016;9:CD012190.ArticlePubMed
  • 51. Stephens G, Derry S, Moore RA. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev 2016;2016:CD011889.ArticlePubMedPMC
  • 52. Diener HC, Gold M, Hagen M. Use of a fixed combination of acetylsalicylic acid, acetaminophen and caffeine compared with acetaminophen alone in episodic tension-type headache: meta-analysis of four randomized, double-blind, placebo-controlled, crossover studies. J Headache Pain 2014;15:76.ArticlePubMedPMCPDF
  • 53. Lipton RB, Diener HC, Robbins MS, Garas SY, Patel K. Caffeine in the management of patients with headache. J Headache Pain 2017;18:107.ArticlePubMedPMCPDF
  • 54. Krøll LS, Callesen HE, Carlsen LN, et al. Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache. A systematic review and meta-analysis. J Headache Pain 2021;22:96.ArticlePubMedPMC
  • 55. Christiansen S, Jürgens TP, Klinger R. Outpatient combined group and individual cognitive-behavioral treatment for patients with migraine and tension-type headache in a routine clinical setting. Headache 2015;55:1072-1091.ArticlePubMed
  • 56. Holroyd KA, O’Donnell FJ, Stensland M, Lipchik GL, Cordingley GE, Carlson BW. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. JAMA 2001;285:2208-2215.ArticlePubMedPMC
  • 57. Andrasik F, Grazzi L, Sansone E, D’Amico D, Raggi A, Grignani E. Non-pharmacological approaches for headaches in young age: an updated review. Front Neurol 2018;9:1009.ArticlePubMedPMC
  • 58. Andrasik F, Grazzi L, Usai S, Bussone G. Pharmacological treatment compared to behavioural treatment for juvenile tension-type headache: results at two-year follow-up. Neurol Sci 2007;28 Suppl 2:S235-S238.ArticlePubMedPDF
  • 59. Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis. Cephalalgia 2016;36:474-492.ArticlePubMedPDF
  • 60. Repiso-Guardeño A, Moreno-Morales N, Armenta-Pendón MA, Rodríguez-Martínez MDC, Pino-Lozano R, Armenta-Peinado JA. Physical therapy in tension-type headache: a systematic review of randomized controlled trials. Int J Environ Res Public Health 2023;20:4466.ArticlePubMedPMC
  • 61. Cumplido-Trasmonte C, Fernández-González P, Alguacil-Diego IM, Molina-Rueda F. Manual therapy in adults with tension-type headache: a systematic review. Neurologia (Engl Ed) 2021;36:537-547.ArticlePubMed
  • 62. Lu L, Wen Q, Hao X, Zheng Q, Li Y, Li N. Acupoints for tension-type headache: a literature study based on data mining technology. Evid Based Complement Alternat Med 2021;2021:5567697.ArticlePubMedPMCPDF
  • 63. Chowdhury D, Datta D, Mundra A. Role of greater occipital nerve block in headache disorders: a narrative review. Neurol India 2021;69:S228-S256.ArticlePubMed
  • 64. Kim JY, Choo YJ, Chang MC. Ultrasound-guided 5-in-1 trigger point injection for treating tension-type headache: a case report. Medicine (Baltimore) 2022;101:e29987.ArticlePubMedPMC
  • 65. Cho SJ. When should headache specialists hold a needle? The role of botulinum toxin injections and occipital nerve blocks. Headache Pain Res 2024;25:73-74.Article
  • 66. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev 2016;4:CD007587.ArticlePubMed
  • 67. Gonçalves DA, Bigal ME, Jales LC, Camparis CM, Speciali JG. Headache and symptoms of temporomandibular disorder: an epidemiological study. Headache 2010;50:231-241.ArticlePubMed
  • 68. Bigal ME, Lipton RB. Modifiable risk factors for migraine progression (or for chronic daily headaches): clinical lessons. Headache 2006;46 Suppl 3:S144-S146.ArticlePubMed
  • 69. Ashina S, Mitsikostas DD, Lee MJ, et al. Tension-type headache. Nat Rev Dis Primers 2021;7:24.ArticlePubMedPDF

Figure & Data

References

    Citations

    Citations to this article as recorded by  

      • PubReader PubReader
      • ePub LinkePub Link
      • Cite this Article
        Cite this Article
        export Copy Download
        Close
        Download Citation
        Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.
        Format:
        • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
        • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
        Include:
        • Citation for the content below
        Update on Tension-type Headache
        Headache Pain Res. 2025;26(1):38-47.   Published online December 30, 2024
        DOI: https://doi.org/10.62087/hpr.2024.0025
        Close
      • XML DownloadXML Download
      Figure
      • 0
      Related articles
      Update on Tension-type Headache
      Image
      Figure 1. Current treatments for tension-type headache.

      Figure 1.

      Update on Tension-type Headache
      2.1. Infrequent episodic tension-type headache 2.2. Frequent episodic tension-type headache 2.3. Chronic tension-type headache 2.4. Probable tension-type headache
      2.4.1. Probable infrequent episodic tension-type headache 2.4.2. Probable frequent episodic tension-type headache 2.4.3. Probable chronic tension-type headache
      A At least 10 episodes of headache occurring on <1 day/mo on average (<12 days/yr) and fulfilling criteria B–D At least 10 episodes of headache occurring on 1–14 day/mo on average for >3 months (≥12 and <180 day/yr) and fulfilling criteria B–D Headache occurring on ≥15 day/mo on average for >3 months (≥180 day/yr), fulfilling criteria B–D One or more episodes of headache fulfilling all but one of criteria A–D for 2.1. Infrequent episodic tension-type headache Episodes of headache fulfilling all but one of criteria A–D for 2.2. Frequent episodic tension-type headache Headache fulfilling all but one of criteria A–D for 2.3. Chronic episodic tension-type headache
      B Lasting from 30 minutes to 7 days Lasting hours to days, or unremitting Not fulfilling ICHD-3 criteria for any other headache disorder
      C At least two of the following four characteristics: Not better accounted for by another ICHD-3 diagnosis
      1. bilateral location
      2. pressing or tightening (non-pulsating) quality
      3. mild or moderate intensity
      4. not aggravated by routine physical activity such as walking or climbing stairs
      D Both of the following: Both of the following:
      1. no nausea or vomiting 1. no more than one of photophobia, phonophobia or mild nausea
      2. no more than one of photophobia or phonophobia 2. neither moderate or severe nausea nor vomiting
      E Not better accounted for by another ICHD-3 diagnosis1
      Table 1. Diagnostic criteria of tension-type headache according to the International Classification of Headache Disorders, 3rd edition (ICHD-3)1

      Table 1.

      Headache and Pain Research : Headache and Pain Research
      © The Korean Headache Society.
      TOP