Tension-type headache
Tension-type headache is the most prevalent primary headache disorder: bilateral, pressing, mild to moderate pain without nausea or significant sensory sensitivity, diagnosed clinically without imaging. Acute attacks respond to acetaminophen or NSAIDs, and amitriptyline is the only agent with strong evidence for prevention in frequent or chronic disease.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Definition: tension-type headache is a primary headache disorder defined by clinical criteria, producing bilateral, pressing or tightening pain of mild to moderate intensity that, unlike migraine, is…
- Epidemiology
Lifetime prevalence: affects a majority of the general population over a lifetime, making it the most common headache disorder encountered in practice.
- Risk factors
Psychological stress: the most consistently identified trigger and risk factor for both episodic attacks and chronicity.
- Pathophysiology
Episodic disease: thought to arise primarily from peripheral mechanisms, including increased pericranial myofascial tenderness and nociceptor sensitization in response to stress or muscular tension.
- Clinical features
Diagnosis is made by International Headache Society clinical criteria for episodic tension-type headache: at least 10 prior episodes, attacks (untreated or unsuccessfully treated) lasting 30 minutes…
- Differential diagnosis
Migraine headache: unilateral, pulsating, moderate to severe pain aggravated by routine activity, with nausea and/or both photophobia and phonophobia together; the POUND criteria (pulsatile, one-day…
- Diagnosis
Diagnosis is established clinically by International Headache Society criteria, based on the characteristic headache pattern (bilateral, pressing, mild to moderate, not worsened by activity, without…
- Management
First step for an acute attack: simple analgesia, taken at the onset of pain for the shortest effective course, limited to fewer than 10 to 15 days per month to avoid medication overuse headache.
- Complications
Chronification: frequent episodic tension-type headache can progress to the chronic form, particularly with untreated stress, poor sleep, or frequent acute analgesic use.
- Prognosis
Episodic disease generally has an excellent prognosis, with most patients responding well to simple analgesics and lifestyle measures without progression.
- Prevention
Limit acute analgesic use to fewer than 10 to 15 days per month to prevent transformation to medication overuse headache.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Migraine headache
Migraine is a primary episodic headache disorder diagnosed by ICHD-3 clinical criteria (recurrent attacks, 4-72 hours, pulsatile/unilateral pain with nausea or photophobia/phonophobia). First-line acute treatment is an NSAID or oral triptan started early in the attack; prevention with a beta-blocker, topiramate, or CGRP-targeted therapy is added once attacks are frequent or disabling.
- Cluster headache
Cluster headache is a trigeminal autonomic cephalalgia causing severe unilateral orbital or temporal pain lasting 15 to 180 minutes, up to eight times daily, with ipsilateral autonomic features. First-line acute treatment is 100% oxygen inhalation or subcutaneous sumatriptan; verapamil is first-line prevention.
- Medication overuse headache
Medication overuse headache is a secondary headache disorder in which frequent use of acute headache medications transforms an underlying migraine or tension-type headache into near-daily pain. Management is discontinuing the overused agent and starting migraine-preventive therapy, with acute medication limited to 10 or fewer days per month.
- Idiopathic intracranial hypertension (pseudotumor cerebri)
Idiopathic intracranial hypertension (formerly pseudotumor cerebri) is raised intracranial pressure of unclear cause, without a mass lesion or hydrocephalus, occurring mainly in obese women of childbearing age and presenting with headache, papilledema, and visual symptoms. Diagnosis requires an elevated lumbar puncture opening pressure with normal CSF and normal or empty-sella imaging; treatment centers on weight loss and acetazolamide to protect vision, with surgery reserved for medically refractory disease.
- Vestibular migraine
Vestibular migraine is a common cause of recurrent episodic vertigo in patients with a personal history of migraine, diagnosed clinically by ICHD-3 criteria after excluding Meniere disease and central causes; acute attacks are treated like migraine with NSAIDs, antiemetics, and triptans, with prophylaxis mirroring standard migraine prevention.