POSTED: 8/10/2022

Tension Headaches

Wednesday, August 10, 2022

What is a tension headache?

Tension type headache, or TTH, is one of many primary headache disorders diagnosed and treated by Neurologists. If you recall from our migraine discussion, a primary headache disorder occurs without a structural cause or insult to the brain.

TTH is defined as a bilateral, non-throbbing, and pressure like headache of mild to moderate intensity that is not worsened by routine physical activity such as walking. This type of headache can be associated with either sensitivity to light or sensitivity to sound, but not both as one would expect with migraines. Additionally, these headaches are not associated with any nausea or vomiting. Any person who has experienced ten or more such headaches where each last anywhere from 30 minutes to seven days is diagnosed with TTH.


TTH are classified primarily based on their frequency. A patient experiencing no more than one tension headache monthly is said to have infrequent episodic TTH. When the headache frequency is between 1-14 monthly, this is referred as frequent episodic TTH. And when the number of headache days exceeds 15, this is called chronic TTH. It is crucial for a patient to accurately track their headache days monthly, whether mild or severe, as this is helpful for the treating Neurologist in determining the type of intervention needed.

How bad are tension headaches and who gets them?

TTH is the most common primary headache disorder in the general population and the second most prevalent disorder in the world. While less disabling than migraines, patients with TTH, especially chronic TTH, can be disabled with up to 29 lost work days annually in some studies.

TTH typically peaks in the fourth decade of life, and while the prevalence decreases with age, up to 30% of patients over the age of 60 can continue to experience tension type headaches. In most population-based studies, TTH tends to be more prevalent in females than males. In the United States, TTH are more prevalent among white Americans than African Americans.

TTH are often comorbid with migraine type headaches, and patients with migraines usually suffer from longer lasting tension type headaches. Additionally, uncontrolled TTH can worsen migraines and vice versa, and both headache types can share similar triggers. While migraines are frequently inherited and familial, genetic factors tend to play a minor role in TTH. 


The diagnosis of TTH is strictly clinical. If patients fulfill the criteria discussed above and are of the right age group, they are diagnosed with TTH. However, should abnormal neurological findings be presents on examination or atypical features associated with the headache, imaging with a brain MRI is often done. Neurologists routinely screen for other concurrent headache types as the choice of therapy may be geared at targeting both headaches simultaneously.

Treatment of TTH:

Unlike migraine headaches, tension type headaches are not strongly associated with increased stroke risk. That being said, the goal of treating tension type headaches mimics that of migraine headaches: reduce attack frequency and severity, improve response to rescue therapies, and reduce disability. The treatment of TTH ranges from lifestyle modification to injections and is tailored based on the frequency, duration, and severity of headaches.

For patients experiencing infrequent non-disabling headaches or have a contraindication for taking medications, behavioral therapies and lifestyle modification can be employed first. This includes biofeedback, relaxation techniques, hot showers, scalp massage, and cognitive behavioral therapy.

For patients experiencing frequent episodic and chronic TTH, initiating pharmacologic treatment is necessary to reduce disability. Medications include abortive, rescue therapy taken when a headache occurs, and preventative therapy taken regularly to reduce headache frequency/severity. The main prevention used is a class of older antidepressants referred to as the tricyclic antidepressants (TCA). These medications are taken once daily, typically at bedtime due to their sedating effect, to reduce frequency of headache attacks. Several other medications have limited evidence that they can be beneficial and some of them are also treatment for migraine headaches. These medications such as Gabapentin can be considered if patients fail or cannot tolerate TCAs. 

If oral medications fail, practitioners may consider trial of trigger point injections and Botox injections, however, these two modalities are considered experimental and based on small studies alone. Combining therapies may sometimes be required to achieve satisfactory headache frequency and severity control.

Dr. Oliver Achi, Neurologist, Medical Director of Neurology Services, Iberia Medical Center 

Appointments with Dr. Achi:  337.374.7242