Tension Type Headache

Tension Type Headache

By Lori Montgomery, MD, CCFP


Tension type headache (TTH) is the most common headache type. About 40% (40 out of 100) of people have had a TTH. They are most often less severe than migraine headaches. A small number of people will have very severe TTH. When they are very severe, or happen very often, they can be very hard to tell apart from migraine. We used to believe that these headaches were caused by stress or muscle tension (hence the name). It has become clear that muscle tension is associated with all kinds of headache, including migraine.

Signs and symptoms

  • pressure or squeezing (not throbbing or pulsating) pain on both sides of the head
  • pain is usually mild to moderate
  • pain is not made worse with exertion (such as climbing stairs)
  • untreated headaches can last from 30 minutes to several days
  • no nausea and vomiting (throwing up) unless the pain is severe
  • very little sensitivity to light, sound, or smell
  • there is no aura (visual or neurological symptom 20 to 30 minutes before the headache) with tension type headaches


Despite the fact that muscle tension occurs in all kinds of headache, we have kept the name tension type headache for this condition. This is because there seems to be something different about the muscles of the head and face in people with TTH. While electromyography (EMG) does not always detect an increase in muscle tension in sufferers of TTH, the muscle is most often more firm to the touch, even when a headache is not present. There is other research, which suggests that other things such as nitric oxide might be important parts of why this headache happens.

Diagnostic tests

There is a set of criteria used to diagnose migraine, established by the International Headache Society. They include a number of the signs and symptoms listed above. If you meet these criteria, and if your physical exam is normal, there is no need for blood tests, computerized tomography (CT) scans, or magnetic resonance imaging (MRIs) to make the diagnosis. If the physical exam is not normal, you may need other tests to make sure the headache is not caused by something else.

Treatment approach

Stress relief
It has been hard to dispel the myth that stress causes TTH. This is because it has been well-known for many years that learning to manage stress effectively help the pain of TTH. But this is true for almost any pain condition.

Non-drug therapies
Studies have shown that non-drug therapies can help to reduce pain levels and enhance pain coping. These include:

  • relaxation
  • meditation
  • activity pacing
  • cognitive behavioural therapy

These self-management strategies can help you to improve your function so you can do more and enjoy life more.

There are no medicines which are specific to TTH, but there is some overlap with the medicines we use for migraine, most often if the headache has migrainous features, like nausea, or light sensitivity. Sometimes, over-the-counter medicines such as anti-inflammatories or acetaminophen can stop or reduce the intensity of a headache. Be careful not to use any of these medicines on more than 10 days per month, because they can cause you to develop a medication overuse headache.
Other treatments will depend on how often the headache happens, and how disabling it is. If it happens more than six to eight times per month, it may be worth considering a medicine which you take daily to reduce the frequency and intensity of TTH. These medicines will never completely get rid of your headaches, but they can help to make life more manageable. Some of these include:

  • tricyclic antidepressants (such as nortriptyline)
  • selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • calcium channel blockers (such as verapamil)
  • beta blockers (such as propranolol)
  • valproic acid

Botox (botulinum toxin type A) has been used at times to treat TTH. It is the subject of research, and may prove to be useful for some people. It has not been officially approved for use in headache.


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