Tension-Type Headache

What is a tension-type headache?

Tension-Type Headache (TTH) is the most common type of headache, and one that almost everyone suffers at some stage through their life. It is often mild, infrequent and easily self treated, however, for a significant number of people it is moderate to severe, debilitating, too frequent, and as much of a problem as migraines.

Tension Type Headache – Critical Features:

  • Most common headache type
  • Impact often minimised by medical professionals
  • Neck muscles proven to play a critical role
  • Shares many similar neurological features with migraine
    • Central sensitisation (lowered pain-pressure thresholds)
    • Overactive brainstem (trigeminocervical complex)
    • Symptoms rather than source dictate treatment
  • Treatment often focussed on behavioural/psychological approach (e.g. mindfulness & relaxation) or medications, or manual ‘press and guess’ approaches.

The only neck treatment developed specifically for treating the sensitivity associated with primary headache disorders is the Watson Headache ® Approach. Other manual techniques for the neck adopt a ‘press and guess’ approach, hoping that by ‘loosening up’ the neck things will improve. This fails to fix the underlying problem and may aggravate the condition, but at best leads to short term relief and a treatment program that never ends.

We not only understand how debilitating TTH can be but provide an expert examination of the upper cervical spine using techniques designed to test and treat the sensitivity of the nerve pathways. This should be performed in all cases to at least eliminate the spine as a cause, and more commonly, provide a solution with reduced dependence on medication, avoiding years of escalating pain and side effects. We are the most experienced clinic in Melbourne, and one of the most experienced in Australia at using the Watson Headache ® Approach – and with complex and persistent headaches, experience matters.

[Read More on Watson Headache ® Approach]

Tension-type headache expert

Even purported experts continue to downplay the significance of tension-type headache. At the 2019 Migraine World Summit, headache specialist (Neurologist) Dr Lawrence Newman gave a presentation on the differences between migraine and tension-type headache and commented:

tension-type headache is not a headache that is disabling, or one that tends to drive people to see a doctor. There is no nausea, light or sound sensitivity. It’s just a mild to moderate headache that comes and goes’.

Very little of what he said reflects the diagnostic criteria and the reality of the condition for many.

  • “Not a headache that is disabling”

TTH is a disabling headache. While the impact for an individual person is less than migraine, it is still impactful. So much so that due to the sheer numbers affected it causes more ‘years lost to disability’ than migraine.

  • “There is no nausea, light or sound sensitivity.” 

TTH is often considered a ‘featureless’ headache devoid of associated symptoms as has been portrayed here. However episodic TTH allows one of photophobia or phonophobia, and when we include ‘chronic’ TTH (occurring more than 14 days per month) mild nausea is also permitted. 

  • “It’s just a mild to moderate headache that comes and goes.”

Diagnosis requires only 2 of; bilateral location, pressing or tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity. So a severe one-sided headache with sensitivity to light is a tension-type headache if it is not pulsatile, not aggravated by routine activity, does not cause nausea or sensitivity to sound. 

  • “TTH is not a headache that tends to drive people to see a doctor”

Only 1 in 6 people with TTH will see a doctor, and this is the only part of the statement that is true. One might think this is hardly surprising given the complete lack of understanding demonstrated by a world expert, of what tension-type headache is.

Clueless Senior Health Care Professional Doctor Shrug Shoulders


One can only imagine the responses sufferers have had to endure. There’s only so many times you can be told to relax, or that you really have depression or anxiety, rather than a headache problem!


Originally termed ‘psychogenic headache’ because it was believed that the ‘pressure’ type quality to the pain was muscle tension as an outward response to mental stress. We now understand that there are dysfunctions in brain regions, not the same as, but not unlike migraine, that

A number of (erroneous) factors have conspired in TTH not being taken very seriously;

  • The ongoing perception amongst many even within the medical profession that people suffering TTH ‘just need to relax’
  • The definition as a ‘mild to moderate and featureless headache. It is literally defined as a ‘not migraine’ headache.
  • Commonality. Everyone has had a tension headache at some time in their life. For the vast majority it is very mild, and responds to doing just about anything (move or exercise, rest, drink water, take a panadol, have a rest and yes……..relax). So we all have some concept of what it is and will tend to minimise how debilitating it can be for those suffering moderate to severe (yes, they can absolutely be severe headaches).

The stigma of tension-type headache

TTH like migraine, has had a variable level of acceptance by the medical community over the centuries. Always considered a medical condition from ancient times, early medical science failed to provide an anatomical ‘source’ for the pain. With stress being a key trigger, tension-type headache became viewed as a psychological problem. The checkered history of tension-type headache is reflected in the number of names it has gone by over the years – muscle contraction headache, psycho-myogenic headache, stress headache, ordinary headache, essential headache, idiopathic headache and psychogenic headache. 

In 1962 the Ad Hoc committee for the classification of headache defined 15 headache types for further investigation and validation. Second on their list (after “vascular headaches”) was Muscle Contraction Headache;

associated with sustained contraction of skeletal muscles in the absence of permanent structural change, usually as a part of the individual’s reaction during ‘life stress’. The ambiguous and unsatisfactory terms “tension,” “psychogenic,” and “nervous” headache refer largely to this group.

While the name had shifted away from directly calling this a psychological disorder suffered by those with nervous tension, the finger is still pointed at ‘life stress’ as a key underlying part of the pathophysiology. The term ‘tension’ remains embedded in the diagnosis of this ‘featureless’ headache, and sadly the notion that this is largely a psychological problem dismissed in large by those who purport to be experts in the area shows we still have a long way to go to bring tension-type headache into focus as a medical disorder.

Tension-type headache and the sensitised brainstem

While it was believed that the cause of tension-type headache was increased muscle tension in the muscles of the head due to ‘life stress’, this has been debunked. Scalp and neck muscle activity is relatively easy to measure and shows very mild (if any) increase and is unrelated to headache status.

Reflex studies have produced mixed results. When looking at the nociceptive blink reflex there inconsistent findings, however the trigeminocervical reflex shows signs of brainstem excitability, especially in chronic TTH.

Interestingly, the more frequent the headaches (i.e. as you move towards becoming ‘chronic’) the more neck dysfunction is apparent. This is not a coincidence.

Many studies in recent times have demonstrated repeatedly that the small muscles in the top of the neck are dysfunctional in tension-type headache sufferers. Often not in a way that limits movement or causes pain from the muscles themselves (this would be call a ‘cervicogenic headache’), but in a way that creates a constant underlying ‘noise’ disrupting the normal functioning of multiple brainstem regions including the TCC. In other words the increasing neck dysfunction may be responsible for the ‘hyper-excitability’ seen in reflex studies – essentially creating the ‘powder keg’ waiting for a trigger to ‘blow it up’.

These small muscles are extremely sensitive. Rather than just helping to ‘turn your head’ (in fact they don’t actually help do that at all), the sub-occipital muscles play a critical role in:

  • Vestibular function; they help your head distinguish between ‘looking down’ and falling forwards. In other words, head-on-body versus whole body movement.
  • Cardiovascular function; they signal ahead to blood pressure centres (solitary nucleus – also the centre for nausea) that you are moving from laying down to sitting up. This preempts this system to compensate for the changes in blood pressure as we move against gravity.
  • Visual system; coordinating with the eye muscle at multiple sites they control the direction of our gaze.
  • Headache production; 40% of the nerves coming in from these muscles converge onto the  same nerves that come in from the head and face (trigeminal nerve). Overstimulation sets off the bodies ‘alert’ system, and the focus shifts to the most important structure – the head. Testing this ‘convergence’ or the cross-wires from the neck to the head is a cornerstone of the Watson Headache ® Approach, and also proven to decrease the overactivity in the TCC

Watson Headache ® Approach and tension-type headache

The most significant non-pharmacological research undertaken has targeted TCC, the brainstem area that is constantly irritated and sets off the hypothalamus when migraines start. In a key study published in Headache in 2012 the familiar pain of headache was reproduced in 100% of tension-type headache sufferers with manual pressure, or palpation of the upper neck. The same occurred in 95% of migraineurs. By using this technique (Watson Headache ® Approach) as a treatment the researchers decreased the underlying sensitivity of the TCC as indicated by normalising the nociceptive blink reflex – a key marker of activity in the TCC..

This highly targeted technique treats the sensitivity, or ‘decreases the noise’, and calms the brainstem down. Treatments that aim to loosen tight muscles and stretch stiff joints can be far too heavy handed, and often are not sustained – resulting in short term relief, or aggravation. At the Melbourne Headache Centre you have access to the most experienced Watson Headache ® Practitioners in the world aside from Dean Watson himself. No drugs and no cracking of the neck. Treatment that gets to the heart of the problem.

Stress is a common trigger for both migraine and TTH, simply because they are essentially disorders of your ‘threat response system’ which is in a state of constant irritation. When a stressor does arrive in the form of emotional stress, change in sleep habits, skipping a meal, or hormonal fluctuations, the capacity of the ‘threat response system’ is pushed to, and beyond it’s limit.  The symptomatic presentation of this will depend on how you have ‘trained’ your nervous system by everything you have done and experienced since you were born – and indeed some genetic predisposition may favour certain presentations.

If you are a clencher/grinder, likelihood is you will get pain in your temples. If you have a ‘weak stomach’ you are likely to experience nausea and vomiting (a.k.a. migraine), if you have motion sickness or some inner ear sensitivity then you are more likely to get vestibular migraine with vertigo.

Are these all completely different things, or just different manifestations of the same problem?

Find out how we treat

Tension-Type Headache

here at the Melbourne Headache Centre

Diagnosis & Symptoms

Tension-type headache has enjoyed recognition from the outset with Aretaeus of Cappadocia (30-90 A.D.) describing ‘Cephalalgia’ as a mild and short-term headache, that would have encompassed TTH along with headaches associated with illness.

In the Ad Hoc classification published in 1962 TTH made a departure from it’s psychological shroud in name only, becoming muscle contraction headache, but it was still quite clear the purported source of the problem was muscle tension as the outward expression of a reaction to stress.

It wasn’t until the first classification of headache in 1988 (ICHD-I) that ‘Tension-Type Headache” was born as has changed very little in subsequent revisions. The most recent International Classification of Headache Disorders (ICHD-3) states the classification for Tension-Type Headache as:

A. At least 10 episodes of headache fulfilling criterion B-D

B. Lasting from 30 minutes to 7 days

C. At least two of the following four characteristics:

  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:

  1. No nausea or vomiting
  2. No more than one of photophobia or phonophobia

E. Not better accounted for by another ICHD-3 diagnosis.


Episodic Tension-Type Headache is further subdivided:

  1. Infrequent: occurring less than one day of the month and less than 12 days per year
  2. Frequent: occurring on 1-14 days per month on average for more than 3 months (12-180 days per year)

with both of these subtypes being further subdivided based on the presence or absence of pericranial tenderness.

On way to understand episodic Tension-Type Headache is it is defined as ‘not a migraine’. In other words it is very much defined by a lack of symptoms (nausea, photophobia, phonophobia) rather than migraine which is characterised by the presence of distinct symptoms.

This seems simple but gets confused when it becomes chronic.

Chronic Tension Type Headache is described as more than 15 days per month on average for more than 3 months of the year (i.e. more than 180 days per year), but there is a key difference in the symptom behaviour under D. (associated symptoms).

D. Both of the following:

  1. No more than one of photophobia, phonophobia or mild nausea
  2. Neither moderate or severe nausea nor vomiting

The allowance for mild nausea with chronic tension-type headache poses a significant problem, on that it is now quite difficult to distinguish from chronic migraine. Interestingly this opens up availability to a broader range of prophylactic medications, and may be why David Dodick claimed “I don’t think I have ever treat a chronic tension type headache”. Most likely in reference to the fact that as the frequency increases the ability to distinguish at any level, chronic forms of migraine or TTH are impossible, and potentially somewhat spurious.



of Australians suffer TTH


report reduced effectiveness at work


report significant neck pain

The numbers are actually quite alarming for a condition that receives so little attention compared to migraine.

TTH is:

  • ranked 2nd globally for years lost to disability (migraine is 3rd)
  • 3rd most prevalent disease worldwide (from 1990-2016)
  • One in six people with TTH consult a general practitioner due to their headache. Even less consulted a specialist.

Prevalence of Tension-Type Headache

  • The 1-year prevalence in 2016 estimates 1.89 Billion people suffered TTH worldwide (1.04 billion suffered migraine).
  • Lifetime prevalence of 42% of the global population
  • 1-year prevalence (age standardised) = 26.1%, with peak prevalence in 35-39 year olds. This varies based on country and method used to determine a headache.
    • 1 year prevalence of ‘any headache’ up to 87%
    • Frequent TTH up to 37%
    • Chronic TTH up to 5%
  • 33.5% or 8.1 million Australians suffered TTH in 2016

Burden and Cost of Tension-Type Headache

Very few studies have looked at the burden of TTH. For the individual the burden is less impactful than migraine, but because it is far more prevalent the impact on society is greater. TTH accounts for:

  • 58% of the burden of headache (migraine = 42%)
  • annual cost of €21 billion to the European Union
  • 9 lost work days per year with 43.6% of sufferers reporting reduced effectiveness at work
  • 10% more likely to have sick leave compared to non-headache sufferers
  • 1.6 housework days lost every 3 months

Common Treatments

Manual Therapy

Due to the pain often being felt in the sub-occipital region or upper cervical spine many people will have sought relief from various forms of manual therapy, and with good reason.

A systematic review of manual therapy for TTH in 2016 showed patients receiving manual therapy (neck treatment) generally progressed better than those receiving conventional treatment (medication) or placebo.

A meta analysis of physiotherapy interventions for TTH indicates that manual therapy plus exercises are significant in reducing frequency and duration of TTH.


Behavioural Interventions

Including cognitive behavioural therapy, hypnotherapy, relaxation, biofeedback produces 37-50% reduction in headache frequency compared to a 2% reduction for wait list controls.



A cochrane review published in 2009 concluded that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches. 3 out of 4 trials that compared acupuncture to physiotherapy, massage or relaxation found that acupuncture was slightly less effective than these therapies combined.



Along with being one of the most common triggers for headache, sleep is often an effective treatment as well. It is unsurprising then that interventions targeting more regulated sleep have demonstrated effectiveness in reducing the frequency of headaches in chronic sufferers.



Medication for Tension-type headache is largely based on symptomatic relief with OTC medications. In a European study of 168 people;

  • 81% reported symptomatic medication intake.
    • 45% took simple analgesics (paracetamol), 54.5% too NSAID (ibuprofen – 42%; ketoprofen – 5%, naproxen – 7.5%)
    • 12% had no relief
    • 59% had moderate relief
    • 29% had total relief
  • 43% took medication ‘early’ vs 53% taking medication ‘late’
  • Taking symptomatic medication for TTH was associated with lower headache frequency and lower depressive levels
  • Taking symptomatic medication was more effective when used by patients with lower headache history, frequency and duration, and lower emotional burden.

It is important to understand that an association does not mean causation. In other words taking medication is not proven to be responsible for lower headache frequency and lower depressive moods.


According to the official classification TTH is a primary headache – that is a headache with no known cause, yet much is understood about the underlying pathophysiology.

Formerly called psychogenic headache, the ‘tension’ originally referred to nervous tension – the condition considered to be the outward expression of anxiety causing the muscles of the scalp to tighten. Despite ‘rebranding’ to muscle contraction headache, and eventually ‘tension-type’ headache, there is sadly a lingering belief that the cause is more psychological than physical.

This is in ignorance of the body of science indicating a number of key factors leading to this headache.

The Neck:

The evidence for the neck is seemingly irrefutable – yet to the detriment of sufferers, refuted it continues to be. TTH sufferers have:

  • higher rates of neck pain (88.4%) compared to migraineurs (76.2%) and non-headache sufferers (56.7%)
  • Consistently better responses to neck treatment above placebo and usual care (medication).
  • An over stimulated trigemino-cervical complex (TCC) that is in a constant state of irritation as indicated by abnormally high reflexes in between headache episodes. 10  11 
  • Increased activity in sub-occipital neck muscles, yet no significant increase in scalp muscle activity12 13 14 


In 2012 Watson and Drummond15  demonstrated, using highly skilled and systematic method, the ability to reproduce familiar headache on 100% of the TTH sufferers. Furthermore, when used as a treatment these techniques known as the Watson Headache ® Approach is able to decrease the sensitivity of the TCC.


In 2005 researchers found people with Chronic Tension Type Headache (more than 15 headache days per month) had significantly reduced movement in their neck and increased forward head posture compared to non-headache controls.16 


What ISN’T causing it:

The origin of pain in TTH has long been attributed to excessive muscle contraction, ischaemia, and inflammation of head and neck muscles. However, surface electromyography could not demonstrate significantly increased activity in TTH. Many studies have demonstrated that there is not a significant change in scalp muscle tension in tension-type headache.

Botox injected into Chronic TTH sufferers compared to placebo showed no significant difference in HA despite decreased EMG activity in Botox group. The conclusion was that muscle tone is not causing the pain of tension type headache.

Differential Diagnosis


Episodic tension-type headache is relatively easy to distinguish from migraine for one very good reason – the way it is described in the classification system is meant to be the exact opposite of a migraine.

A headache accompanied by nausea is a migraine. If the headache is accompanied by both photophobia and phonophobia it is a migraine, but if only accompanied by one of them it is a tension-type headache. This in itself should raise questions about the validity of the classification. If a tension type headache can activate neural pathways that involved sensitivity to light OR sensitivity to sound, why could they not both be there? The answer is of course, they can be and we arbitrarily assign the name migraine  – but clearly this is not due to a change in pathophysiology.

This gets problematic in the chronic condition as chronic tension-type headache is allowed mild nausea. Under the criteria for migraine this would make it a migraine, which makes one wonder why they included nausea for chronic tension type headache.


Cervicogenic Headache: 

While again this seems relatively easy, it is only because the definition of cervicogenic headache was created so as not to overlap with tension-type headache. In fact when the studies defining cervicogenic headache were first published the authors noted that the headache it is frequently bilateral, but including bilateral as a feature of cervicogenic headache would mean that tension-type headache would cease to exist.

What is important to understand is that the classification system was designed to define distinct groups for the purposes of research. Many people blur the boundaries though and it often makes makes a precise diagnosis difficult.

Pressure Headaches: 

Headaches associated with abnormal internal fluid pressure (either blood pressure or CSF) can at a mild level be difficult to distinguish from tension-type headache.

CSF headaches – a high pressure CSF headache as might be found with an obstruction (Chiari Malformation, tumour), are very postural distinctive as they improve rapidly when the sufferer is standing and increase dramatically when they lay down. Low pressure CSF headaches (from a CSF leak) behave equally as mechanically but in the exact opposite way – dramatically worsening on standing and easing rapidly with laying down.

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