How is tension-type headache different from migraine?

Tension-type headache is usually a mild-to-moderate, pressing, band-like pain on both sides of the head without nausea or strong light and sound sensitivity, and it is not worsened by routine activity. Migraine is typically more severe, often pulsating and one-sided, worsened by activity, and accompanied by nausea and sensory sensitivity.

What is the difference between episodic and chronic tension-type headache?

The distinction is based on how often headaches occur. Episodic forms happen on fewer than fifteen days per month, while the chronic form is defined by headache on fifteen or more days per month over an extended period, and central pain mechanisms are thought to be more prominent in the chronic form.

Tension-Type Headache

Tension-type headache is the most common primary headache disorder, experienced by most people at some point in life. It is typically felt as a mild-to-moderate, pressing or tightening pain on both sides of the head, often likened to a band around the skull, without the throbbing quality, nausea, or marked light and sound sensitivity that characterise migraine. Although usually less disabling than migraine on an individual basis, its very high prevalence makes it an important contributor to the overall burden of headache.

Definition

Tension-type headache is a primary headache disorder characterised by recurrent episodes of bilateral, pressing or tightening (non-pulsating) pain of mild to moderate intensity, not aggravated by routine physical activity and not associated with nausea, though mild photophobia or phonophobia may be present.

Scope

This entry describes tension-type headache as defined by the International Classification of Headache Disorders, including its clinical features, its episodic and chronic forms, what is known of its mechanisms, and its epidemiology. It is a reference description and not a guide to diagnosis or management of any individual.

Core questions

How is tension-type headache distinguished from migraine?
What separates the episodic from the chronic form?
What is the role of pericranial muscle tenderness and central pain processing?

Key concepts

Bilateral pressing or tightening pain
Episodic versus chronic tension-type headache
Pericranial muscle tenderness
Peripheral myofascial nociception
Central sensitisation in chronic forms
Distinction from migraine

Mechanisms

The mechanisms of tension-type headache are incompletely understood and are thought to differ between the episodic and chronic forms. In infrequent episodic headache, peripheral factors such as increased tenderness and nociceptive input from pericranial myofascial tissues appear to dominate. In frequent and chronic tension-type headache, central mechanisms, including sensitisation of pain pathways and altered central pain modulation, are believed to play a greater role, which may explain the transition from occasional to persistent headache. The pain is not attributed to a structural lesion, consistent with its status as a primary headache.

Clinical relevance

Tension-type headache is the headache most people recognise from everyday experience, and distinguishing it from migraine and from secondary headaches is a routine part of headache evaluation. This entry presents the disorder for reference and evidence-appraisal purposes and does not offer individualised diagnostic or treatment recommendations.

Epidemiology

Tension-type headache is the most prevalent primary headache disorder, with lifetime prevalence affecting the majority of the population. Although each episode is usually less disabling than a migraine attack, its high frequency in the population means it contributes substantially to the global burden of headache, as quantified in Global Burden of Disease analyses.

Evidence & guidelines

The International Classification of Headache Disorders, 3rd edition (ICHD-3) defines the diagnostic criteria and the episodic and chronic subtypes of tension-type headache, and Global Burden of Disease analyses provide the principal population-level evidence on its prevalence and burden.

History

Once attributed largely to sustained muscle contraction and labelled muscle-contraction or tension headache, the disorder was renamed tension-type headache in the International Headache Society classification to reflect uncertainty about its cause. Research has since shifted emphasis from a purely muscular explanation toward a combination of peripheral myofascial and central pain-processing mechanisms.

Debates

How large is the muscular contribution to tension-type headache?: The older muscle-contraction model has been tempered by evidence that pericranial tenderness and myofascial input matter most in episodic forms, while central sensitisation predominates in chronic forms; the relative weight of peripheral versus central mechanisms remains an active question.

Seminal works

ichd3-2018
bendtsen-2009

Frequently asked questions

How is tension-type headache different from migraine?: Tension-type headache is usually a mild-to-moderate, pressing, band-like pain on both sides of the head without nausea or strong light and sound sensitivity, and it is not worsened by routine activity. Migraine is typically more severe, often pulsating and one-sided, worsened by activity, and accompanied by nausea and sensory sensitivity.
What is the difference between episodic and chronic tension-type headache?: The distinction is based on how often headaches occur. Episodic forms happen on fewer than fifteen days per month, while the chronic form is defined by headache on fifteen or more days per month over an extended period, and central pain mechanisms are thought to be more prominent in the chronic form.