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SEPTEMBER 1, 2002 / VOLUME 66, NUMBER 5 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 797

Primary headache is treated sympto-matically, with the goal being relief andpreventing recurrence. Although sec-ondary headache may also require symp-tomatic relief, treatment of the underly-ing disease process is the focus of care.

PathophysiologyAlthough tension-type headaches are

common, the pathophysiology and likelymechanism remain unclear. Currentknowledge of the nociceptive (pain re-ceptor) system suggests that the deriva-tive pain of tension-type headaches has amuscular origin. Muscular or myofascialpain tends to be dull and achy, poorlylocalized, and radiating, whereas painoriginating from cutaneous structures issharp, localized, and nonradiating. Thesupposition that the pain is muscular inorigin and related to increased restingmuscle tension corresponds with the cur-rent clinical understanding of tension-type headache and derived treatmentapproaches.

Controversy arises because an elec-tromyogram (EMG) often cannot detectincreased resting muscle tension in

Tension-type headache, for-merly called tension head-ache or muscle contractionheadache, is a common con-dition usually self-treated

with over-the-counter (OTC) analgesics.Prevalence rates of tension-type head-aches vary among studies from 291 to 712

percent of patients examined, because ofdifferences in research study design.3

Headaches are classified into two cate-gories: primary and secondary. Primaryheadaches (including migraine, tension-type, and cluster headaches) have noapparent underlying organic diseaseprocess. Secondary headaches are causedby an underlying organic disease and are asymptom of a recognized disease process.The International Headache Society’s crite-ria for diagnosing tension-type headacheand chronic tension-type headache,4 andsome commonly used criteria for chronicdaily headache,5 are listed in Table 1.4

Tension-type headache typically causes pain that radiates in a band-like fashion bilater-ally from the forehead to the occiput. Pain often radiates to the neck muscles and isdescribed as tightness, pressure, or dull ache. Migraine-type features (unilateral, throb-bing pain, nausea, photophobia) are not present. All patients with frequent or severeheadaches need careful evaluation to exclude any occult serious condition that may becausing the headache. Neuroimaging is not needed in patients who have no worrisomefindings on examination. Treatment of tension-type headache typically involves the useof over-the-counter analgesics. Use of pain relievers more than twice weekly placespatients at risk for progression to chronic daily headache. Sedating antihistamines orantiemetics can potentiate the pain-relieving effects of standard analgesics. Analgesicscombined with butalbital or opiates are often useful for tension-type pain but have anincreased risk of causing chronic daily headache. Amitriptyline is the most widelyresearched prophylactic agent for frequent headaches. No large trials with rigorousmethodologies have been conducted for most non-medication therapies. Among thecommonly employed modalities are biofeedback, relaxation training, self-hypnosis, andcognitive therapy. (Am Fam Physician 2002;66:797-804,805. Copyright© 2002 AmericanAcademy of Family Physicians.)

Tension-Type HeadachePAUL J. MILLEA, M.D., M.S., M.A., and JONATHAN J. BRODIE, M.D.Medical College of Wisconsin, Milwaukee, Wisconsin

O A patient informa-tion handout on ten-sion headaches, writ-ten by the authors ofthis article, is providedon page 805.

Members of variousfamily practice depart-ments develop articlesfor “Practical Therapeu-tics.” This article is onein a series coordinatedby the Department ofFamily and CommunityMedicine at the Med-ical College of Wiscon-sin, Milwaukee. Guesteditors of the series areLinda N. Meurer, M.D.,M.P.H., and DouglasBower, M.D.

See editorial on page 728 and definitions of strength-of-evidencelevels on page 893.

COVER ARTICLEPRACTICAL THERAPEUTICS

patients diagnosed with tension-typeheadache. A recent review article6 noted thatthe relationship between EMG level and painis complex enough to warrant further investi-gation. Muscle hardness (measured by exter-nal probing of resting muscle) has been foundto be increased in the pericranial muscles ofpatients with chronic tension-type headache.7

These findings indicate that muscle hardnesswas similar during periods with and withoutheadache and that muscle hardness is “perma-nently altered” in patients with chronic ten-

sion-type headache.7 Further research sug-gests that nitric oxide may be the local media-tor of tension-type headache. Infusion of anitric oxide donor reproduces tension-typeheadache in patients previously diagnosedwith chronic tension-type headache.8 [Evi-dence level B, lower quality randomized con-trolled trial (RCT)]. Also, blocking nitricoxide production with an investigative agent(L-NMMA) reduces both muscle hardnessand pain associated with tension-typeheadache.9 [Evidence level B, lower qualityRCT]

Evaluation of the Headache PatientHISTORY

Tension-type headaches can last from 30minutes to several days and can be continuousin severe cases. The pain is mild or moderatelyintense and is described as tightness, pressure,or a dull ache. The pain is usually experiencedas a band extending bilaterally back from theforehead across the sides of the head to theocciput.10 Patients often report that this ten-sion radiates from the occiput to the posteriorneck muscles. In its most extensive form, thepain distribution is “cape like,” radiating alongthe medial and lateral trapezius muscles cov-ering the shoulders, scapular, and interscapu-lar areas.10

In addition to its characteristic distributionand intermittent nature, the history obtainedfrom patients with tension-type headache dis-closes an absence of signs of any seriousunderlying condition.11 Patients with tension-type headache do not typically report anyvisual disturbance, constant generalized pain,fever, stiff neck, recent trauma, or bruxism.Table 24 lists disease processes that may haveheadache as a symptom.

A thorough headache history shouldinclude questions about the type, amount,effect, and duration of self-treatment strate-gies. Patients typically self-treat their ten-sion-type headaches with OTC analgesics,caffeinated products, massage or chiropractictherapy for symptom relief. A headache his-

798 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 5 / SEPTEMBER 1, 2002

Tension-type headache pain is usually experienced as a bandextending bilaterally back from the forehead across the sidesof the head to the occiput and may extend to the posteriorneck muscles.

TABLE 1

Diagnostic Criteria for Tension-Type, Chronic Tension-Type,and Chronic Headache

Tension-type headacheA. At least 10 previous headache episodes fulfilling criteria B through D;

number of days with such headaches: less than 180 per year or 15 per monthB. Headaches lasting from 30 minutes to 7 daysC. At least two of the following pain characteristics:

1. Pressing or tightening (nonpulsating) quality2. Mild to moderate intensity (nonprohibitive) 3. Bilateral location4. No aggravation from walking stairs or similar routine activities

D. Both of the following:1. No nausea or vomiting2. Photophobia and phonophobia absent, or only one is present

Chronic tension-type headacheSame as tension-type headache, except number of days with such headaches:

at least 15 days per month, for at least six monthsChronic daily headacheFeatures of tension-type headacheOccurs at least 6 days per week

Adapted with permission from Classification and diagnostic criteria for headachedisorders, cranial neuralgias and facial pain. Headache Classification Committeeof the International Headache Society. Cephalalgia 1988;8(suppl 7):1-96, withinformation from reference 12.

tory should also include discussion of anylifestyle changes (e.g., smoking) that mayhave preceded or exacerbated the headache.11

Patients who have chronic daily headachepresent with the typical pain characteristicsof tension-type headache but have symp-toms that occur daily or almost daily. Acareful history will generally reveal that thedaily tension-type headache was precededby intermittent migraine-type headachesrather than intermittent tension-typeheadaches.

The progression of either migraine or ten-sion-type headache into chronic daily head-ache can occur spontaneously but often occursin relation to frequent use of analgesic medica-tion. Repeated use of analgesics, especiallyones containing caffeine or butalbital, can leadto “rebound” headaches as each dose wears offand patients then take another round of med-ication. Common features of chronic dailyheadache associated with frequent analgesic

use are early morning awakening with head-ache, poor appetite, nausea, restlessness, irri-tability, memory or concentration problems,and depression.12

Patients should be screened for psychiatriccomorbidity, because anxiety, depression, andpsychosocial stress can be prevalent in pa-tients with tension-type headaches.13

PHYSICAL EXAMINATION

Clinical signs of headache secondary tohypertension may be similar to tension-typeheadaches. Although patients often attributeheadaches to any degree of hypertension, onlysevere hypertension (values greater than200/120 mm Hg) is definitely associated with

Tension Headache


Repeated use of analgesics, especially ones containing caf-feine or butalbital, can lead to “rebound” headaches.

TABLE 2

Acute Secondary Headache Disorders

Headache associated with head traumaAcute post-traumatic headache

Headache associated with vascular disordersSubarachnoid hemorrhageAcute ischemic cerebrovascular disorderUnruptured vascular malformationArteritis (e.g., temporal arteritis)Carotid or vertebral artery painVenous thrombosisArterial hypertension

Headache associated with nonvascular intracranial disorderBenign intracranial hypertension (pseudotumor cerebri)Intracranial infectionLow cerebrospinal fluid pressure (e.g., headache subsequent

to lumbar puncture)

Adapted with permission from Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. HeadacheClassification Committee of the International Headache Society. Cephalalgia 1988;8(suppl 7):1-96.

Headache associated with substance use or withdrawalAcute use or exposureChronic use or exposure

Headache associated with noncephalic infectionViral infectionBacterial infection

Headache associated with metabolic disorderHypoxiaHypercapniaMixed hypoxia and hypercapniaHypoglycemiaDialysisOther metabolic abnormality

Headache or facial pain associated with disorder of cranium, neck,eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranialstructures

Cranial neuralgias, nerve trunk pain, and deafferentation pain

headache. Headache resolution with bloodpressure control confirms the diagnosis.11

Physical examination of a patient withheadache should include a neurologic evalua-tion to rule out any serious intracranial pathol-ogy. Specifically, cranial nerve defects, cerebel-lar dysfunction, papilledema or absent venouspulsations on fundal examination, visual fielddefects, or motor or sensory deficits should beconsidered. These findings may suggest occultbrain tumors, hemorrhage, or increased cere-brospinal fluid pressure.

Temporal mandibular joint dysfunctionoften complicates headache and should bescreened for by palpating the temporalmandibular joints for tenderness and askingthe patient about habits such as bruxism andgum chewing. If signs suggestive of secondaryheadache are present, appropriate diagnosticstudies should be done before making a defin-itive diagnosis of tension-type headache [Ref-erence 15—Evidence level C, expert opinion].Table 314,15 lists indications for the use of neu-roimaging in patients with progressive or con-tinuous headache symptoms. Palpation of thehead in patients with tension-type headache

may reveal tenderness in the pericranial mus-cles and tension in the nuchal musculature ortrapezius.

Treatment Treatment goals for patients with tension-

type headache should include recommendingeffective OTC analgesic agents and discover-ing and ameliorating any circumstances thatmay be triggering the headaches or causingthe patient concern. Tension-type headache ismost commonly self-treated with OTC non-steroidal anti-inflammatory drugs (NSAIDs)and acetaminophen. A telephone survey16

found that 98 percent of responders with ten-sion-type headache reported using analgesics.The most common agents used were aceta-minophen (56 percent), aspirin (15 percent),or other agents (17 percent).16

Research confirms that NSAIDs and aceta-minophen are effective in reducing headachesymptoms; however, this research offers lim-ited guidance about which one to choose forindividual patients. A large, randomized con-trolled trial17 assigned patients with tension-type headache to treatment with doses ofplacebo, 400 mg of ibuprofen, or 1,000 mg ofacetaminophen. Both medications were welltolerated and significantly more effective than


Patients with chronic tension-type headache should limittheir use of analgesics to two times weekly to prevent thedevelopment of chronic daily headache.

TABLE 3

Indications for Neuroimaging in Patients with Headache Symptoms

Focal neurologic finding on physical examinationHeadache starting after exertion or Valsalva’s

maneuverAcute onset of severe headacheHeadache awakens patient at nightChange in well-established headache patternNew-onset headache in patient >35 years of ageNew-onset headache in patient who has HIV

infection or previously diagnosed cancer

HIV = human immunodeficiency virus.

Information from references 14 and 15.

The Authors

PAUL J. MILLEA, M.D., M.S., M.A., is assistant professor of family medicine at the MedicalCollege of Wisconsin, Milwaukee. Dr. Millea received his medical degree from the MedicalCollege of Wisconsin, a master of science in addiction studies from the University of Ari-zona College of Medicine, Tucson, and a master of arts in bioethics from the Medical Col-lege of Wisconsin. He completed a residency in family practice at Baylor College of Medi-cine, Houston, and a fellowship in family therapy at Galveston Family Institute, Houston.

JONATHAN J. BRODIE, M.D., is in private practice in Milwaukee, Wis. Dr. Brodie receivedhis medical degree from the University of Connecticut School of Medicine, Farmington.He completed a faculty development fellowship at the Medical College of Wisconsin anda family practice residency at Texas Tech University, Lubbock.

Address correspondence to Paul J. Millea, M.D., Department of Family and CommunityMedicine, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI53226-0509 (e-mail: [email protected]). Reprints are not available from the authors.

placebo at relieving the symptoms of head-ache. Ibuprofen was more effective than aceta-minophen.17 [Evidence level A, RCT]

A similar trial18 comparing 25 mg of keto-profen with 1,000 mg of acetaminophenreported that both agents were significantlymore effective than placebo at two hours afterdosing but no better than placebo in achievingtotal pain relief at four hours after dosing. Thisresult probably reflects the short duration andself-limiting nature of the episodic tension-type headache.18 [Evidence level A, RCT]

In patients with chronic tension-typeheadache, the treatment goals are to initiateeffective prophylactic treatment and to man-age any residual headaches in a manner thatprevents the frequent use of analgesics and therisk for progression to chronic daily headachesyndrome.

Patients with chronic tension-type head-ache should limit their use of analgesics to twotimes weekly to prevent the development ofchronic daily headache. If the patient requiresanalgesic medication more frequently, adjunc-tive headache medications can be initiated.

Analgesics can be augmented with a sedat-ing antihistamine, such as promethazine(Phenergan) and diphenhydramine (Bena-dryl), or an antiemetic, such as metoclopra-mide (Reglan) and prochlorperazine (Com-pazine). If this regimen is inadequate, thepatient can try acetaminophen or aspirincombined with caffeine and butalbital. Thiscombination is usually quite effective but isalso the most frequent cause of chronicdaily headache. Before initiating this regi-men, patients should be informed of thepossibility of chronic daily headache andinstructed to limit their use of the combina-tion to twice weekly. The physician shouldcarefully monitor the patient’s progress andprescribe only enough medication to sup-port this limited usage.

PROPHYLAXIS OF FREQUENT HEADACHES

A wide variety of prophylactic agents havebeen researched in the management of

chronic tension-type headache, and compre-hensive reviews are available for interestedreaders.19

Amitriptyline (Elavil) is the most re-searched of the prophylactic agents forchronic tension-type headache. It is typicallyused in doses of 10 to 75 mg, one to twohours before bedtime to minimize grogginesson awakening. Double-blind randomizedcontrolled studies confirm its use in patientswith chronic tension-type headache.20 [Evi-dence level A, RCT] Anticholinergic sideeffects (dry mouth, blurred vision, orthosta-sis) and weight gain can limit its usefulness insome persons.

Selective serotonin reuptake inhibitors(SSRIs) cause fewer side effects, and several ofthese agents (paroxetine [Paxil], venlafaxine[Effexor], and fluoxetine [Prozac]) haveshown their efficacy in the prophylaxis ofchronic tension-type headache in small stud-ies.21,22 One small study23 showed that 20 mgof citalopram (Celexa) had no beneficial effecton tension-type headache, while anothersmall trial24 noted that amitriptyline and flu-oxetine were equally effective in reducing thenumber of days with headache pain eachmonth. The beneficial effect of fluoxetineonly manifested after two months of treat-ment and was slightly inferior to the effect ofamitriptyline.24

Smoking cessation is an important issueto address in patients with chronic tension-type headache. The number of cigarettessmoked has been “significantly related” to theheadache index score and to the number ofdays with headache each week.25 Higher levelsof nicotine are also correlated with trendstoward higher measures of anger, anxiety, anddepression.

Tension Headache


Amitriptyline (10 to 75 mg, one to two hours before bed-time) is the most researched of the prophylactic agents forchronic tension-type headaches.

CHRONIC DAILY HEADACHE

The first decision in treating patients whohave chronic daily headache is to ascertainhow often they are using OTC analgesics.“Rebound” headache is particularly com-mon with use of narcotics and combinationproducts containing butalbital and caffeine.Patients with rebound headache will im-prove if their daily analgesic medication canbe withdrawn, although this is not easily ac-complished.26 The initial task is to assurepatients that, although they will experienceincreased discomfort during the analgesicwithdrawal period, their headache frequencyand intensity will begin to reduce within twoweeks after their withdrawal is complete.

For nonpregnant patients using fewer thanseven to 12 tablets or capsules of analgesicdaily, the simplest method is to abruptly stopthe analgesic and initiate prophylaxis withamitriptyline. Patients will typically experi-ence withdrawal symptoms for several days toweeks. These symptoms include nervousness,restlessness, increased headaches, nausea,vomiting, insomnia, diarrhea, and tremor.27

Patients who cannot tolerate complete cessa-tion may taper the analgesic dosage over fourto six weeks and begin amitriptyline prophy-laxis when they have completely stopped tak-ing the analgesic.

In patients using more than 12 tablets orcapsules of analgesic daily, particularly thosecontaining butalbital, abrupt cessation is notappropriate because of the possibility ofmore serious withdrawal symptoms, in-cluding seizure or delirium.28 [Evidence level C,expert opinion] Pregnant patients may be atrisk for miscarriage caused by withdrawalsymptoms.

A recent approach to discontinuing dailyanalgesics using a short steroid taper hasbeen reported from a large, open-label trial.29

[Evidence level B, uncontrolled study] Onlypatients taking simple analgesics were stud-ied; persons dependent on barbiturates, ben-zodiazepines, or opiate medications were ex-

cluded. Participants immediately ceased allanalgesics and began a short course of taper-ing prednisone (60 mg for two days, 40 mgfor two days, and 20 mg for two days), com-bined with ranitidine (300 mg once daily forsix days). Amitriptyline was instituted on theday following the last dose of prednisone.Over 400 patients with chronic dailyheadache successfully withdrew from theiranalgesics using this regimen.

After stopping daily analgesic use, patientsoften revert to the headache pattern that pre-ceded the chronic daily headache (typically,sporadic migraine headache). If this doesoccur, prophylactic treatment should con-tinue, and migraine-specific treatment shouldbe given for the acute headache.30

Nonmedication Therapies for HeadacheAlthough medication is the most com-

monly used treatment for chronic tension-type headache, a number of other methodshave some evidence of efficacy. No large trialswith well-designed methodologies have beenconducted for most nonmedication therapies;reports of beneficial effects need to be tem-pered by the high rates of placebo effects forpain treatment.

The most frequently used nonmedicationtreatments for headache are biofeedback, relax-ation training, self-hypnosis, and cognitivetherapy. One study31 showed improvement in39 percent of 94 patients with headache usingrelaxation training alone. Adding biofeedbackincreased the portion of patients experiencingimprovement to 56 percent.31 One small, long-term study32 of relaxation and EMG biofeed-back showed that improvement was main-tained at five years’ follow-up.

Numerous small studies have investigatedcognitive psychotherapy alone and in combi-nation with other behavioral treatment forchronic tension-type headache. Among thesetrials, at least 50 percent of patients hadreduced symptoms when treated with pro-gressive relaxation, cognitive therapy, or acombination of the two.33 This study33 com-


pared patients who self-administered treat-ments at home with patients receiving therapyin the office and noted a trend toward greatersymptom reduction in patients receiving in-office treatment; however, this difference wasnot statistically significant.

A recent systematic review of acupuncturetreatment for headache found 40 random-ized controlled studies, but only one studywas categorized as “rigorous.” In all of thetrials of tension-type headache that wereexamined, patients receiving acupuncturehad superior outcomes, compared withpatients in the control groups. The authorsof the review concluded that, “overall, theexisting evidence suggests that acupuncturehas a role in the treatment of recurrentheadaches”.34 [Evidence level A, systematicreview of RCTs]

Studies have also been conducted investi-gating the role of spinal manipulation forheadache relief.35 [Evidence level A, RCTs] Ina trial comparing manipulation with the useof amitriptyline, both modalities showedimprovement in headache intensity, fre-quency, and medication usage. However,headache intensity was significantly less in theamitriptyline group. Four weeks after cessa-tion of therapy, patients in the spinal manipu-lation group continued to experience benefitsfrom the intervention.35

The use of traditional physical therapy forheadache has been investigated in a ran-domized controlled trial.36 [Evidence levelB, uncontrolled study] Study participantsreceived weekly sessions of education inproper posture and instruction in a homeexercise program, and used ice packs, mas-sage, and “passive mobilization” of the cer-vical facets. Both headache frequency andpsychologic well-being improved signifi-cantly in the group receiving physical ther-apy at the end of six weeks and at the 12-month follow-up.36

The authors indicate that they do not have any con-

flicts of interest. Sources of funding: none reported.

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