How to diagnose tension headaches

In this article, learn the diagnostic criteria of the most misunderstood primary headache disorder—tension headaches.
Last update28th Feb 2021

Tension headaches are the most common type of primary headache disorder seen in practice, and perhaps the most misunderstood.

The name implies that muscle tension or anxious tension is the cause, but this is not accurate! Tension-type headache is not related to over-contracted muscles or anxiety—the mechanism is an abnormality in neuronal modulation of the trigeminal nerve.

The trigeminal nerve carries the sensory input from the face and cranium to the central nervous system and connects to the muscles of the head and vicinity.

Figure 1. The trigeminal nerve carries sensory input from the face and cranium to the central nervous system and muscles of the head. Abnormal neuronal modulation of this nerve causes tension headaches.

The trigeminal nerve connections are reviewed in the Medmastery course Neurology Essentials. Briefly, they involve the relationship between the central pathways that facilitate pain in the trigeminal nucleus and the pain nociceptors in the cranial structures—blood vessels, mucus membranes, and pericranial muscles.

Tension headaches are often bilateral, and are described by patients as pressure-like, vice-like, cap-like or merely as a tightness. In general, this sensation is experienced around the whole head, including the forehead and back of the head.

Figure 2. Common descriptors of tension headaches.

The intensity of tension headaches can vary, but it is rarely severe, and generally, they are not aggravated by activity.

Diagnostic criteria for tension headaches

There are four key criteria that must be met for a diagnosis of tension headache:

  1. The headache typically lasts from 30 minutes to seven days.
  2. The headaches have at least two of the following four characteristics:
  • They are bilateral
  • They have a pressing or tightening (non-pulsating) quality
  • They are of mild or moderate intensity
  • They are not aggravated by routine physical activity such as walking or climbing stairs
  1. There must be no nausea or vomiting, and while photophobia or phonophobia may occur, it must not be both.
  2. These headaches are not better accounted for by another International Classification of Headache Disorders 3rd edition diagnosis or any other reasonable cause.

You may find pericranial tenderness with palpation around the cranium in tension-type headaches. And, you may need to differentiate trigger points in the temporalis or suboccipital muscles from other cranial structures.

There is a close association between tension headaches and migraines. In fact, these two types of headaches often occur together and you should use the criteria listed above to exclude the possibility of a migraine.

Figure 3. The diagnostic criteria for tension headaches.

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Subtypes of tension headaches

There are three subtypes of tension headaches, differentiated by their frequency:

  1. Infrequent tension-type headaches occur about once a month, but less than 12 days a year.
  2. Frequent tension-type headaches present with at least 10 episodes of headache per month for > 3 months.
  3. Chronic tension-type headaches evolve from frequent tension-type headaches and present with > 15 headache days per month.

That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

  • Ferguson, LW and Gerwin, R. 2005. Clinical Mastery in the Treatment of Myofascial Pain. Baltimore: Lippincott Williams & Wilkins.
  • Fernández-de-las-Peñas, C, Arendt-Nielsen, L, and Gerwin, R. 2010. Tension-Type and Cervicogenic Headache—Pathophysiology, Diagnosis and Management. Boston: Jones and Bartlett Publishers.
  • Goadsby, PJ and Silberstein, SD. 1997. Headache. Vol 17 of Blue books of practical neurology. Boston: Butterworth-Heinemann.
  • Goadsby, PJ, Silberstein, SD, and Dodick, DW. 2005. Chronic Daily Headache for Clinicians. Hamilton: BC Decker.
  • Kaniecki, R. 2012. Tension-type headache. Continuum (Minneap Minn). 18: 823–834. PMID: 22868544
  • Silberstein, SD, Lipton, RB, and Goadsby, PJ. 2002. Headache in Clinical Practice. 2nd edition. London: Martin Dunitz.

About the author

Robert Coni, DO EdS
Neurohospitalist, Medical Director and Coordinator at the Grand Strand Medical Center, and Clinical Assistant Professor at the University of South Carolina.
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