Muscle Contraction Tension Headache



Tension-type headache (TTH) represents one of the most costly diseases because of its very high prevalence. TTH is the most common type of headache, and it is classified as episodic (ETTH) or chronic (CTTH). It had various ill-defined names in the past including tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, and psychogenic headache. See Medscape's Headache Resource Center for more information.

The International Headache Society (IHS) defines TTH more precisely and differentiates between the episodic and the chronic types. The following is a modified outline of the IHS diagnostic criteria:

Episodic tension-type headache

Chronic tension-type headache


Pathogenesis of TTH is complex and multifactorial, with contributions from both central and peripheral factors. In the past, various mechanisms including vascular, muscular (ie, constant overcontraction of scalp muscles), and psychogenic factors were suggested. The more likely cause of these headaches is believed now to be abnormal neuronal sensitivity and pain facilitation, not abnormal muscle contraction.

Various evidence suggests that, like migraine, TTH is associated with exteroceptive suppression (ES2), abnormal platelet serotonin, and decreased cerebrospinal fluid beta-endorphin. In one study, plasma levels of substance P, neuropeptide Y, and vasoactive intestinal peptide were found to be normal in patients with CTTH and unrelated to the headache state.

Several concurrent pathophysiologic mechanisms may be responsible for TTH; according to Jensen, extracranial myofascial nociception is one of them. Headache is not related directly to muscle contraction, and possible hypersensitivity of neurons in the trigeminal nucleus caudalis has been suggested.

Bendtsen described central sensitization at the level of the spinal dorsal horn/trigeminal nucleus due to prolonged nociceptive inputs from pericranial myofascial tissues.[1] The central neuroplastic changes may affect regulation of peripheral mechanisms and can lead to increased pericranial muscle activity or release of neurotransmitters in myofascial tissues. This central sensitization may be maintained even after the initial eliciting factors have been normalized, resulting in conversion of ETTH into CTTH.

Further research is necessary to understand and clarify the mechanisms of TTH. Research may lead to the development of more specific and effective management in the future.



United States

TTH is the most common primary headache syndrome.


Rasmussen et al reported a lifetime prevalence of TTH of 69% in men and 88% in women in the Danish population.[2] The patient may experience more than one primary headache syndrome. In one study by Ulrich et al, the 1-year prevalence of TTH was the same among individuals with and without migraine.[3]


Women are slightly more likely to be affected than men.


TTH can occur at any age, but onset during adolescence or young adulthood is common. It can begin in childhood.


Tension-type headaches (TTHs) are characterized by pain that is usually mild or moderate in severity and bilateral in distribution. Unilateral pain may be experienced by 10-20% of patients. Headache is a constant, tight, pressing, or bandlike sensation in the frontal, temporal, occipital, or parietal area (with frontal and temporal regions most common).



Various precipitating factors may cause TTH in susceptible individuals. One half of patients with TTH identify stress or hunger as a precipitating factor.

Laboratory Studies

Imaging Studies

Medical Care


Psychiatry consultations: CTTH can mask or be associated with comorbid conditions such as depression, anxiety, or other serious emotional disorders.


Balanced meals


These nonpharmacologic methods have shown improvement of central nervous-system related symptoms:

Medication Summary

The goals of pharmacotherapy for tension-type headaches (TTHs) are to relieve the headache, reduce morbidity, and prevent complications.

Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall, Tempra)

Clinical Context:  First choice for treatment of headache, especially during pregnancy and breastfeeding.

Class Summary

These agents can be used for abortive therapy.

Ibuprofen (Motrin, Advil)

Clinical Context:  First choice for treatment of headache, especially during pregnancy and breastfeeding.

Naproxen sodium (Anaprox, Naprelan)

Clinical Context:  First choice for treatment of headache, especially during pregnancy and breastfeeding.

Class Summary

These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. They generally are used in mild to moderately severe headaches; however, they also may be effective for severe headaches.

Nortriptyline (Pamelor, Aventyl HCl)

Clinical Context:  Has demonstrated effectiveness in treatment of pain.

Amitriptyline (Elavil)

Clinical Context:  Has demonstrated effectiveness in treatment of pain.

Class Summary

These drugs increase the synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake by the presynaptic neuronal membrane.

Cymbalta can also be helpful for patients who have coexisting depression.

Fluoxetine (Prozac)

Clinical Context:  Has potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.

Sertraline (Zoloft)

Clinical Context:  Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Paroxetine (Paxil)

Clinical Context:  Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Class Summary

These agents specifically inhibit presynaptic reuptake of serotonin. May be considered as an alternative to TCAs.

Magnesium chloride (Slow-Mag, Mag-Delay)

Clinical Context:  Magnesium metabolism may have a significant role in both the etiology and the treatment of muscle contraction tension headache.

Class Summary

Electrolytes such as magnesium may help in the treatment of tension headache.


Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

Disclosure: Nothing to disclose.

Specialty Editors

Joseph Carcione Jr, DO, MBA, Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center

Disclosure: Nothing to disclose.

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting; Sunovion Consulting fee None

Chief Editor

Howard A Crystal, MD, Professor, Departments of Neurology and Pathology, State University of New York Downstate; Consulting Staff, Department of Neurology, University Hospital and Kings County Hospital Center

Disclosure: Nothing to disclose.


  1. Bendtsen L. Central sensitization in tension-type headache--possible pathophysiological mechanisms. Cephalalgia. Jun 2000;20(5):486-508. [View Abstract]
  2. Rasmussen BK, Olesen J. Epidemiology of migraine and tension-type headache. Curr Opin Neurol. Jun 1994;7(3):264-71. [View Abstract]
  3. Ulrich V, Russell MB, Jensen R. A comparison of tension-type headache in migraineurs and in non- migraineurs: a population-based study. Pain. Oct 1996;67(2-3):501-6. [View Abstract]
  4. Holroyd KA, O'Donnell FJ, Stensland M, Lipchik GL, Cordingley GE, Carlson BW. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. JAMA. May 2 2001;285(17):2208-15. [View Abstract]
  5. Saper JR, Silberstein SD, Lake AE 3rd. Double-blind trial of fluoxetine: chronic daily headache and migraine. Headache. Oct 1994;34(9):497-502. [View Abstract]
  6. Bendtsen L, Jensen R. Amitriptyline reduces myofascial tenderness in patients with chronic tension-type headache. Cephalalgia. Jul 2000;20(6):603-10. [View Abstract]
  7. Saper JR, Winner PK, Lake AE. An open-label dose-titration study of the efficacy and tolerability of tizanidine hydrochloride tablets in the prophylaxis of chronic daily headache. Headache. Apr 2001;41(4):357-68. [View Abstract]
  8. Biondi M, Portuesi G. Tension-type headache: psychosomatic clinical assessment and treatment. Psychother Psychosom. 1994;61(1-2):41-64. [View Abstract]
  9. Soderberg EI, Carlsson JY, Stener-Victorin E, Dahlof C. Subjective Well-being in Patients With Chronic Tension-type Headache: Effect of Acupuncture, Physical Training, and Relaxation Training. Clin J Pain. Jun 2011;27(5):448-56. [View Abstract]
  10. Adelman LC, Adelman JU, Von Seggern R. Venlafaxine extended release (XR) for the prophylaxis of migraine and tension-type headache: A retrospective study in a clinical setting. Headache. Jul-Aug 2000;40(7):572-80. [View Abstract]
  11. Altura BM, Altura BT. Tension headaches and muscle tension: is there a role for magnesium?. Med Hypotheses. Dec 2001;57(6):705-13. [View Abstract]
  12. Arena JG, Hightower NE, Chong GC. Relaxation therapy for tension headache in the elderly: a prospective study. Psychol Aging. Mar 1988;3(1):96-8. [View Abstract]
  13. Ashina M, Bendtsen L, Jensen R. Plasma levels of calcitonin gene-related peptide in chronic tension- type headache. Neurology. Nov 14 2000;55(9):1335-40. [View Abstract]
  14. Ashina M, Bendtsen L, Jensen R. Plasma levels of substance P, neuropeptide Y and vasoactive intestinal polypeptide in patients with chronic tension-type headache. Pain. Dec 1999;83(3):541-7. [View Abstract]
  15. Ashina M, Bendtsen L, Jensen R. Possible mechanisms of action of nitric oxide synthase inhibitors in chronic tension-type headache. Brain. Sep 1999;122 ( Pt 9):1629-35. [View Abstract]
  16. Bendtsen L, Jensen R, Olesen J. A non-selective (amitriptyline), but not a selective (citalopram), serotonin reuptake inhibitor is effective in the prophylactic treatment of chronic tension-type headache. J Neurol Neurosurg Psychiatry. Sep 1996;61(3):285-90. [View Abstract]
  17. Benoliel R, Sharav Y. Craniofacial pain of myofascial origin: temporomandibular pain & tension-type headache. Compend Contin Educ Dent. Jul 1998;19(7):701-4, 706, 708-10 passim; quiz 722. [View Abstract]
  18. Borgeat F, Elie R, Larouche LM. Pain response to voluntary muscle tension increases and biofeedback efficacy in tension headache. Headache. Oct 1985;25(7):387-91. [View Abstract]
  19. Cohen GL. Protriptyline, chronic tension-type headaches, and weight loss in women. Headache. Jul-Aug 1997;37(7):433-6. [View Abstract]
  20. Diamond S, Balm TK, Freitag FG. Ibuprofen plus caffeine in the treatment of tension-type headache. Clin Pharmacol Ther. Sep 2000;68(3):312-9. [View Abstract]
  21. Friedman AP. Assessment of Fiorinal with Codeine in the treatment of tension headache. Clin Ther. 1986;8(6):703-21. [View Abstract]
  22. Friedman AP. Characteristics of tension headache: a profile of 1,420 cases. Psychosomatics. Jul 1979;20(7):451-7, 461. [View Abstract]
  23. Gerwin RD. Chronic daily headache. N Engl J Med. May 4 2006;354(18):1958; author reply 1958. [View Abstract]
  24. Granella F, D'Alessandro R, Manzoni GC, Cerbo R, Colucci D'Amato C, Pini LA, et al. International Headache Society classification: interobserver reliability in the diagnosis of primary headaches. Cephalalgia. Feb 1994;14(1):16-20. [View Abstract]
  25. Jensen R. Pathophysiological mechanisms of tension-type headache: a review of epidemiological and experimental studies. Cephalalgia. Jul 1999;19(6):602-21. [View Abstract]
  26. Jensen R. Tension-type Headache. Curr Treat Options Neurol. Mar 2001;3(2):169-180. [View Abstract]
  27. Jensen R, Olesen J. Initiating mechanisms of experimentally induced tension-type headache. Cephalalgia. May 1996;16(3):175-82; discussion 138-9. [View Abstract]
  28. Jensen R, Olesen J. Tension-type headache: an update on mechanisms and treatment. Curr Opin Neurol. Jun 2000;13(3):285-9. [View Abstract]
  29. Kunkel RS. Muscle contraction (tension) headache. Clin J Pain. 1989;5(1):39-44. [View Abstract]
  30. Lance JW. Headache. Ann Neurol. Jul 1981;10(1):1-10. [View Abstract]
  31. Lancet. Biofeedback and tension headache. Lancet. Oct 25 1980;2(8200):898-9. [View Abstract]
  32. Langemark M, Olesen J. Pericranial tenderness in tension headache. A blind, controlled study. Cephalalgia. Dec 1987;7(4):249-55. [View Abstract]
  33. Langemark M, Olesen J. Sulpiride and paroxetine in the treatment of chronic tension-type headache. An explanatory double-blind trial. Headache. Jan 1994;34(1):20-4. [View Abstract]
  34. Leistad RB, Sand T, Westgaard RH. Stress-induced pain and muscle activity in patients with migraine and tension-type headache. Cephalalgia. Jan 2006;26(1):64-73. [View Abstract]
  35. Lipchik GL, Holroyd KA, O'Donnell FJ, Cordingley GE, Waller S, Labus J, et al. Exteroceptive suppression periods and pericranial muscle tenderness in chronic tension-type headache: effects of psychopathology, chronicity and disability. Cephalalgia. Sep 2000;20(7):638-46. [View Abstract]
  36. Marks DR, Rapoport AM. Practical evaluation and diagnosis of headache. Semin Neurol. 1997;17(4):307-12. [View Abstract]
  37. Murros K, Kataja M, Hedman C. Modified-release formulation of tizanidine in chronic tension-type headache. Headache. Sep 2000;40(8):633-7. [View Abstract]
  38. Myers DE, Shaikh Z, Zullo TG. Hypoalgesic effect of caffeine in experimental ischemic muscle contraction pain. Headache. Nov-Dec 1997;37(10):654-8. [View Abstract]
  39. Nakashima K, Tumura R, Wang Y. Effects of tizanidine administration on exteroceptive suppression of the temporalis muscle in patients with chronic tension-type headache. Headache. Sep 1994;34(8):455-7. [View Abstract]
  40. Nuechterlein KH, Holroyd JC. Biofeedback in the treatment of tension headache. Current status. Arch Gen Psychiatry. Aug 1980;37(8):866-73. [View Abstract]
  41. Olesen J. Clinical and pathophysiological observations in migraine and tension- type headache explained by integration of vascular, supraspinal and myofascial inputs. Pain. Aug 1991;46(2):125-32. [View Abstract]
  42. Peterson AL, Talcott GW, Kelleher WJ. Site specificity of pain and tension in tension-type headaches. Headache. Feb 1995;35(2):89-92. [View Abstract]
  43. Porta M. A comparative trial of botulinum toxin type a and methylprednisolone for the treatment of tension-type headache. Curr Rev Pain. 2000;4(1):31-5. [View Abstract]
  44. Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain. Apr 1993;53(1):65-72. [View Abstract]
  45. Rasmussen BK, Jensen R, Schroll M. Epidemiology of headache in a general population--a prevalence study. J Clin Epidemiol. 1991;44(11):1147-57. [View Abstract]
  46. Redillas C, Solomon S. Prophylactic pharmacological treatment of chronic daily headache. Headache. Feb 2000;40(2):83-102. [View Abstract]
  47. Rollnik JD, Karst M, Fink M. Coping strategies in episodic and chronic tension-type headache. Headache. Mar 2001;41(3):297-302. [View Abstract]
  48. Rossi LN, Cortinovis I, Menegazzo L. Classification criteria and distinction between migraine and tension- type headache in children. Dev Med Child Neurol. Jan 2001;43(1):45-51. [View Abstract]
  49. Schachtel BP, Furey SA, Thoden WR. Nonprescription ibuprofen and acetaminophen in the treatment of tension- type headache. J Clin Pharmacol. Dec 1996;36(12):1120-5. [View Abstract]
  50. Silberstein SD. Advances in understanding the pathophysiology of headache. Neurology. Mar 1992;42(3 Suppl 2):6-10. [View Abstract]
  51. Silberstein SD. Tension-type and chronic daily headache. Neurology. Sep 1993;43(9):1644-9. [View Abstract]
  52. Silberstein SD. Tension-type headaches. Headache. Sep 1994;34(8):S2-7. [View Abstract]
  53. Silberstein SD, Lipton RB. Chronic daily headache. Curr Opin Neurol. Jun 2000;13(3):277-83. [View Abstract]
  54. Simons DG, Mense S. Understanding and measurement of muscle tone as related to clinical muscle pain. Pain. Mar 1998;75(1):1-17. [View Abstract]
  55. Solomon S. Diagnosis of primary headache disorders. Validity of the International Headache Society criteria in clinical practice. Neurol Clin. Feb 1997;15(1):15-26. [View Abstract]
  56. Solomon S, Elkind A, Freitag F. Safety and effectiveness of cranial electrotherapy in the treatment of tension headache. Headache. Jul 1989;29(7):445-50. [View Abstract]
  57. Stewart WF, Shechter A, Rasmussen BK. Migraine prevalence. A review of population-based studies. Neurology. Jun 1994;44(6 Suppl 4):S17-23. [View Abstract]
  58. Sutton EP, Belar CD. Tension headache patients versus controls: a study of EMG parameters. Headache. May 1982;22(3):133-6. [View Abstract]
  59. Walker Z, Walker RW, Robertson MM, Stansfeld S. Antidepressant treatment of chronic tension-type headache: a comparison between fluoxetine and desipramine. Headache. Jul 1998;38(7):523-8. [View Abstract]
  60. Wheeler AH. Botulinum toxin A, adjunctive therapy for refractory headaches associated with pericranial muscle tension. Headache. Jun 1998;38(6):468-71. [View Abstract]
  61. White AR, Resch KL, Chan JC. Acupuncture for episodic tension-type headache: a multicentre randomized controlled trial. Cephalalgia. Sep 2000;20(7):632-7. [View Abstract]
  62. Wittrock DA. The comparison of individuals with tension-type headache and headache- free controls on frontal EMG levels: a meta-analysis. Headache. Jul-Aug 1997;37(7):424-32. [View Abstract]
  63. Wober-Bingol C, Wober C, Karwautz A. Tension-type headache in different age groups at two headache centers. Pain. Sep 1996;67(1):53-8. [View Abstract]
  64. Zagami AS. Pathophysiology of migraine and tension-type headache. Curr Opin Neurol. Jun 1994;7(3):272-7. [View Abstract]
  65. Ziegler DK. Tension headache. Med Clin North Am. May 1978;62(3):495-505. [View Abstract]
  66. Zissis N, Harmoussi S, Vlaikidis N. A randomized, double-blind, placebo-controlled study of venlafaxine XR in out-patients with tension-type headache. Cephalalgia. Mar 7 2007;[View Abstract]
  67. Zwart JA, Bovim G, Sand T. Tension headache: botulinum toxin paralysis of temporal muscles. Headache. Sep 1994;34(8):458-62. [View Abstract]