Tension-type headache (TTH) is the most prevalent neurological disorder worldwide and is characterized by recurrent headaches of mild to moderate intensity, bilateral location, pressing or tightening quality, and no aggravation by routine physical activity. Diagnosis is based on headache history and the exclusion of alternative diagnoses, with clinical criteria provided by the International Classification of Headache Disorders, third edition. Although the biological underpinnings remain unresolved, it seems likely that peripheral mechanisms are responsible for the genesis of pain in TTH, whereas central sensitization may be involved in transformation from episodic to chronic TTH. Pharmacological therapy is the mainstay of clinical management and can be divided into acute and preventive treatments. Simple analgesics have evidence-based effectiveness and are widely regarded as first-line medications for the acute treatment of TTH. Preventive treatment should be considered in individuals with frequent episodic and chronic TTH, and if simple analgesics are ineffective, poorly tolerated or contraindicated. Recommended preventive treatments include amitriptyline, venlafaxine and mirtazapine, as well as some selected non-pharmacological therapies. Despite the widespread prevalence and associated disability of TTH, little progress has been made since the early 2000s owing to a lack of attention and resource allocation by scientists, funding bodies and the pharmaceutical industry.
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The authors thank T. P. Do, for skilful assistance and providing the initial sketches for Figs. 1 and 2. They also thank R. Burstein for helping with editing and advising on structural and functional neuroanatomy in Fig. 2. They also thank K. MacDonald from Alliance for Headache Disorders Advocacy for providing her perspective on tension-type headache.
S.A. received honoraria for consulting from Allergan/AbbVie, Amgen, Biohaven, Eli Lilly, Impel NeuroPharma, Novartis, Satsuma, Supernus, Theranica and Percept. S.A. is an associate editor for Neurology Reviews and BMC Neurology, serves on an Advisory Board for the Journal of Headache and Pain, and is a member of the Education Committee of the International Headache Society. D.D.M. has received honoraria as a consultant and/or speaker from Allergan/AbbVie, Amgen, Biogen, Cefaly, Eli Lilly, Genesis Pharma, Medscape, Merz, Mylan, Novartis, Roche, Sanofi, Specifar and Teva Pharmaceuticals; has received funding for clinical trials from Alder, Cefaly, Electrocore, Biogen, Eli Lilly, Genesis Pharma, Merz, Novartis and Teva. D.D.M. is also past president of the European Headache Federation, current co-chair of the Headache Panel in the European Academy of Neurology and president of the Hellenic Headache Society, and is an associate editor for Journal of Headache and Pain. D.D.M. does not own stocks from any pharmaceutical company. M.J.L. has received honoraria as a consultant and/or speaker for Eli Lilly, Sanofi-Aventis and YuYu Pharma; has been the PI or co-investigator in trials sponsored by Eli Lilly, Novartis, Teva (Otsuka), Allergan/AbbVie, Yuhan Company, Samjin Pharm and DongA ST; received research support from the National Research Foundation of Korea; is a trustee member of the board of the International Headache Society and junior editor of Cephalalgia. S-J.W. has served on the advisory boards of Daiichi-Sankyo, Eli Lilly and Taiwan Novartis; has received honoraria as a moderator from Allergan/AbbVie, Pfizer, Eli Lilly and Eisai and has been the PI in trials sponsored by Eli Lilly, Novartis, and Allergan/AbbVie. S-J.W. has received research grants from the Taiwan Minister of Technology and Science (MOST), Brain Research Center, National Yang-Ming University from The Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan, Taipei Veterans General Hospital and Taiwan Headache Society. R.M. has received honoraria as speaker for Eli Lilly, Novartis and Teva Pharmaceuticals. D.B. received honoraria for consulting for Allergan, Amgen, Biohaven, Eli Lilly, Novartis and Teva, and has received grant support from Amgen, the National Headache Foundation and the FDA. D.B. is an editor for Current Pain and Headache Reports. P.P.-R. has received honoraria as a consultant and/or speaker for Allergan/AbbVie, Almirall, Biohaven, Chiesi, Eli Lilly, Lundbeck, Medscape, Neurodiem, Novartis and Teva Pharmaceuticals. Her research group has received research grants from AGAUR, ERANet Neuron, la Caixa foundation, International Headache Society, Migraine Research Foundation, FEDER RISC3CAT, Instituto Investigación Carlos III, PERIS, Novartis and Teva; and has received funding for clinical trials from AbbVie, Alder, Electrocore, Eli Lilly, Lundbeck, Novartis and Teva. P.P.-R. is a trustee member of the board of the International Headache Society and a member of the Council of the European Headache Federation, and is on the editorial board of Revista de Neurologia; is an associate editor for Cephalalgia, Headache, Frontiers in Neurology, Neurologia and is on the Scientific Advisory Board of the Journal of Headache and Pain. P.P.-R. does not own stocks from any pharmaceutical company. R.H.J. has received honoraria for lectures and patient leaflets from MSD, Berlin-Chemie Menarini, ATI, Novartis, Teva, Allergan and Pfizer and is conducting clinical trials for Eli-Lilly and Lundbeck. H.-C.D. received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from Allergan/AbbVie, Amgen, Electrocore, Lilly, Medtronic, Novartis, Pfizer, Teva and Weber & Weber. Electrocore provided financial support for research projects. The German Research Council (DFG), the German Ministry of Education and Research (BMBF) and the European Union support his headache research. H.-C.D. serves on the editorial boards of Cephalalgia and Lancet Neurology, chairs the Clinical Guidelines Committee of the German Society of Neurology and is a member of the Clinical Trials Committee of the IHS. R.B.L. is the Edwin S. Lowe Professor of Neurology at the Albert Einstein College of Medicine in New York. He receives research support from the NIH. R.B.L. also receives support from the Migraine Research Foundation and the National Headache Foundation. R.B.L. serves on the editorial board of Neurology, is senior adviser to Headache, associate editor for Cephalalgia and has reviewed for the NIA and NINDS, holds stock options in Biohaven Holdings and CntrlM; serves as consultant, advisory board member, or has received honoraria or conducted research funded by Allergan/Abbvie, American Academy of Neurology, American Headache Society, Amgen, Biohaven, Biovision, Dr. Reddy’s (Promius), Electrocore, Eli Lilly, eNeura Therapeutics, GlaxoSmithKline, Grifols, Lundbeck (Alder), Merck, Pernix, Pfizer, Teva, Trigemina, Vector, Vedanta. R.L. receives royalties from Wolff’s Headache seventh and eighth editions, Oxford University Press, 2009, Wiley and Informa. All other authors declare no competing interests.
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Sensitivity to light.
Sensitivity to sound.
- Chronic daily headache
Primary or secondary headache, defined as the presence of a headache on ≥15 days/month for at least 3 months, which may include chronic tension-type headache, chronic migraine, new daily persistent headache, medication overuse headache or other disorders with headaches.
- Probable TTH
Tension-type headache (TTH) that is missing one of the features required to fulfil all ICHD-3 criteria for a type or subtype of TTH.
- Medication overuse headache
Secondary headache characterized as headache occurring on ≥15 days/month that is attributed to regular overuse of analgesics or migraine-specific acute medications (on ≥10 or ≥15 days/month, depending on the medication) in individuals with a pre-existing headache disorder such as tension-type headache or migraine.
- New daily persistent headache
Primary headache disorder characterized by unremitting pain within 24 h of a clearly remembered onset and for >3 months.
- Cognitive behavioural therapy
A time-limited psychotherapeutic approach that focuses on assessing and modifying dysfunctional moods and thoughts (cognitive) and actions and behaviours (behavioural) and replacing them with strategies to help patients reach their goals.
A psychotherapeutic approach in which physiological data are fed back to the user in the form of visual and auditory stimuli, and in the case of tension-type headache there is a focus on recognizing activation of the nervous system and learning techniques to calm and relax the nervous system.
- Relaxation therapy
A psychological intervention that teaches various approaches to relaxing the nervous system including paced diaphragmatic breathing, imagery, distraction and meditation.
- Stress management therapy
A combination of relaxation with cognitive coping skills for preventing and managing stress and headaches.
- Headache triggers
Factors associated with an increased probability of headache over a relatively short, clinically relevant time period.
- Transformed migraine
Subtype of the chronic daily headache, not defined by ICHD, that initially begins as episodic migraine and then evolves over months or years to daily or near-daily headaches resembling a mixture of tension-type headache and migraine.
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Cite this article
Ashina, S., Mitsikostas, D.D., Lee, M.J. et al. Tension-type headache. Nat Rev Dis Primers 7, 24 (2021). https://doi.org/10.1038/s41572-021-00257-2
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