Definition

Epidemiology

• The most common primary headache type
• 1-year prevalence: 14–93 per 100,000 for episodic TTH; 8.1 per 100,000 for chronic TTH
• More common in women than men, regardless of age, race, or education
• More prevalent in Western countries; more common in White than African American populations
• Typically arises in middle age, often coinciding with anxiety, fatigue, and depression
• Most patients self-treat and never seek medical attention — Goldman-Cecil Medicine

ICHD-3 Diagnostic Criteria

Frequent Episodic TTH

Chronic TTH

Clinical Features

• Location: Bilateral; occipital, temporal, frontal, or diffuse ("band-like" or "vice-like" pressure)
• Quality: Dull, aching, pressure, tightness, fullness — not pulsating
• Onset: Gradual (unlike migraine)
• Duration: May persist for days, weeks, months, or years without significant fluctuation — this persistence throughout the day is a hallmark of chronic TTH
• Associated: Anxiety and depression present in the majority of patients with protracted headaches; ~1/3 have recognizable depressive symptoms
• Sleep: Usually undisturbed, but headache develops soon after awakening
• Activity: Does not worsen with routine physical activity

• No persistent throbbing quality
• No nausea, photophobia, phonophobia (or at most one of the latter two)
• No clear lateralization
• Does not seriously interfere with daily activities — Adams and Victor's Principles of Neurology

Pathophysiology

• EMG recordings show no persistent muscle contraction in most patients
• Some studies note pericranial and trapezius muscle hardening (Sakai et al.)
• Nitric oxide has been implicated — it creates central sensitization to sensory input from cranial structures
• Inhibitors of nitric oxide reduce muscle hardness and pain in chronic TTH (Ashina et al.)
• Myofascial tenderness is increased, especially in chronic TTH
• Genetic factors remain uncertain — Adams and Victor's Principles of Neurology; Goldman-Cecil Medicine

Treatment

Acute / Episodic TTH

⚠️ Analgesic use >3 days/week can worsen headaches and lead to medication-overuse headache.

Prophylaxis (Chronic TTH)

• Amitriptyline is the only proven prophylactic for chronic TTH — start at 10 mg at bedtime, titrate slowly to 100 mg
• Other tricyclics (nortriptyline 25–100 mg/day; doxepin 25–75 mg/day; maprotiline 10–25 mg/day)
• SSRIs (fluoxetine 10–20 mg/day) — tricyclics are generally more efficacious than SSRIs
• Botulinum toxin A — placebo-controlled trials were negative for chronic TTH
• Muscle relaxants, physical therapy, acupuncture can be useful adjuncts — Goldman-Cecil Medicine; Harrison's 22E

Non-pharmacological

• Biofeedback, relaxation techniques, meditation, massage
• Address underlying anxiety and stress
• Gradual withdrawal of overused analgesics, ergotamines, or triptans is critical in chronic daily headache

Prognosis

• Variable; most episodic cases improve with appropriate management
• Adolescents with TTH and ≥2 psychiatric comorbidities (depression, anxiety) have a worse prognosis
• Migraine and traumatic headaches may be complicated by superimposed TTH — Goldman-Cecil Medicine

Recent Evidence (2024–2025)

• A 2025 systematic review and meta-analysis (PMID: 40129422) confirmed physiotherapy approaches are effective in chronic TTH
• A 2026 clinical practice guideline (PMID: 41685545) supports chiropractic management for cervicogenic and tension-type headaches
• The GBD 2023 analysis (PMID: 41240916) — headache disorders, including TTH, remain a major global burden through 2023