Tension-type headache is the most common type of headache worldwide and affects a large portion of society. According to research, approximately 30-78% of adults experience tension-type headache at some point in their lives. Although it is seen slightly more frequently in women, it significantly affects both genders. This headache, which can begin in childhood and adolescence, most commonly appears in the 20-40 age range and is one of the leading causes of workforce loss.

This type of headache is not only a medical problem but also an important public health issue. Because when it becomes repetitive and chronic:

• It restricts daily activities,
• Reduces work and school performance,
• Negatively affects social relationships,
• Significantly decreases quality of life.

Especially in people experiencing chronic tension-type headache, the state of continuous pain progresses intertwined with sleep disorders, depression, and anxiety. This condition directly affects not only the person’s physical but also psychological and social life.

Fortunately, with correct diagnosis and appropriate treatment methods, tension-type headache can be effectively controlled and patients’ quality of life can be significantly improved.

Who Gets It More Frequently?

Tension-type headache can affect people of all ages, but it is more common in some groups:

• Young adults (20-40 years): Tension-type headache is the most commonly encountered headache type during this period when work and personal life stress is most intense.
• Women: The occurrence rate is slightly higher in women due to hormonal fluctuations, stress load, and sleep irregularities.
• Those working under intense stress: It is more frequently reported in those working in professions requiring high responsibility and intense work pace such as banking, healthcare, and education.
• Those spending long periods in front of screens: With the increase in computer and phone use, the incidence has significantly increased especially among office workers.
• Those experiencing sleep disorders: Insufficient or irregular sleep both triggers headaches and leads to chronicity of pain.
• Those with postural disorders: Especially in those working at desks in non-ergonomic conditions, tension in neck and shoulder muscles facilitates headaches.

For this reason, tension-type headache is considered not only an individual problem but a widespread community health problem directly related to modern lifestyle.

What is Tension-Type Headache?

Tension-type headache is a type of headache felt on both sides of the head, in a pressing or pressure-like manner, appearing in mild or moderate intensity.

• It differs from migraine: It is not throbbing, symptoms associated with migraine such as nausea-vomiting are mostly absent.
• Divided into episodic and chronic:
  • Episodic: Attacks lasting less than 15 days per month.
  • Chronic: Form appearing 15 days or more per month, seriously affecting quality of life.
• It generally starts slowly, intensity may vary throughout the day. It mostly increases during stressful periods.
• Pain can start from the back of the head and spread to the forehead region and can be accompanied by neck-shoulder muscle tension.

What Causes Tension-Type Headache?

Although the exact cause of tension-type headache is not fully known, many triggering factors play a role. These factors can trigger pain alone or together:

• Stress: Work, family, or personal problems lead to pain by increasing muscle tension.
• Muscle tension: Excessive contraction in neck, shoulder, and head muscles is one of the most important causes of pain.
• Sleep irregularity: Insufficient, poor quality, or excessive sleep can trigger headaches.
• Eye fatigue: Long-term computer, phone use, or uncorrected vision problems increase pain.
• Wrong posture: Non-ergonomic work environment, sitting bent over or looking forward for long periods increases muscle tension.
• Nutrition and caffeine: Staying hungry for long periods, skipping meals, or sudden cessation of caffeine consumption can trigger headaches.
• Psychological factors: Depression and anxiety are closely related to tension-type headache.
• Teeth grinding (bruxism): Excessive use of jaw and temple muscles contributes to pain.

Symptoms of Tension-Type Headache

Symptoms are generally characteristic and can be distinguished from other headaches like migraine:

• Pressure or “band around the head” sensation on both sides of the head
• Mild or moderate intensity, non-throbbing pain
• Continuous-type pain that does not worsen with physical activity
• Tension, stiffness in neck and shoulder muscles
• Generally absence of nausea-vomiting
• Pain that may increase in later hours of the day, triggered by stress

Rarely, mild light or sound sensitivity may accompany, but this condition is not as pronounced as in migraine.

How is Tension-Type Headache Diagnosed?

Diagnosis is made through detailed patient history and physical examination. A special blood test or imaging method is not mandatory for diagnosis. The doctor evaluates the duration, frequency, triggers, and accompanying symptoms of the pain.

In physical examination, especially neck and shoulder muscle tension draws attention. Neurological examination is generally normal. If there are “red flag” symptoms such as suddenly starting very severe headache, fever, neurological findings, additional examinations are performed.

International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria- 2. Tension-Type Headache (TTH)

Tension-type headache is the most common among primary headache disorders. Pain is generally bilateral, pressing or tightening in nature, mild-moderate intensity, and does not increase with physical activity.

There are three subtypes in ICHD-3 classification:

1. Infrequent episodic tension-type headache
2. Frequent episodic tension-type headache
3. Chronic tension-type headache

2.1 Infrequent Episodic Tension-Type Headache

1. At least 10 attacks occurring on average less than 1 day per month (<12 days per year).
   B. Each headache lasts from 30 minutes to 7 days.
   C. Has at least two of the following four characteristics:
2. Bilateral location
3. Pressing or tightening quality (not pulsating)
4. Mild or moderate intensity
5. Not aggravated by routine physical activities (such as climbing stairs)
6. Both of the following are satisfied:
7. No nausea or vomiting (anorexia may occur).
8. No more than one of photophobia or phonophobia (not both together).
9. Not better accounted for by another disorder.

2.2 Frequent Episodic Tension-Type Headache

2. At least 10 attacks occurring on 1-14 days per month (≥12 and <180 days per year).
   B-E. Same criteria as above (2.1) apply.

2.3 Chronic Tension-Type Headache

1. Headache occurring on ≥15 days per month for ≥3 months (≥180 days per year).
   B. Each pain can last from 30 minutes to several days or can be continuous.
   C. Has at least two of the following four characteristics:
2. Bilateral localization
3. Pressing/tightening quality pain
4. Mild or moderate intensity
5. Not aggravated by routine physical activity
6. Both of the following are satisfied:
7. No nausea or vomiting
8. Only one of photophobia or phonophobia may be present
9. Not better accounted for by another disease.

Can Tension-Type Headache and Migraine Occur Together? How Are They Distinguished?

Tension-type headache and migraine are the two most common types among headache disorders. In many people, these two headache types can occur together. According to research, approximately 50% of migraine patients also develop tension-type headache at some point in their lives. This situation both makes diagnosis difficult and affects the treatment process.

Similarities Between the Two Headache Types

• Both lead to workforce loss and decline in quality of life.
• Both types can be triggered by stress, sleep irregularity, and fatigue.
• In some patients, two different types of pain can be experienced on the same day.

Distinguishing Features

Tension-type headache and migraine can be confused with each other, but there are some important differences:

What Does Their Co-occurrence Mean?

When tension-type headache and migraine occur together in the same person, the pain profile becomes more complex. In this case, for correct diagnosis and appropriate treatment plan, consultation with a neurology specialist is absolutely necessary. Because medications or lifestyle adjustments used alone may not be sufficient.

Tension-Type Headache Treatment

Treatment of tension-type headache is not limited to a single method; a personalized and multifaceted approach is required. The treatment plan is shaped according to the severity, frequency of headache, and the person’s lifestyle. For best results, both medication and non-medication methods should be applied together.

Pain Relievers (Must Be Under Doctor’s Control)

Painkillers can be used for acute relief during headache. However, uncontrolled and frequent use of these medications can lead to a new problem called “medication overuse headache.”

Most commonly used medications:

• Paracetamol: Safe and effective in mild and moderate intensity pains.
• NSAIDs (ibuprofen, naproxen): Reduces pain, also benefits muscle tension.
• Aspirin: Can be used in suitable patients for mild and moderate intensity pains.
• Caffeine-containing combinations: Can show rapid effect in resistant pains.

Points to consider in medication use:

• Should not be used more than 15 days per month.
• Taking it in the early period when pain starts is more effective.
• Dose increase must be done with doctor approval.
• Medication selection should be done carefully in those with stomach, liver, or kidney problems.

Long-Term Headache Control

If headache recurs frequently or has become chronic (15 days or more per month), pain relievers alone are not sufficient. In this case, preventive (prophylactic) treatment comes into question. The aim is to reduce attack frequency and increase quality of life.

Medications that can be used:

• Tricyclic antidepressants (e.g., Amitriptyline): The most commonly preferred preventive treatment option.
• Beta blockers (e.g., Propranolol): Can be beneficial especially in cases occurring together with migraine.
• Muscle relaxants (e.g., Tizanidine): Can reduce tension in neck and shoulder muscles.

Also, if there is teeth grinding (bruxism), it must be evaluated. Night guard (splint) use, stress-reducing methods, or dentist support to treat this condition can provide significant reduction in headaches.

Preventive treatment generally lasts at least 6 months and is gradually discontinued under doctor control. Regular follow-up during treatment is very important.

Physiotherapy or Ergonomic Posture Training

Physiotherapy is an important component of tension-type headache treatment. It offers effective methods for reducing muscle tensions and correcting postural disorders.

Physiotherapy approaches:

• Manual therapy techniques
• Stretching exercises
• Strengthening programs
• Postural training
• Trigger point therapy
• Electrotherapy methods

Ergonomic posture training:

• Arranging the work environment
• Correct sitting positions
• Keyboard and monitor placement
• Regular breaks and exercises
• Maintaining neck and shoulder positions

Psychological Support and Anxiety Treatment

Since psychological factors play an important role in tension-type headache, mental support and anxiety treatment are critical. This approach is especially necessary in situations accompanied by stress and anxiety.

Psychological treatment methods:

• Cognitive behavioral therapy (CBT)
• Stress management techniques
• Relaxation exercises
• Mindfulness and meditation
• Biofeedback
• Progressive muscle relaxation

Anxiety treatment:

• Anxiolytic medications (short-term)
• Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants (long-term)
• Psychotherapy
• Lifestyle changes
• Support groups

A holistic approach should be adopted in tension-type headache treatment. The best results are obtained when lifestyle changes, stress management, and psychological support are applied together instead of treatment with medication alone. Providing education to patients about lifestyle changes and regular follow-up are important factors that increase treatment success.

Frequently Asked Questions About Tension-Type Headache

1. What is the Difference Between Tension-Type Headache and Migraine?

Tension-type headache and migraine are the two most common headache disorders and are often confused with each other. However, knowing the differences between them is very important for making the correct diagnosis.

Tension-Type Headache Characteristics

• Squeezing pain like a band on both sides of the head
• Not throbbing, rather continuous and dull in character
• Progresses in mild to moderate intensity
• Does not increase with physical activity
• Generally no nausea and vomiting
• Light and sound sensitivity is rare

Migraine Characteristics

• Mostly on one side of the head, throbbing and pulsating pain
• Progresses in moderate to severe intensity
• Significantly worsens with physical activity
• Nausea and vomiting are common
• Pronounced light and sound sensitivity exists
• In some patients, visual or sensory symptoms called aura may accompany

The Importance of Keeping a Headache Diary

Distinguishing between tension-type headache and migraine may sometimes not be easy with patient description alone. Therefore, keeping a headache diary is very useful. The diary should include the following information:

• Date and time when pain started
• Duration and intensity of pain
• Character of pain (throbbing or pressing?)
• Accompanying symptoms (nausea, photosensitivity, vomiting, etc.)
• Factors triggering pain (stress, sleep irregularity, hunger, hormonal changes, etc.)
• Medications used and their effects

When this diary is shared with the doctor, it more clearly reveals which headache type is being experienced and helps make the correct personalized treatment plan.

2. Does Tension-Type Headache Completely Go Away? Does It Become Chronic?

Whether tension-type headache completely goes away is one of the most curious topics for patients. This depends on the type of headache and underlying causes.

Episodic tension-type headache (less than 15 days per month):

• Generally controllable and can be completely overcome.
• Decreases significantly when triggering factors are eliminated.
• Can be successfully managed with lifestyle changes.

Chronic tension-type headache (15 days or more per month):

• Requires longer-term treatment.
• Complete recovery is more difficult but possible.
• Psychological support and pharmacological treatment may be needed.

Risk factors for chronification:

• Excessive painkiller use (more than 15 days per month)
• Untreated anxiety and depression
• Inadequacy in stress management
• Lifestyle problems
• Accompanying teeth grinding

With the correct treatment approach, the frequency and intensity of tension-type headache can be significantly reduced, even completely eliminated.

3. Which Medications Help Tension-Type Headache? How Often Can They Be Used?

Many people experiencing tension-type headache frequently ask the question “Which medications can I use?” Correct selection of medications and using them at the correct frequency is very important for controlling pain.

Medications Used in Acute Treatment

These medications provide short-term relief when headache starts:

• Paracetamol: One of the safest and most preferred medications. Can be used up to 4 grams total per day.
• Ibuprofen: Has both pain-relieving and anti-inflammatory effects. Can be taken up to 1200 mg per day.
• Aspirin: Effective in mild and moderate intensity pains. Can be used up to 3 grams per day.
• Naproxen: A longer-acting option, generally can be used 2 doses per day.

⚠️ Critical Warnings

• Painkillers should not be used more than 15 days per month.
• Overuse can lead to Medication Overuse Headache.
• Taking the medication as soon as pain starts is more effective.
• Dose should not be increased without doctor recommendation.

Medications Used in Chronic Tension-Type Headache

If headache occurs more than 15 days per month or seriously affects daily life, preventive treatment may be needed. These medications are used only under doctor control:

• Amitriptyline: From the tricyclic antidepressant group, the most commonly preferred preventive medication.
• Propranolol: In the beta blocker group, beneficial in some patients.
• Tizanidine: With its muscle relaxant property, especially effective in patients with neck and shoulder muscle tension.

Preventive medications are part of a long-term treatment plan and should be used with regular doctor control.

4. How Much Do Stress and Computer Use Affect Tension-Type Headache?

Two major parts of modern life, stress and technology use, are among the most important triggers of tension-type headache. Small habits we unknowingly make in our daily lives can lead to increased frequency and intensification of headaches.

Effect of Stress

• Most important trigger: The most common cause of tension-type headache is stress.
• Muscle tension: Stress causes pain by contracting neck, shoulder, and head muscles.
• Chronic stress: Long-continuing stress causes headaches to become more frequent and unbearable.
• Mental effects: When combined with psychological conditions such as anxiety and depression, pain control becomes even more difficult.

Effect of Computer and Phone Use

• Muscle tension: Staying at the computer or phone for long periods creates tension especially in neck and shoulder muscles.
• Wrong posture: Sitting bent over or looking forward leads to “postural disorder.” This triggers musculoskeletal problems known as “tech neck.”
• Eye fatigue: Focusing on the screen for long periods can cause dryness, burning in the eyes, and headache.

Preventive Measures

• 5-10 minute break every 1 hour
• Position your monitor at eye level.
• Use ergonomic chair, keyboard, and mouse.
• Do short neck and shoulder stretching exercises throughout the day.
• 20-20-20 rule: Every 20 minutes, look 20 feet (6 meters) away for 20 seconds.

Stress Management Techniques

• Deep breathing and breathing exercises,
• Muscle relaxation techniques,
• Meditation and mindfulness practices,
• Regular walking and exercise programs,
• Adequate and quality sleep.

Reducing stress and properly managing computer use is one of the most effective methods in preventing tension-type headache.

5. Which Doctor Should I See for Tension-Type Headache? When Is It an Emergency?

Many people experiencing tension-type headache wonder “Which doctor should I see?” or “Is this an emergency?” Correct specialist selection and knowing emergency symptoms are critically important in treatment.

Which Doctor Should I See?

• Initial consultation: Family physician or internal medicine specialist is suitable for basic evaluation and initial treatment.
• Specialist evaluation: Neurology specialist determines the type of headache and arranges the treatment plan.
• Accompanying psychological conditions: If there is anxiety disorder or depression, psychiatry specialist support may be needed.
• Musculoskeletal system problems: If neck and shoulder muscle tension is prominent, physical therapy specialist may be beneficial.
• Teeth grinding (bruxism): If there is nighttime teeth grinding or jaw muscle problems, oral and maxillofacial surgeon or dentist should evaluate.

Situations Requiring Doctor Visit

• Having more than 4 headache attacks per month
• Painkillers no longer being effective
• Headache progressively intensifying
• Significant decline in daily life, work, or school performance
• Creating serious effects on sleep, concentration, and mood

Emergency Symptoms (Go to Hospital Immediately!)

• Suddenly starting, very severe headache (“worst headache of my life”)
• Headache accompanied by fever and neck stiffness
• Vision impairment, double vision, speech difficulty, or comprehension problems
• Confusion, confusion, fainting
• One-sided weakness or numbness
• Headache with severe nausea-vomiting
• Severe headache starting for the first time after age 50

When these symptoms occur, it may not be tension-type headache but a serious condition posing vital risk. Emergency department visit is immediately necessary.