Tension type headaches (TTH) are recurrent episodes of headache lasting minutes to weeks. The pain is typically pressing or tightening in quality, of mild to moderate intensity, and bilateral in location, and does not worsen with the routine physical activity. Nausea and vomiting is usually absent, but photophobia or phonophobia may be present.

These headaches were previously known by many terms such as psychogenic headache, stress headache, psychomyogenic headache, muscle contraction headache etc. However, the term "tension type headache" (TTH) has been chosen by the International Classification Headache Diagnosis I (ICHD I) in 1988 and have been retained by ICHD II in 2004.

The words "tension" and "type" underscore its uncertain pathogenesis and indicate that some kind of mental or muscular tension may play a causative role. However, a large number of clinical and neuro-physiological studies leave little doubt about its neurobiological basis and takes it away from the realms of psychological diseases.

In International headache Society classification (ICHD II), tension type headaches have been divided into two forms, episodic (ETTH) and chronic (CTTH). The episodic tension type headache has been divided into two groups, namely infrequent and frequent. All the three types of tension type headaches share similar clinical features except for frequency. It is also suggested that on clinical examination, the clinicians should look for pericranial tenderness in patients with tension type headaches and sub-classify them as those associated or not associated with pericranial tenderness.

Clinically, it is difficult at times to distinguish TTH from early phase of migraine attack. Further, many chronic patients of TTH overuse medications and in this setting differentiating medication overuse headache from CTTH becomes difficult. ICHD II has introduced the diagnostic category of probable tension type headache to address this situation. For probable episodic tension type headache, migraine without aura needs to be excluded. For probable CTTH, medication overuse headache (MOH) needs to be ruled out in addition. It is to be noted that ICHD II version requires withdrawal of medication for 2 months and disappearance of headache following the withdrawal to diagnose MOH. This is paradoxical as majority of CTTH patients overuse medications. 

The diagnosis of tension type headache is essentially clinical and relies only on symptoms. Thus a detailed history taking through examination (to rule out any secondary cause) is mandatory. No laboratory tests can make the diagnosis.

Clinic features

“The Cochrane Review of Acupuncture for Tension-Type Headache,” by Linde et al (1) gives, for the first time, evidence that acupuncture is effective for frequent, episodic, or chronic TTH and thus provides a valuable nonpharmacological treatment option. In the light of the data, one would expect these findings to redefine the clinical significance of acupuncture for the treatment of TTH within Western medicine.

TTH is widespread; epidemiological studies show a one-year prevalence of 30% to 60% for episodic TTH and 2% to 3% for chronic TTH (2). It is also hard to treat.

Tension-type headache is one of the main reasons for the consumption of analgesics worldwide, but this conventional therapy poses a dangerous problem in Western medicine. It is estimated, for example, that in Germany 80% of over-thecounter painkillers are taken by headache patients and account for 2,000 to 7,000 deaths annually, mainly due to gastrointestinal bleeding (D.O. Stichtenoth, personal communication, February 2006) (3).

In contrast, acupuncture is rated as a relatively safe therapy (4).

For prophylactic treatment of chronic TTH, tricyclic antidepressants, mainly amitriptyline, are most widely used. Surprisingly, only 14 trials of this therapy, with very small samples (median 36, range 15-197), inadequate efficacy parameters, and short durations, have been performed. 5 Ten of these are positive, but the clinical relevance of their outcomes is questionable. This contrasts to acupuncture, for which the Cochrane review lists 11 strictly selected randomized controlled trials with 2,317 participants (median 62, range 10-1,265) for TTH.

In view of the data presented in the Cochrane review, one should expect that acupuncture will soon be recommended as a nonpharmacological therapy because of its high level of evidence (ie, a positive systematic review), its negligible adverse effects, and its effectiveness on the reduction of headache days in chronic TTH.

1. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2009;1:CD007587.

2. Schwartz BS, Stewart WF, Simon D, Lipton RB. Epidemiology of tension-type headache. JAMA. 1998;279:381-383. Cochrane Reviews EXPLORE November/December 2009, Vol. 5, No. 6 357.

3. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 1999;340:1888-1899.

4. Witt CM, Pach D, Brinkhaus B, et al. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009;16:91-97.

5. Paola Schiapparelli, Gianni Allais, Sara Rolando, Gisella Airola. Acupuncture in primary headache treatment. Neurol Sci (2011) 32 (Suppl 1):S15–S18.