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1 · SNAPSHOT

Tension-Type Headache body chart — Illustrative, not diagnostic. Canva body chart for Tension-Type Headache.

The most common primary headache, and the one students most often manage without asking the two questions that matter.

Illness script in one line: bilateral, band-like pressing or tightening head pain, mild to moderate, dull and non-pulsating, not made worse by walking up stairs, with no nausea and at most one of light or sound sensitivity.

Caseload frequency: very high. Read further: epidemiology [1], burden of migraine and tension-type headache [2]. That it is the most common primary headache is what you need.

The two questions that matter

1. "Does it get worse walking up stairs?" Not aggravated by routine physical activity is a formal diagnostic criterion for tension-type headache. Migraine is aggravated by activity. This isn't. It's the cleanest single discriminator you have and it takes four seconds.

2. "How many days a month do you take something for it?" Medication overuse headache is the single most common reason a frequent headache stops responding to anything [3]. Ask, every time.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

MAIN PROBLEM

"A tight band around my head." Or: pressure · a vice · a weight · my head feels squeezed.

They rarely say "pain". Listen for pressure words.

BODY CHART

Bilateral. Unilateral should make you re-rank immediately.
Band-like: frontal, temporal, occipital, or all three.
± suboccipital, upper trapezius and temporalis tenderness. Common.
± neck stiffness. Common, and not the same as causal.

BEHAVIOUR — and this is where the criteria live

Feature	Tension-type headache
Quality	Pressing or tightening. NON-pulsating.
Intensity	Mild to moderate. Usually gets through the day.
Effect of routine physical activity	NOT aggravated. ← the cleanest discriminator
Nausea or vomiting	Absent.
Photophobia / phonophobia	At most ONE. Never both.
Duration	Minutes to days. Variable.

Aggs: stress, fatigue, sustained desk work, eye strain, poor sleep, missed meals.
Eases: movement, rest, sleep, getting away from the trigger. Often eases with activity, which is the opposite of migraine.
Irritability: typically low.

HISTORY — five things, and two of them are new

Frequency: episodic or chronic? Under 15 days a month, or 15 and over? That single number changes the management and the prognosis conversation.
Analgesic days per month. The medication overuse question. Ask it as a number, not as "do you take much?"
A headache diary. Read further: development of a headache diary and the diagnostic criteria [4]. Give them one at session one. It is the highest-yield thing you'll do.
Jaw: clenching, grinding, clicking, morning jaw ache. Read further: temporomandibular disorders in migraine and tension-type headache [5]. Examine the jaw.
Sleep, workload, mood and stress load.

SPECIAL / SCREENING QUESTIONS — every time

Thunderclap onset. New headache over 50. Progressive or changing pattern. Positional change. Fever. Neurological deficit. Cancer or immunosuppression history. Papilloedema. Trauma. Pregnancy or postpartum. Painful eye with autonomic features.

Red and orange flags for secondary headaches are set out as the SNNOOP10 list [6]. Read further: its sensitivity in high-risk secondary headache detection [7]. No verified accuracy data in our library. Use it as a checklist, not a score.

Plus the CAD/VBI screen if there's any neck involvement — the 5 D's and 3 N's.

Assessing this region? Download the Cervical Spine assessment template →

3 · HYPOTHESIS RANKING

Top three, and the one feature that separates each

Pattern	The discriminating feature
1. Tension-type headache	Bilateral, pressing, mild–moderate, NOT aggravated by routine activity, no nausea, at most one of photo/phonophobia.
2. Migraine	Unilateral, throbbing, moderate–severe, AGGRAVATED by routine activity, nausea, both photophobia and phonophobia. Every row is the opposite.
3. Cervicogenic headache	Unilateral, side-locked, reproduced from the upper cervical segments, provoked by neck movement or sustained posture. Its own page — go there.

And the one that mimics it

Pattern	The discriminating feature
Medication overuse headache	Headache on 15 or more days a month in someone taking acute medication regularly. It looks like chronic TTH and won't respond until the medication is addressed.

Also on the list

Pattern	The discriminating feature
Temporomandibular disorder	Jaw pain, clicking, limited opening. Overlaps with TTH; systematically reviewed. Examine the jaw.
Cluster headache	Severe unilateral orbital pain, short-lasting, autonomic features, restless.
Secondary headache	Any SNNOOP10 flag.

Read further: differences and similarities between tension-type headache and migraine [8], clinical overviews of both [9][10]. They overlap, and they coexist. Use three discriminators, not one.

4 · RED FLAGS — DON'T MISS THIS

Free forever. Safety is never behind a paywall.

Every headache page needs this section, and this one needs it most, because tension-type headache is the diagnosis a benign-looking secondary headache gets given by default.

Finding	What it means
Thunderclap — maximal within seconds to a minute	Subarachnoid haemorrhage until proven otherwise. EMERGENCY.
New or changed headache over 50	Giant cell arteritis, tumour. Urgent.
Progressive, or a clear change in the established pattern	Urgent.
New neurological deficit, seizure, or altered consciousness	EMERGENCY.
Worse lying flat, worse on waking, worse with valsalva	Raised intracranial pressure. Urgent.
Fever, neck stiffness, rash	Meningitis. EMERGENCY.
Cancer history, immunosuppression, HIV	Urgent.
Papilloedema	Urgent.
Trauma, pregnancy or postpartum, painful eye with autonomic features	Urgent.
Any of the 5 D's or 3 N's with neck involvement	CAD/VBI. Do not manipulate. Escalate.

Two things to hold onto

The SNNOOP10 list exists so you don't have to hold ten things in your head. Use it as a checklist, not a score. No verified accuracy data in our library.

"No neurological findings" describes the typical case. It is not permission to skip the screen.

Any red flag: stop, escalate, and check it with your educator.

Members

The 4-minute lesson is for members

Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No Australian guideline for this presentation; anchored to the EFNS guideline on the treatment of tension-type headache (Bendtsen et al. 2010, PMID 20482606) for treatment.

The safety anchor is the SNNOOP10 list of red and orange flags for secondary headaches, published in Neurology (Do et al. 2019, PMID 30587518), with its sensitivity in high-risk secondary headache detection examined (García-Azorín et al. 2022, PMID 36003002). No physiotherapy guideline exists; the physiotherapy evidence is anchored to a systematic review and meta-analysis of physiotherapy approaches in chronic tension-type headache (Onan et al. 2025, PMID 40129422).

PubMed Source

The EFNS guideline is a pharmacological treatment guideline written for neurologists. It is not a physiotherapy management guideline — none exists for this condition.

Members

The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

1998Schwartz et al. (1998). Epidemiology of tension-type headache. JAMA, 279(5), 381-3. https://doi.org/10.1001/jama.279.5.381
2025Zhao et al. (2025). The burden of migraine and tension-type headache in Asia from 1990 to 2021. The journal of headache and pain, 26(1), 49. https://doi.org/10.1186/s10194-025-01990-9
2023Ashina et al. (2023). Medication overuse headache. Nature reviews. Disease primers, 9(1), 5. https://doi.org/10.1038/s41572-022-00415-0
2024González-González & Herrero (2024). Development of a Headache Diary and Assessment of Tension-Type Headache Diagnostic Criteria and Oral Behaviors, Joint Range of Motion, and Tenderness to Palpation: An Observational Study. Journal of chiropractic medicine, 23(1-2), 37-46. https://doi.org/10.1016/j.jcm.2024.02.003
2024Bizzarri et al. (2024). Temporomandibular disorders in migraine and tension-type headache patients: a systematic review with meta-analysis. Journal of oral & facial pain and headache, 38(2), 11-24. https://doi.org/10.22514/jofph.2024.011
2019Do et al. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology, 92(3), 134-144. https://doi.org/10.1212/WNL.0000000000006697
2022García-Azorín et al. (2022). Sensitivity of the SNNOOP10 list in the high-risk secondary headache detection. Cephalalgia : an international journal of headache, 42(14), 1521-1531. https://doi.org/10.1177/03331024221120249
2023Onan et al. (2023). Debate: differences and similarities between tension-type headache and migraine. The journal of headache and pain, 24(1), 92. https://doi.org/10.1186/s10194-023-01614-0
2019Burch (2019). Migraine and Tension-Type Headache: Diagnosis and Treatment. The Medical clinics of North America, 103(2), 215-233. https://doi.org/10.1016/j.mcna.2018.10.003
2025Pan et al. (2025). Hallmarks of primary headache: part 2- Tension-type headache. The journal of headache and pain, 26(1), 164. https://doi.org/10.1186/s10194-025-02098-w
2023Fernández-de-Las-Peñas et al. (2023). The cervical spine in tension type headache. Musculoskeletal science & practice, 66, 102780. https://doi.org/10.1016/j.msksp.2023.102780
2025Onan et al. (2025). The efficacy of physiotherapy approaches in chronic tension-type headache: a systematic review and meta-analysis. Journal of oral & facial pain and headache, 39(1), 34-48. https://doi.org/10.22514/jofph.2025.003
2024Jung et al. (2024). Physical Therapist Interventions to Reduce Headache Intensity, Frequency, and Duration in Patients With Cervicogenic Headache: A Systematic Review and Network Meta-Analysis. Physical therapy, 104(2). https://doi.org/10.1093/ptj/pzad154
2023Repiso-Guardeño et al. (2023). Physical Therapy in Tension-Type Headache: A Systematic Review of Randomized Controlled Trials. International journal of environmental research and public health, 20(5). https://doi.org/10.3390/ijerph20054466
2024Lu et al. (2024). Myofascial Release for the Treatment of Tension-Type, Cervicogenic Headache or Migraine: A Systematic Review and Meta-Analysis. Pain research & management, 2024, 2042069. https://doi.org/10.1155/2024/2042069
2024Park et al. (2024). Improving Function and Quality of Life in Patients with Chronic Neck Pain, Tension-Type Headache, and Forward Head Posture: The Role of Eyeball Exercise and Cervical Stabilization Programs. Medical science monitor : international medical journal of experimental and clinical research, 30, e944315. https://doi.org/10.12659/MSM.944315
2024Xie et al. (2024). Efficacy and safety of simple analgesics for acute treatment of episodic tension-type headache in adults: a network meta-analysis. Annals of medicine, 56(1), 2357235. https://doi.org/10.1080/07853890.2024.2357235
2010Bendtsen et al. (2010). EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. European journal of neurology, 17(11), 1318-25. https://doi.org/10.1111/j.1468-1331.2010.03070.x
2024Gopichandran et al. (2024). Effectiveness of Progressive Muscle Relaxation and Deep Breathing Exercise on Pain, Disability, and Sleep Among Patients With Chronic Tension-Type Headache: A Randomized Control Trial. Holistic nursing practice, 38(5), 285-296. https://doi.org/10.1097/HNP.0000000000000460
2018Kong et al. (2018). Testing of diagnosis criteria of tension-type headache: A multicenter clinical study. Cephalalgia : an international journal of headache, 38(12), 1833-1840. https://doi.org/10.1177/0333102418759784

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