HEADACHE CURRENTS
Headache Currents
Tension-Type Headache – The Normal and Most
Prevalent Headache
Rigmor Højland Jensen, DrMed Sci
Premise.—Tension-type headache (TTH) is the most preva-
lent form of primary headache in the general population but
paradoxically the least studied headache.
Problem.—In this article, the epidemiology and diagnostic
challenges of TTH are presented and discussed. The typical
features and differential diagnosis of TTH are highlighted and
the situations more likely to raise doubts are discussed.
Potential Solution.—A structured approach to the patient
and a better comprehension of the very frequent coexistence
of migraine and medication overuse headache in the clinical
population are emphasized. According to the IHS classifica-
tion, several diagnoses should be applied but still some clini-
cians prefer to apply a single combined diagnosis in the
severely affected patients, namely chronic migraine. Such
uneven practice may complicate the diagnostic comparability
and the entire management of TTH. The present treatment
strategies for TTH are summarized and hopefully an increased
awareness of TTH can translate into better quality of care and
a more specific diagnosis and treatment for the numerous
TTH sufferers.
Key words: tension-type headache, primary headache, prevalence, clinical
presentation, treatment
MAIN BODY
Tension-type headache (TTH) is the most prevalent head-
ache1 and is well defined as a primary headache in the ICHD
classification.2 The underlying mechanisms of pain are inter-
esting and could be important for all types of headache but
TTH is mostly regarded as a normal headache and has not
achieved the same scientific and industrial interest as
migraine.
TTH is characterized by frequency and by a mild to moder-
ate headache that is not associated with the typical debilitating
migraine symptoms of nausea, vomiting, photo, and
phonophobia.2
Most clinical patients describe their TTH as their normal
milder headaches in contrast to their major headaches,
migraine, or cluster headaches, for which they usually seek
From the Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup,
University of Copenhagen, Glostrup, Denmark (R.H. Jensen).
Address all correspondence to R.H. Jensen, Danish Headache Center, Rigshospitalet-
Glostrup, Nordre Ringvej 57, building 24, DK-2600 Glostrup, Denmark.
Accepted for publication February 8, 2017.
.............
Headache
C 2017 American Headache Society
V Conflict of Interest: None.
1
medical assistance. Such report bias may thus have led to the
lower priority that TTH are subject to and emphasize the
need for a revised awareness of a possible underlying TTH.3
To provide a correct management, several diagnoses should be
applied to the same patient. Furthermore, TTH can also pre-
sent as a great imitator and may thus mimic chronic migraine,
medication overuse headache (MOH), and very rarely, a life
threatening secondary headache.
TTH patients seek also less medical help than migraineurs. In a
population study, only 16% of patients with TTH had been in
contact with their general practitioner because of their TTH in
contrast to 56% of migraineurs.3 When data are corrected for the
much higher prevalence of TTH, the total use of medical contacts
is however 54% higher for TTH than for migraine.4,5 Severely
affected, especially patients with chronic TTH may see numerous
doctors and spend large sums of money on so called alternative
treatments, and live for decades without effective pain relief.
Epidemiology
TTH varies considerably both in frequency, duration and
severity from rare shortlasting episodes of discomfort to fre-
quent, long lasting or continuous disabling headaches. Unlike
migraine, there is a clear and positive correlation between fre-
quency and severity of TTH. TTH should therefore always be
weighted according to frequency with the present subdivision
into three subgroups, an infrequent form <12 days per year, a
frequent episodic form between 12 and 179 days per year and
a chronic form 180 days per year or more.2 In its infrequent
mild form, TTH is a self-limiting nuisance and persons with
infrequent TTH are regarded as headache free controls in most
studies. In its frequent or chronic subforms, it become distress-
ing and socially disturbing due to the more constant pain, sur-
passing the burden of migraine and cluster headache.4,5
Considering all subjects with TTH as a homogenous group
may thus be misleading. The life time prevalence of TTH was
as high as 78% in a population-based study in Denmark but
the vast majority, namely 59%, had infrequent episodic TTH
and were not in need of medical care.6 However, within the
last year 24-37% of the population had TTH once a month
or more, 10% had it weekly, and 2-3% had chronic TTH,
usually for the greater part of their lifetime.6,7
The male:female ratio of TTH is 4:5 indicating that, unlike
migraine, females are only slightly more affected than men.1,6
The average age of onset of TTH is higher than in migraine,
namely 25-30 years in cross-sectional epidemiological studies.1,6
.............
2 | Headache | Month 2017
Fig. 1.—A typical diagnostic diary from a patient with chronic TTH with coexisting migraine. The Xs indicate TTH (X Mild, XX Mod-
erate, and XXX Severe Intensity) and M indicates migraine attacks.
In both sexes, the prevalence seems to peak between the age
of 30 to 39 years and appears to decrease only slightly with
advancing years.6
The overall prognosis of TTH is however fairly positive. In
a 12-year follow-up study of a general population, Lyngberg
et al found that 47% of subjects with chronic TTH had
remission, while 12% with episodic TTH had developed the
chronic form. Poor outcome was associated with baseline
chronic TTH, coexisting migraine, not being married, and
sleeping problems.8 Further longitudinal studies are needed to
identify the mechanisms and the predictive factors for a posi-
tive outcome.
Diagnosis
Over the years there has been much controversy about
TTH as a specific clinical entity and the entire existence of
TTH has even been questioned by a few experts. This is most
likely due to referral bias but there may be other reasons for
this paradox.
First, TTH is a fairly featureless headache and may mimic
other primary or secondary headaches. Patients with pure epi-
sodic TTH rarely attend headache clinics and are not seen by
these experts; only 16% of TTH sufferers from the general
population seek medical help due to TTH, and only 3% seek
Headache Currents
specialized care.9,10 “Pure” TTH without migraine or migrain-
eous features are also more frequent in the general population
than in the specialized clinics.6,9 However, in the very large
Landmark study from 2004, 94% of clinical headache patients
had definite or probable migraine and only 3% had pure epi-
sodic TTH.11 However, the prevalence of coexisting migraine
and TTH was not studied.
Second, case definitions in TTH may also be difficult
because TTH may overlap with mild attacks of migraine and
vice versa. Some patients and doctors may therefore have diffi-
culty distinguishing the different types of attacks, and add
only one diagnosis, mainly migraine, although in clinical pop-
ulations patients may have up to five different ICHD
diagnoses.12,13
Furthermore, a diagnosis of migraine may overrule the diag-
nosis of the featureless TTH; therefore, a single diagnosis of
chronic migraine often is applied despite migraine attacks may
occur only in a subset of days in contrast to the chronic TTH
(Fig. 1).
Lastly, most headache specialist focus on migraine, where
there is a broad armamentarium of pharmacological treat-
ments.12-14 The headache specialist rarely is specialized in
TTH and the TTH patients often seek the pharmacies
3 | Headache | Month 2017
Table 1.—The Eight Most Important Questions to a Headache
Patient
Have you one or several different types of headache? Describe them
one by one.
How long do your headaches last?
(seconds, minutes, hours, days)
How frequent are your headaches?
What is the intensity of pain?
What do you do during a headache attack?
Where is the pain located?
Are there any associated symptoms?
Do you take any medication? If yes, how much and how frequent?
directly for OTC drugs or visit other pain specialists such as
chiropractors, general practioners, dentists, and physical
therapists.
In the general population, 94% of migraineurs also experi-
ence TTH and 56% experience frequent episodic TTH.6,9 In
contrast, TTH occurs with similar prevalence in those with
and without migraine, leading to the assumption that
migraine may trigger TTH, whereas TTH does not trigger
migraine.
A detailed interview, a clinical neurological examination, and
use of a diagnostic diary for several weeks are therefore very
important for a complete picture of the individual patient and the
various headaches. The questions in Table 1 are relevant and may
be important to facilitate the diagnostic process (Table 1).
History
Patients with TTH usually describe their pain as a “dull,”
“non pulsating” headache. The pain is typically bilateral (90%)
and a strict unilateral location calls for increased attention and
secondary causative factors for headache should be considered.14
The pain quality is pressing and tightening and terms such as a
sensation of “tightness,” “pressure,” or “soreness” are used. The
pain is often described as an external pain coming from the
outside, in contrast to migraine patients that describe their pain
coming from the inside. Some patients refer to a “band” or a
“cap” compressing their head, while others mention a heavy
“weight” over their head and/or their shoulders.
In one study, TTH was of a pressing quality in 78% of
patients, mild or moderate in 99%, bilateral in 90%, and
72% had no aggravation by physical activity.15 The accompa-
nying symptoms of nausea, photophobia and phonophobia
occur only rarely and if present, they are usually mild. The
presence of nausea may again raise suspicion of migraine
attacks or medication overuse. In addition, nausea and aggra-
vation by physical activity are important predictors of a
migraine attack. Patients suffering from both conditions can
thus learn to discriminate between TTH and migraine by
these accompanying symptoms.15
Headache Currents
As described, a detailed diagnostic diary16 is useful initially
and supplemented by a simplified calender for the follow-up
subsequent to the diagnosis, and an example of diary for
a TTH patient with coexisting migraine is illustrated in
Figure 1.
A detailed history of any possible triggers is also of utmost
importance, especially in the episodic subforms. As in
migraine, elimination of any possible triggers such as dental
pathology, cyclic hormonal relationship, sinus disease, unphy-
siological working conditions, posture, unbalanced meals and
inadequate sleep, stress, anxiety, and depression may reduce
the frequency of attacks but in practice, consistent triggers can
be difficult to identify.
In summary, a secondary headache should always be consid-
ered in all patients consulting for headache, most frequently
MOH but also serious life threatening cases may mimic
TTH. The major differential diagnoses are listed in Table 2.
Examination and Investigations
Although diagnostic tests are widely used in patients with
TTH, they are seldom indicated unless alarming features such
as progressive headache, abnormal neurological findings and/
or marked treatment resistance are present. In addition to the
primary diagnosis, a careful history is very important to
uncover coexisting diseases such as depression or anxiety,17
which can complicate the outcome.
In TTH, the neurological examination should also include
manual palpation of the pericranial muscles, particularly the
temporal, masseteric, neck and sternocleidomastoid muscles,
and an evaluation of posture. Muscular trigger points can also
easily be identified. This will demonstrate any peripheral mus-
cular factor to the patient directly, and indicates the potential
benefit of physical training, posture correction, and relaxation
therapy.
In case of alarming features mentioned above, recent changes
in headache pattern, weight loss or marked weight increase,
personality or cognitive changes, blood samples and neuroimag-
ing with CT or MRI and a spinal tap should be undertaken.
EEG and neuroimaging of cervical and/or lumbal spine are
not indicated or recommended as the specificity in relation to
headache is poor and very often misleading for both patients
and the doctors.
TREATMENT
Is Non-Pharmacological Treatment Relevant for TTH-
Patient?
Non-pharmacological management should be considered for
all patients with TTH and is also widely used. Physical thera-
py is the most used non-pharmacological treatment of TTH
and includes active treatment strategies such as improvement
of posture, relaxation, exercise programs, combined with
4 | Headache | Month 2017
Headache Currents

Table 2.—Warning Symptoms, Possible Differential Diagnosis to Tension-Type Headache and Suggested Strategy (Any New Headache in an
Individual Patient Should Be Treated With Caution)

Warning Feature Differential Diagnosis Suggested Investigation

Thunderclap-abrupt onset of a new headache
Atypical aura
(>1 hour or motorsymptoms)
New headache in a patient older than
40 years
New headache in a pre-pubertal child
Nausea and progressive headache frequency
Intense headache aggravated by physical
activity and accompanying symptoms
Progressive headache accompanied by focal
neurological or cognitive symptoms or
signs
Progressive pulsating headache, tinnitus and
transient visual disturbances
Subarachnoid haemorrhage
Migraine, TIA, or stroke
Intracranial tumor or temporal arteritis
Intracranial tumor
Medication overuse headache
Migraine
Intracranial space-occypying lesion
Idiopathic intracranial hypertension
CT-C and MRA, and if negative a lumbar
puncture
Detailed history, CT-C or MRI
Detailed history, CT-C or MRI as well as blood
tests
Detailed history, and eventually MRI
Detailed medication registration and a new
neurological examination
Detailed history and diagnostic diary
Detailed examination and CT-C or MRI
MRA and MRV and if normal lumbar puncture
and opening pressure

ultrasound and electrical stimulation.18,19 A controlled study
combined various techniques such as massage, relaxation, and
home-based exercises but noted only a modest effect.20 Spinal
manipulation has no effect for the treatment of episodic
TTH.21 Oromandibular treatment with occlusal splints is
often recommended but has not yet been tested in trials of
reasonable quality and cannot be recommended in gener-
al.22,23 There are also conflicting results regarding the efficacy
of acupuncture for the treatment of TTH.19
Psychological treatment strategies have achieved reasonable
scientific support for effectiveness.24 Relaxation training is a
self-regulation strategy that provides patients with the ability
to consciously reduce muscle tension and autonomic arousal
that can precipitate and result from headaches. In electromyo-
graphic (EMG), biofeedback, patients are presented with an
auditory or visual display of electrical activity of the muscles
in the face, neck, or shoulders.19,24 This feedback helps the
patients to develop control over pericranial muscle tension. It
is most likely that cognitive changes (ie, self-efficacy) supple-
ment the reductions in muscle tension and thus account for
the improvement in TTH with EMG biofeedback. Cognitive-
behavioral therapy (stress management) aims to teach the
patient to identify thoughts and beliefs that generate stress
and aggravate headaches.24 The exact degree of effect of psy-
chological treatment strategies is difficult to estimate, but
cognitive-behavioral therapy has been found comparable with
treatment with tricyclic antidepressants, while a combination
of the two treatments seemed to be more effective than either
treatment alone.25
How Can the Acute Attack of TTH Be Treated?
Acute pharmacological therapy refers to the treatment of
individual attacks of headache in patients with episodic and
chronic TTH. Most headaches in patients with episodic TTH
are mild to moderate and the patients often can self-manage
using simple analgesics. The efficacy of the simple analgesics
tends to decrease with increasing frequency of the headaches.
In patients with chronic TTH, simple analgesics are usually
ineffective and should be used with caution because of the
risk of MOH at a regular intake of simple analgesics above 14
days a month or opioid combination analgesics above 9 days
a month.2 Other interventions such as non-drug treatments
and prophylactic pharmacotherapy should therefore always be
considered.
Most randomized placebo-controlled trials have demonstrat-
ed that aspirin in doses of 500 and 1000 mg and acetamino-
phen 1000 mg are effective in the acute therapy of TTH.26
There is no consistent difference in efficacy between aspirin
and acetaminophen. The non-steroidal anti-inflammatory
drugs (NSAIDs), ibuprofen in doses of 200-400 mg, naproxen
sodium 375-550 mg, ketoprofen 25-50 mg, and diclofenac
potassium 50-100 mg have all been demonstrated more effec-
tive than placebo in acute TTH. Most, but not all, compara-
tive studies report that the above-mentioned NSAIDs are
more effective than acetaminophen and aspirin.
The combination of analgesics with caffeine, codeine, seda-
tives, or tranquilizers is frequently used and increased efficacy
when adding caffeine to aspirin or ibuprofen has been
reported. However, combination analgesics should generally be
5 | Headache | Month 2017
avoided because of the risk of dependency, abuse, and chroni-
fication of the headache to MOH. Triptans do not have a
clinically relevant effect, and muscle relaxants are not effective
in TTH.
To summarize, simple analgesics are the mainstays in the
acute therapy of TTH. Acetaminophen 1000 mg may be rec-
ommended as drug of first choice because of better gastric
side effect profile.19 If acetaminophen is not effective, ibupro-
fen 400 mg in restricted dosages (maximum 2-3 days/week)
may be recommended.19 Physicians should always be aware of
the risk of developing MOH as a result of frequent and exces-
sive use of analgesics in acute therapy. Triptans, muscle relax-
ants, and opioids do not have a role in the treatment of
TTH.
What Is the Best Pharmacological Prevention of TTH?
Prophylactic pharmacotherapy should be considered or
added to patients with chronic TTH who has limited response
to non-pharmacological treatment. The tricyclic antidepressant
amitriptyline is the only drug that has proven to be effective
in several controlled trials in TTH.19,27 Bendtsen et al
reported that amitriptyline 75 mg/day reduced headache index
(duration 3 intensity) with 30% compared with placebo.26
The effect is long-lasting (at least 6 months) and not related
to the eventual presence of depression. It is important that
patients are properly informed about it as an original antide-
pressant but it has an independent action on pain at much
lower dosages irrespective of its antidepressant effect. Amitrip-
tyline should always be started at low dosages (10 mg/day)
and titrated by 10 mg weekly until the patient has either
good therapeutic effect or significant side effects are encoun-
tered. The maintenance dose is usually 30 to 70 mg daily
administered 1 to 2 hours before bedtime.19 A significant
effect of amitriptyline may be observed already in the first
week on the therapeutic dose. It is therefore advisable to
change to other prophylactic therapy, if the patient does not
respond after 4 weeks on maintenance dose. The side effects
of amitriptyline are mainly dose dependent and include dry
mouth, drowsiness, dizziness, obstipation, and weight gain.
The tricyclic antidepressant clomipramine and the tetracy-
clic antidepressants maprotiline and mianserin have been
reported more effective than placebo, while the selective sero-
tonin reuptake inhibitors (SSRIs) are ineffective.19,29 Interest-
ingly, antidepressants with action on both serotonin and
noradrenaline seem to be as effective as amitriptyline with the
advantage that they are tolerated in lower doses than needed
for the treatment of a concomitant depression.29 Thus, the
noradrenergic and specific serotonergic antidepressant mirtaza-
pine 30 mg/day reduced headache index by 34% more than
placebo in difficult to treat patients, including patients who
had not responded to amitriptyline.27 Their mechanisms of
action is probably via a reduction or modification of the
Headache Currents
central sensitization, which is prominent in chronic TTH.28,29
The serotonin and noradrenaline reuptake inhibitor venlafax-
ine 150 mg/day reduced headache days from 15 to 12 per
month.30 However, the latter study is difficult to compare
with the other studies mentioned, because it was a small paral-
lel group study performed in a mixed group of patients with
either frequent episodic or chronic TTH.30 Tizanidine, botuli-
num toxin, propranolol, or valproic acid are ineffective and
not recommended for the prophylactic treatment of TTH.
To summarize, the initial approach to prophylactic therapy
of chronic TTH is non-pharmacological strategies and second
the use of amitriptyline. Due to the risk of MOH, concomi-
tant use of daily analgesics should be avoided. If the patient
does not respond to amitriptyline, mirtazapine could be
attempted. Venlafaxine could be considered in patients with
concomitant depression, if tricyclics or mirtazapine are not
tolerated. The physician should keep in mind that the efficacy
of preventive drug therapy in TTH is often modest, and that
the efficacy should outweigh the side effects. Discontinuation
should be attempted every 6-12 months.
Are There Other Strategies That Should Be Included in TTH-
Treatment?
Overall there are 2 major targets for future treatment strate-
gies: (a) to identify the source of peripheral nociception to
prevent the development of central sensitization and thereby
prevent the conversion of episodic into chronic TTH, and (b)
to reduce the central sensitization that already is established in
chronic TTH.30,31
As neither non-pharmacological nor pharmacological man-
agement is highly efficient, it is usually recommended to com-
bine multiple strategies although proper evidence hereof is
lacking. It is, therefore, reassuring that the first study that has
evaluated the efficacy of a multidisciplinary headache clinic
reports positive results.12,32,33 Treatment results for all patients
discharged within one year were evaluated. Patients with epi-
sodic TTH demonstrated a 50% reduction in frequency, 75%
reduction in intensity, and 33% in absence rate, whereas
chronic TTH patients responded with 32%, 30%, and 40%
reductions, respectively.12,32,33
What Is the Future of TTH?
As TTH is the most prevalent but the least studied type of
headache, TTH still has to fight for its existence and accep-
tance. A detailed interview of all patients and systematic use
of headache diaries in the clinic may also reveal their milder
TTHs and better differentiate TTH from migraines. The
mechanisms in TTH are probably very similar to low back
pain and other generalized pain disorders in contrast to
migraine and cluster headache. A close collaboration with pain
scientists may lead to significant progress in the future under-
standing and the treatment of TTH.
6 | Headache | Month 2017
Increased scientific awareness and a good pathophysiological
model for TTH are urgently needed especially for develop-
ment of a mechanism-based specific treatment. Such new
treatment, that is, a “triptan” for TTH will be ground break-
ing not only for the headache field but also for generalized
myofascial pain. It will also change the general view on TTH
and provide significant relief to the tremendous number of
patients that are burdened from TTH in a global perspective.
KEY CONCLUSIONS
 TTH is the most frequent primary headache and
equals migraine in costs
 Patients with coexisting migraine regard TTH as
their normal headache and often under report this
type in contrast to their migraines
 TTH is a featureless bilateral, pressing, mild to mod-
erate headache without associated symptoms
 The most frequent differential diagnoses are
migraine without aura and MOH
 Most clinical headache patients suffer from both
TTH and migraine and both diagnosis should be
applied according to the IHS classification
 A headache diary, a detailed history, and examina-
tions are mandatory
References
1. Jensen R, Stovner LJ. Epidemiology and comorbidity of head-
ache. Lancet Neurol. 2008;7:354-361.
2. International Headache Society, Headache Classification Com-
mittee. The international classification of headache disorders, 3rd
edition (beta version). Cephalalgia. 2013;33:629-808.
3. Bendtsen L, Jensen R. Tension-type headache: The most com-
mon, but also the most neglected, headache disorder. Curr Opin
Neurol. 2006;19:305-309.
4. GBD 2015 Disease and Injury Incidence and Prevalence Collab-
orators. Global, regional, and national incidence, prevalence, and
years lived with disability for 310 diseases and injuries, 1990-
2015: A systematic analysis for the Global Burden of Disease
Study 2015. Lancet. 2016;388:1545-1602.
5. Andlin-Sobocki P, Jonsson B, Wittchen HU, Olesen J. Cost of disor-
ders of the brain in Europe. Eur J Neurol. 2005;12(Suppl. 1):1-27.
6. Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Has the
prevalence of migraine and tension-type headache changed over a
12-year period? A Danish population survey. Eur J Epidemiol.
2005;20:243-249.
7. Steiner TJ, Stovner LJ, Katsarava Z, et al. The impact of head-
ache in Europe: Principal results of the Eurolight project.
J Headache Pain. 2014;15:31.
Headache Currents
8. Lyngberg AC, Rasmussen BK, Jorgensen T, Jensen R. Prognosis
of migraine and tension-type headache: A population-based fol-
low-up study. Neurology. 2005;65:580-585.
9. Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Secular
changes in health care utilization and work absence for migraine
and tension-type headache: A population based study. Eur J Epi-
demiol. 2005;20:1007-1014.
10. Allena M, Steiner TJ, Sances G, et al. Impact of headache disor-
ders in Italy and the public-health and policy implications: A
population-based study within the Eurolight Project. J Headache
Pain. 2015;16:100.
11. Tepper SJ, Dahl€of CG, Dowson A, et al. Prevalence and diagno-
sis of migraine in patients consulting their physician with a com-
plaint of headache: Data from the Landmark study. Headache.
2004;44:856-864.
12. Jensen R, Jensen R, Zeeberg P, Dehlendorff C, Olesen J. Predic-
tors of outcome of the treatment programme in a multidisciplin-
ary headache centre. Cephalalgia. 2010;30:1214-1224.
13. Diamond S. Coexisting migraine and tension-type headache.
Arch Neurol. 1993;50:795.
14. Gaul C, van Doorn C, Webering N, et al. Clinical outcome of a
headache-specific multidisciplinary treatment program and adher-
ence to treatment recommendations in a tertiary headache center:
An observational study. J Headache Pain. 2011;12:475-483.
15. Rasmussen BK, Jensen R, Olesen J. A population-based analysis
of the diagnostic criteria of the International Headache Society.
Cephalalgia. 1991;11:129-134.
16. Jensen R, Tassorelli C, Rossi P, et al. A basic diagnostic headache
diary (BDHD) is well accepted and useful in the diagnosis of
headache. A multicentre European and Latin American study.
Cephalalgia. 2011;31:1549-1560.
17. Janke EA, Holroyd KA, Romanek K. Depression increases onset
of tension-type headache following laboratory stress. Pain. 2004;
111:230-238.
18. Jensen R, Roth JM. Physiotherapy of tension-type headaches. In:
Olesen J, Goadsby PJ, Ramadan N, Tfelt-Hansen P, Welch KM,
eds. The Headaches, 3rd ed. Philadelphia: Lippincott Williams
Wilkins; 2005: 721-6J.
19. Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G,
Schoenen J. EFNS guideline on the treatment of tension-type
headache - report of an EFNS task force. Eur J Neurol. 2010;17:
1318-1325.
20. Torelli P, Jensen R, Olesen J. Physiotherapy for tension-type
headache: A controlled study. Cephalalgia. 2004;24:29-36.
21. Bove G, Nilsson N. Spinal manipulation in the treatment of epi-
sodic tension-type headache: A randomized controlled trial.
JAMA. 1998;280:1576-1579.
22. List T, Jensen R. TMD: Old ideas and new concepts. Cephalalgia.
2017;333102416686302. doi: 10.1177/0333102416686302.
23. Graff-Radford SB, Canavan DW. Headache attributed to orofa-
cial/temporomandibular pathology. In: Olesen J, Goadsby PJ,
Ramadan N, Tfelt-Hansen P, Welch KM, eds. The Headaches,
3rd ed. Philadelphia: Lippincott Williams Wilkins; 2005:
102935.
24. Holroyd KA, Martin PR, Nash JM. Psychological treatments of
tension-type headache. In: Olesen J, Goadsby PJ, Ramadan N,
7 | Headache | Month 2017
Tfelt-Hansen P, Welch KM, eds. The Headaches, 3rd ed. Phila-
delphia: Lippincott Williams Wilkins; 2005:711-719.
25. Holroyd KA, O’Donnell FJ, Stensland M, Lipchik GL,
Cordingley GE, Carlson BW. Management of chronic tension-
type headache with tricyclic antidepressant medication, stress
management therapy, and their combination: A randomized con-
trolled trial. JAMA. 2001;285:2208-2215.
26. Steiner TJ, Lange R, Voelker M. Aspirin in episodic tension-type
headache: Placebo-controlled dose-ranging comparison with para-
cetamol. Cephalalgia. 2003;23:59-66.
27. Bendtsen L, Jensen R, Olesen J. A non-selective (amitriptyline),
but not a selective (citalopram), serotonin reuptake inhibitor is
effective in the prophylactic treatment of chronic tension-type
headache. J Neurol Neurosurg Psychiatry. 1996;61:285-290.
28. Bendtsen L, Jensen R. Mirtazapine is effective in the prophylactic
treatment of chronic tension-type headache. Neurology. 2004;62:
1706-1711.
Headache Currents
29. Banzi R, Cusi C, Randazzo C, Sterzi R, Tedesco D, Moja L.
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-
norepinephrine reuptake inhibitors (SNRIs) for the prevention of
tension-type headache in adults. Cochrane Database Syst Rev.
2015; (5):CD011681.
30. Zissis NP, Harmoussi S, Vlaikidis N, et al. randomized, double-
blind, placebo-controlled study of venlafaxine XR in out-patients
with tension-type headache. Cephalalgia. 2007;27:315-324.
31. Bendtsen L. Central sensitization in tension-type headache -
possible pathophysiological mechanisms. Cephalalgia. 2000;20:
486-508.
32. Zeeberg P, Olesen J, Jensen R. Efficacy of multidisciplinary treat-
ment in a tertiary referral headache centre. Cephalalgia. 2005;25:
1159-1167.
33. Wallasch TM, Angeli A, Kropp P. Outcomes of a headache-
specific cross-sectional multidisciplinary treatment program.
Headache. 2012;52:1094-1105.