Clinical Evidence Concise: A Publication of BMJ Publishing Group

Headache (Chronic Tension Type)


Am Fam Physician. 2003 Sep 1;68(5):929-930.

What are the effects of treatments?


Amitriptyline (Only Short-Term Evidence)

One systematic review of small, brief randomized controlled trials (RCTs) has found that amitriptyline versus placebo reduces duration and frequency of chronic tension-type headache.


Cognitive Behavior Therapy

One systematic review of three small RCTs and one subsequent RCT found limited evidence that cognitive behavior therapy reduced symptoms at six months compared with no treatment.



Two systematic reviews and one small RCT found insufficient evidence from heterogeneous RCTs that acupuncture was more effective than placebo in people with episodic or chronic tension-type headache. Many of the RCTs were of poor quality. Some of the RCTs may have lacked power to exclude a clinically important effect.

Botulinum Toxin; Relaxation and Electromyographic Biofeedback Therapy; Serotonin Reuptake Inhibitors; Tricyclic Antide-pressants Other Than Amitriptyline

We found insufficient evidence about the effects of these interventions.



Two RCTs found insufficient evidence about the effects of benzodiazepines compared with placebo or other treatments. Benzodiazepines are commonly associated with adverse effects if taken regularly.

Regular Acute Pain Relief Medication

We found no RCTs. We found insufficient evidence from one nonsystematic review of observational studies about benefits of common analgesics in people with chronic tension-type headache. It found that sustained frequent use of some analgesics was associated with chronic headache and reduced effectiveness of prophylactic treatment.


The 1988 International Headache Society criteria for chronic tension-type headache are headaches on 15 or more days a month (180 days per year) for at least six months; pain that is bilateral, pressing, or tightening in quality, of mild or moderate intensity, that does not prohibit activities and that is not aggravated by routine physical activity; presence of no more than one additional clinical feature (nausea, photophobia, or phonophobia) and no vomiting.1 Chronic tension-type headache is distinguished from chronic daily headache, which is simply a descriptive term for any headache type occurring for 15 days or more a month that may be caused by chronic tension-type headache as well as migraine or analgesic-associated headache.2 In contrast to chronic tension-type headache, episodic tension-type headache can last from 30 minutes to seven days and occurs for fewer than 180 days a year. Terms based on assumed mechanisms (muscle contraction headache, tension headache) are not operationally defined, and old studies that used these terms may have included people with many different types of headache. The greatest obstacle to the study of tension-type headache is the lack of any single proven specific or reliable, clinical, or biologic defining characteristic of the disorder.


The prevalence of chronic daily headache from a survey of the general population in the United States was 4.1 percent. One half of the people with chronic daily headache met the International Headache Society criteria for chronic tension-type headache.3 In a survey of 2,500 undergraduate students in the United States, the prevalence of chronic tension-type headache was 2 percent.4 The prevalence of chronic tension-type headache was 2.5 percent in a Danish population-based survey of 975 individuals.5

Etiology/Risk Factors

Tension-type headache is more prevalent in women (65 percent of cases in one survey).6 Symptoms begin before 10 years of age in 15 percent of people with chronic tension-type headache. Prevalence declines with age.7 There is a family history of some form of headache in 40 percent of people with chronic tension-type headache.8


The prevalence of chronic tension-type headache declines with age.7

search date: June 2002

Adapted with permission from Goadsby PJ. Headache (chronic tension type). Clin Evid Concise 2003; 9:269–70.



show all references

1. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain. Cephalalgia. 1988;8:1–96....

2. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology. 1996;47:871–5.

3. Schwartz BS, Stewart WF, Simon D, et al. Epidemiology of tension-type headache. JAMA. 1998;279:381–3.

4. Rokicki LA, Semenchuk EM, Bruehl S, et al. An examination of the validity of the HIS classification system for migraine and tension-type headache in the college student population. Headache. 1999;39:720–7.

5. Rasmussen BK, Jensen R, Olesen J. A population-based analysis of the diagnostic criteria of the International Headache Society. Cephalalgia. 1991;11:129–34.

6. Friedman AP, von Storch TJ, Merritt HH. Migraine and tension headaches: a clinical study of two thousand cases. Neurology. 1954;4:773–88.

7. Lance JW, Curran DA, Anthony M. Investigations into the mechanism and treatment of chronic headache. Med J Aust. 1965;2:909–14.

8. Russell MB, Ostergaard S, Bendtsen L, et al. Familial occurrence of chronic tension-type headache. Cephalalgia. 1999;19:207–10.

This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom.



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