Tension Headache Characteristics and Diagnosis

Clinical Characteristics

Tension-type headaches are typically bilateral with pressing, tightening, or non-pulsatile character, and are usually mild to moderate in severity, according to the American Academy of Family Physicians 1, 2
The pain is often bilateral, affecting both sides of the head, and is not aggravated by routine physical activity, as noted by the American Academy of Family Physicians 1
Associated symptoms generally lack nausea/vomiting, though may have anorexia, and typically don't have both photophobia and phonophobia, as reported by the American Academy of Family Physicians 1, 2

Missed meals can trigger tension headaches, as stated by the American Academy of Family Physicians 1

Tension-type headaches must be distinguished from migraines, which often present with unilateral location, throbbing character, moderate to severe intensity, worsening with activity, and associated symptoms like nausea/vomiting and photophobia/phonophobia, according to the American Academy of Family Physicians and Nature Reviews Neurology 2, 3
Cluster headaches feature strictly unilateral, severe pain lasting 15-180 minutes with ipsilateral autonomic symptoms like lacrimation, nasal congestion, and ptosis, as described by Nature Reviews Neurology 2, 3

Secondary headaches should always be considered and ruled out, particularly when there are "red flags" such as sudden onset, fever, focal neurological symptoms, or onset after age 50, as advised by Nature Reviews Neurology 3, 4
Routine neuroimaging is not indicated for typical tension-type headaches without concerning features on history or examination, as recommended by Nature Reviews Neurology 4, 5