Submitted Successfully!
To reward your contribution, here is a gift for you: A free trial for our video production service.
Thank you for your contribution! You can also upload a video entry or images related to this topic.
Version Summary Created by Modification Content Size Created at Operation
1 -- 1741 2023-03-21 18:36:54 |
2 format correct Meta information modification 1741 2023-03-22 01:48:39 |

Video Upload Options

Do you have a full video?


Are you sure to Delete?
If you have any further questions, please contact Encyclopedia Editorial Office.
Baglioni, V.; Orecchio, S.; Esposito, D.; Faedda, N.; Natalucci, G.; Guidetti, V. Tension-Type Headache in Children and Adolescents. Encyclopedia. Available online: (accessed on 15 April 2024).
Baglioni V, Orecchio S, Esposito D, Faedda N, Natalucci G, Guidetti V. Tension-Type Headache in Children and Adolescents. Encyclopedia. Available at: Accessed April 15, 2024.
Baglioni, Valentina, Silvia Orecchio, Dario Esposito, Noemi Faedda, Giulia Natalucci, Vincenzo Guidetti. "Tension-Type Headache in Children and Adolescents" Encyclopedia, (accessed April 15, 2024).
Baglioni, V., Orecchio, S., Esposito, D., Faedda, N., Natalucci, G., & Guidetti, V. (2023, March 21). Tension-Type Headache in Children and Adolescents. In Encyclopedia.
Baglioni, Valentina, et al. "Tension-Type Headache in Children and Adolescents." Encyclopedia. Web. 21 March, 2023.
Tension-Type Headache in Children and Adolescents

In pediatric neurology, tension-type headache (TTH) represents a very common type of primary headache during the pediatric age. Despite the high prevalence of TTH, this diagnosis is often underestimated in childhood, with relevant difficulties in the differential diagnosis of TTH from secondary and primary headache manifestations. Even among primary headaches, a clinical overlap is not so infrequent in children: migraine attacks could present tension headache-like features while tension-type headaches may display migraine-like symptoms as well. Several variables play a role in the complex trajectory of headache evolution, such as hormonal changes during adolescence, triggers and genetic and epigenetic factors. 

primary headache tension-type headache pediatric neurology

1. Introduction

Primary headache is one of the ten most disabling medical conditions in the general population [1] and is one of the most common causes of pain among children and adolescents, with a relevant impact on the quality of life of patients and their families [2].
Headache in children and adolescents is the third most common disease-related cause of school absenteeism and can lead to impairment in the quality of life, both in family life and in leisure activities and school/work productivity [3]. Furthermore, affected young people may be at greater risk of developing both further physical problems in adulthood and psychopathological problems such as anxiety and depression [4][5][6]. In particular, it was recently estimated that children with a headache diagnosis cause considerable excess costs in public health care systems (up to 400 € per capita) [3].
Tension-type headache (TTH) is one of the most prevalent neurological disorders in the world [7][8]. Despite its relevance, this condition in pediatric neurology is often underestimated or misdiagnosed, due to its vague symptoms in childhood, with significant difficulties in the differential diagnosis with other primary or secondary headaches. Nevertheless, it is a type of primary headache that is relatively less researched in the literature, probably because of its less disabling nature than other types of primary headaches (e.g., migraine and cluster headache) [1][9][10][11].
During the pediatric age, there is often an overlap of symptoms between TTH and migraine; moreover, in the transition from childhood to adulthood, the clinical presentation of headaches often changes, usually from migraine to TTH or vice versa [6].
Thus, a timely and effective diagnostic framework and therapeutic approach is also aimed to prevent the chronicization of headaches into more severe and highly disabling forms.

2. Developmental Trajectories in Children and Adolescents

Studying the progression over time of primary headaches is important, both from a clinical and a public health perspective. As previously mentioned, the characteristics of early-onset primary headache tend to change over time, with possible switching from one headache form to another [6].
Many studies have investigated the evolution of headache from childhood to adulthood, most of them being prospective studies on follow-up pediatric populations. Overall, approximately 25% of migraine patients were found to switch to TTH and vice versa [6]. The presence of neurodevelopmental disorders correlates with the persistence of the headache [6]. Furthermore, the male gender is more associated with remission. The consequent predominance of females during adolescence could be, in part, explained by the hormonal changes that may influence the pathophysiology of pediatric migraine, as in adult migraine. In this regard, some authors found an increased risk of headaches was found in girls who had menarche earlier [12][13][14][15], which could be explained by a common pathogenic factor such as estrogen sensitivity [16].
With aging, some triggers (such as stress) tend to be less frequent, while alcohol, smoking and neck pain usually become more prominent; a decrease in the frequency of some characteristics such as photophobia, phonophobia and vertigo was also observed [17].
In patients followed up for 10 years, it has been shown that headaches improve or regress in 60–80% of cases [18]. As for TTH specifically, it is more likely to improve in the transition from adolescence to adulthood than migraine [19].
A positive family history of headache was significantly more frequent in children with an early onset [19]. An early onset of the disease probably reflects a greater biological predisposition or increased susceptibility to specific environmental risk factors, thus potentially leading also to a worse prognosis [6][15].
Hormonal changes, different levels of stress exposure, life events and circumstances may be some of the factors that contribute to the change in the migraine phenotype over time [20][21][22]. Moreover, the prognosis of pediatric headache is adversely affected by initial diagnosis of migraine and by changes in the localization of the headache [23].
Primary headaches can indeed tend to chronicization. According to the ICHD-3 classification, chronic primary headache (CPH), tension-type or migraine-type, is defined by the presence of head pain on at least 15 days per month for more than 3 months [8].
There are little data available concerning CPH in the pediatric population and the ICHD-3 does not include notes for diagnosing pediatric CPH [8], so most of our knowledge comes from experience in adulthood.
The prevalence of CPH in children is estimated to be 0.78% to 1.5%. If the patient has been using regular and excessive headache medications for at least 3 months, the diagnosis of Medication-Overuse Headache should be considered [7]. It has been claimed that up to half of the subjects diagnosed with CPH are affected by this type of headache [24]. Most patients with this disorder improve after discontinuation of the abused drug and, moreover, respond better to prophylactic treatments.
Many studies suggest that medication abuse is lower in adolescents than in adults, this may be because adolescents are more likely to depend on their caregivers for access to medication [8][24].

3. Treatment Strategies

Given the high prevalence and the important impact on the quality of life of young patients, tension headache requires adequate management. Treatment of TTH is based on pain resolution (acute therapy) and the prevention of recurrence of headache episodes (chronic or prophylactic therapy).
Literature data concerning the treatment of primary headaches in childhood are still scarce, especially as regards TTH. Furthermore, there are no guidelines about the developmental age. In clinical practice, therapeutic strategies are based both on non-pharmacological therapies, including lifestyle modifications, as well as on pharmacological therapy [25].
The therapeutic choice must be weighed after a careful assessment of the patient and the impact that the headache has on the patient’s quality of life. Therefore, non-pharmacological approaches should be considered as first-line treatments.
Lifestyle recommendations should play a crucial role in headache management. Children and adolescents suffering from primary headache should be advised to maintain a balanced lifestyle including regular sleep and meals, adequate hydration, limited caffeine consumption, not smoking, very limited alcohol consumption and regular physical activities, which should be promoted to prevent metabolic disorders and to avoid stressors. In addition, the use of video games and electronic devices should be limited [26].
Among the other non-pharmacological approaches, behavioral treatments include relaxation techniques, biofeedback, cognitive behavioral therapy (CBT) or combinations of these treatments [27]. Relaxation-based therapy embraces interventions that focus on progressive muscle relaxation and similar strategies such as hypnosis. CBT comprises a multitude of interventions, such as family CBT, parent–operant strategies, multicomponent CBT and pain coping skills [27]. Finally, biofeedback techniques help patients to control functions of their autonomic nervous system (e.g., heart rate, blood pressure, muscle tension) by observing monitoring devices and reproducing desired behaviors [28].
These techniques have demonstrated efficacy in the treatment of pediatric headache [29] and are well accepted by patients and parents because of the very low risk of adverse effects in comparison with pharmacological treatments [30]. A recent interdisciplinary multimodal therapy program (which involved eight modules regarding headache education, stress management, relaxation techniques, physical activation, mindfulness and sensory training) showed reduced headache frequency and disability at six and twelve months after completion [31]. The best-known behavioral treatments for TTH are electromyographic (EMG) biofeedback and thermal biofeedback [32][33], which have shown greater responses in children than in adults [28].
Psychosocial stressors related to social and economic status, family conditions and academic performance, as well as psychiatric and somatic comorbidities and behavioral problems, can contribute to or worsen TTH. When these dynamics are detected, a biopsychosocial approach to care should be adopted [34][35]. Such an approach may also be useful considering that children with TTH in some cases live with negative parental relationships or in disadvantaged family environments from emotional, economic, or socio-cultural points of view [35][36]. Management of stressors, anxiety and mood disorders should take precedence over pharmacological management of headache [37].
Acute pharmacological therapy is based on paracetamol and NSAIDs. In particular, paracetamol should be the first-line medicine, feasible even for the youngest [38]. On the other hand, despite being recommended for the treatment of pediatric migraine, ibuprofen has not obtained the same consensus in TTH [37].
Other NSAIDs (ketoprofen, diclofenac, naproxen) have shown efficacy in the treatment of headache in adults, but definitive data on their use in pediatric TTH are not available [39].
Prophylactic therapy aims to reduce the frequency, intensity and duration of headache episodes, with an improvement in the quality of life. Pharmacological approaches should be considered only if non-pharmacological therapies have not been effective [37][38][40].
There are currently no clear recommendations for the prophylactic treatment of pediatric patients with primary headache [41]; the use of preventive drugs in pediatric tension headaches is therefore completely “off-label” [40][42].
Amitriptyline, in relatively low doses, is generally the first choice for TTH prophylaxis [43]. Common side effects include drowsiness, weight gain, dry mouth, dizziness, sweating, constipation and increased appetite [10].
In a prospective double-blind study of patients aged 14 to 76 years, valproate was superior to placebo in the prophylactic treatment of chronic primary headache (albeit more so in chronic migraine than in chronic tension-type headache) [44].
Tolerability issues of valproate include dizziness, abdominal pain, nausea, somnolence, tremor, impotence and hair loss [44].
More recently, the efficacy of magnesium as a prophylactic treatment for TTH has been considered, with a significant improvement in symptoms and reduction in the frequency of attacks, thus improving the disabling aspects of the headache itself [40][45]. Table 1 summarizes the treatment approaches for TTH in children and adolescents.
Table 1. Tiered treatment approaches to tension-type headache in children and adolescents. CBT, cognitive behavioral therapy; h, hour; y, year.
Treatment Approaches   Ref.
First line:
Lifestyle modifications
  • Hydration (recommended 4–8 y, 1.2 L; 9–13 y, 1.6–1.8 L; 14–18 y, 1.8–2.6 L)
  • Sleep (recommended at least 8 h/night)
  • Diet (consistent, well-balanced meals, limitation of caffeine)
  • Stress avoidance
  • Electronic devices (avoid or limit screen time)
  • Regular Exercise
  • Avoidance of smoking, alcohol drinking, other abuse substances
Second line:
Non-pharmacological treatments
  • Behavioral therapy (CBT, biofeedback, stress management techniques)
  • Other complementary treatments
Third line: Pharmacological therapy Acute/abortive treatment:
  • Paracetamol (15–20 mg/kg every 4–6 h; max. 90 mg/kg/day)
  • Ibuprofen (if <12 y, 10 mg/kg every 6–8 h; if >12 y, 400–600 mg every 6–8 h; max. 1800 mg/day)
  • Amitriptyline (1 mg/kg/day)
  • Valproate (10–20 mg/kg/day)
  • Magnesium (200–300 mg, twice per day)



  1. Vos, T.; Barber, R.M.; Bell, B.; Bertozzi-Villa, A.; Biryukov, S.; Bolliger, I.; Charlson, F.; Davis, A.; Degenhardt, L.; Dicker, D.; et al. Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability for 301 Acute and Chronic Diseases and Injuries in 188 Countries, 1990–2013: A Systematic Analysis for the Global Burden of Disease Study 2013. Lancet 2015, 386, 743–800.
  2. Swain, M.S.; Henschke, N.; Kamper, S.J.; Gobina, I.; Ottová-Jordan, V.; Maher, C.G. An International Survey of Pain in Adolescents. BMC Public Health 2014, 14, 447.
  3. Obermeier, V.; Murawski, M.; Heinen, F.; Landgraf, M.N.; Straube, A.; von Kries, R.; Ruscheweyh, R. Total Health Insurance Costs in Children with a Migraine Diagnosis Compared to a Control Group. J. Headache Pain 2021, 22, 140.
  4. Guidetti, V.; Galli, F.; Fabrizi, P.; Giannantoni, A.S.; Napoli, L.; Bruni, O.; Trillo, S. Headache and Psychiatric Comorbidity: Clinical Aspects and Outcome in an 8-Year Follow-up Study. Cephalalgia Int. J. Headache 1998, 18, 455–462.
  5. Wöber, C.; Wöber-Bingöl, C. Clinical Management of Young Patients Presenting with Headache. Funct. Neurol. 2000, 15 (Suppl. S3), 89–105.
  6. Antonaci, F.; Voiticovschi-Iosob, C.; Di Stefano, A.L.; Galli, F.; Ozge, A.; Balottin, U. The Evolution of Headache from Childhood to Adulthood: A Review of the Literature. J. Headache Pain 2014, 15, 15.
  7. Mier, R.W.; Dhadwal, S. Primary Headaches. Dent. Clin. N. Am. 2018, 62, 611–628.
  8. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd Edition (Beta Version). Cephalalgia Int. J. Headache 2013, 33, 629–808.
  9. Deuschl, G.; Beghi, E.; Fazekas, F.; Varga, T.; Christoforidi, K.A.; Sipido, E.; Bassetti, C.L.; Vos, T.; Feigin, V.L. The Burden of Neurological Diseases in Europe: An Analysis for the Global Burden of Disease Study 2017. Lancet Public Health 2020, 5, e551–e567.
  10. Ashina, S.; Mitsikostas, D.D.; Lee, M.J.; Yamani, N.; Wang, S.-J.; Messina, R.; Ashina, H.; Buse, D.C.; Pozo-Rosich, P.; Jensen, R.H.; et al. Tension-Type Headache. Nat. Rev. Dis. Primer 2021, 7, 24.
  11. Genc, D.; Vaičienė-Magistris, N.; Zaborskis, A.; Şaşmaz, T.; Tunç, A.Y.; Uluduz, D.; Wöber, C.; Wöber-Bingöl, Ç.; Steiner, T.J. The Burden Attributable to Headache Disorders in Children and Adolescents in Lithuania: Estimates from a National Schools-Based Study. J. Headache Pain 2021, 22, 24.
  12. MacGregor, E.A. Classification of Perimenstrual Headache: Clinical Relevance. Curr. Pain Headache Rep. 2012, 16, 452–460.
  13. Aegidius, K.L.; Zwart, J.-A.; Hagen, K.; Dyb, G.; Holmen, T.L.; Stovner, L.J. Increased Headache Prevalence in Female Adolescents and Adult Women with Early Menarche. The Head-HUNT Studies. Eur. J. Neurol. 2011, 18, 321–328.
  14. Lieba-Samall, D.; Wöberl, C.; Frantall, S.; Brannathl, W.; Schmidtl, K.; Schrolnbergerl, C.; Wöber-Bingöll, Ç.; Group, P. Study Headache, Menstruation and Combined Oral Contraceptives: A Diary Study in 184 Women with Migraine. Eur. J. Pain 2011, 15, 852–857.
  15. Kröner-Herwig, B.; Vath, N. Menarche in Girls and Headache—A Longitudinal Analysis. Headache J. Head Face Pain 2009, 49, 860–867.
  16. Martin, V.T.; Behbehani, M. Ovarian Hormones and Migraine Headache: Understanding Mechanisms and Pathogenesis—Part I. Headache J. Head Face Pain 2006, 46, 3–23.
  17. Kelman, L. Migraine Changes with Age: IMPACT on Migraine Classification. Headache J. Head Face Pain 2006, 46, 1161–1171.
  18. Bille, B. Migraine and Tension-Type Headache in Children and Adolescents. Cephalalgia Int. J. Headache 1996, 16, 78.
  19. Guidetti, V.; Galli, F. Evolution of Headache in Childhood and Adolescence: An 8-Year Follow-Up. Cephalalgia Int. J. Headache 1998, 18, 449–454.
  20. Tietjen, G.E. Childhood Maltreatment and Headache Disorders. Curr. Pain Headache Rep. 2016, 20, 26.
  21. Faria, V.; Erpelding, N.; Lebel, A.; Johnson, A.; Wolff, R.; Fair, D.; Burstein, R.; Becerra, L.; Borsook, D. The Migraine Brain in Transition: Girls vs. Boys. Pain 2015, 156, 2212–2221.
  22. Malter Cohen, M.; Jing, D.; Yang, R.R.; Tottenham, N.; Lee, F.S.; Casey, B.J. Early-Life Stress Has Persistent Effects on Amygdala Function and Development in Mice and Humans. Proc. Natl. Acad. Sci. USA 2013, 110, 18274–18278.
  23. Evans, R.W.; Mathew, N.T. Handbook of Headache; Lippincott Williams & Wilkins: Philadelphia, PA, USA, 2005; ISBN 978-0-7817-5223-7.
  24. Lipton, R.B.; Manack, A.; Ricci, J.A.; Chee, E.; Turkel, C.C.; Winner, P. Prevalence and Burden of Chronic Migraine in Adolescents: Results of the Chronic Daily Headache in Adolescents Study (C-DAS): May 2011. Headache J. Head Face Pain 2011, 51, 693–706.
  25. Parisi, P.; Papetti, L.; Spalice, A.; Nicita, F.; Ursitti, F.; Villa, M.P. Tension-Type Headache in Paediatric Age. Acta Paediatr. 2011, 100, 491–495.
  26. Raucci, U.; Boni, A.; Evangelisti, M.; Della Vecchia, N.; Velardi, M.; Ursitti, F.; Terrin, G.; Di Nardo, G.; Reale, A.; Villani, A.; et al. Lifestyle Modifications to Help Prevent Headache at a Developmental Age. Front. Neurol. 2021, 11, 618375.
  27. Palermo, T.M.; Eccleston, C.; Lewandowski, A.S.; de C Williams, A.C.; Morley, S. Randomized Controlled Trials of Psychological Therapies for Management of Chronic Pain in Children and Adolescents: An Updated Meta-Analytic Review. Pain 2010, 148, 387–397.
  28. Sarafino, E.P.; Goehring, P. Age Comparisons in Acquiring Biofeedback Control and Success in Reducing Headache Pain1. Ann. Behav. Med. 2000, 22, 10–16.
  29. Andrasik, F.; Larsson, B.; Grazzi, L. Biofeedback Treatment of Recurrent Headaches in Children and Adolescents. In Headache and Migraine in Childhood and Adolescence; CRC Press: Boca Raton, FL, USA, 2001; ISBN 978-0-429-21805-7.
  30. Andrasik, F.; Grazzi, L.; Usai, S.; Bussone, G. Pharmacological Treatment Compared to Behavioural Treatment for Juvenile Tension-Type Headache: Results at Two-Year Follow-Up. Neurol. Sci. 2007, 28, S235–S238.
  31. Sobe, H.; Richter, M.; Berner, R.; von der Hagen, M.; Hähner, A.; Röder, I.; Koch, T.; Sabatowski, R.; Klimova, A.; Gossrau, G. Functional Improvement in Children and Adolescents with Primary Headache after an Interdisciplinary Multimodal Therapy Program: The DreKiP Study. J. Headache Pain 2022, 23, 109.
  32. Arndorfer, R.E.; Allen, K.D. Extending the Efficacy of a Thermal Biofeedback Treatment Package to the Management of Tension-Type Headaches in Children. Headache J. Head Face Pain 2001, 41, 183–192.
  33. Grazzi, L.; Andrasik, F.; D’Amico, D.; Leone, M.; Moschiano, F.; Bussone, G. Electromyographic Biofeedback-Assisted Relaxation Training in Juvenile Episodic Tension-Type Headache: Clinical Outcome at Three-Year Follow-Up the in of and for on with at Is an as By. Cephalalgia 2001, 21, 798–803.
  34. Polese, D.; Belli, A.; Esposito, D.; Evangelisti, M.; Luchetti, A.; Di Nardo, G.; Parisi, P.; Bruni, O. Psychological Disorders, Adverse Childhood Experiences and Parental Psychiatric Disorders in Children Affected by Headache: A Systematic Review. Neurosci. Biobehav. Rev. 2022, 140, 104798.
  35. Karwautz, A.; Wöber, C.; Lang, T.; Böck, A.; Wagner-Ennsgraber, C.; Vesely, C.; Kienbacher, C.; Wöber-Bingöl, C. Psychosocial Factors in Children and Adolescents with Migraine and Tension-Type Headache: A Controlled Study and Review of the Literature. Cephalalgia 1999, 19, 32–43.
  36. Aromaa, M.; Sillanpää, M.; Rautava, P.; Helenius, H. Pain Experience of Children with Headache and Their Families: A Controlled Study. Pediatrics 2000, 106, 270–275.
  37. Papetti, L.; Spalice, A.; Nicita, F.; Paolino, M.C.; Castaldo, R.; Iannetti, P.; Villa, M.P.; Parisi, P. Migraine Treatment in Developmental Age: Guidelines Update. J. Headache Pain 2010, 11, 267–276.
  38. Anttila, P. Tension-Type Headache in Childhood and Adolescence. Lancet Neurol. 2006, 5, 268–274.
  39. Haag, G. Letter to the Editor Concerning 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.
  40. Carotenuto, M.; Esposito, M.; Pascotto, A. Cefalea di tipo tensivo: Diagnostica e terapia. G. Neuropsichiatr. Dellà Evol. 2012, 32, 29–37.
  41. Papetti, L.; Salfa, I.; Battan, B.; Moavero, R.; Termine, C.; Bartoli, B.; Di Nunzio, F.; Tarantino, S.; Alaimo Di Loro, P.; Vigevano, F.; et al. Features of Primary Chronic Headache in Children and Adolescents and Validity of Ichd 3 Criteria. Front. Neurol. 2019, 10, 92.
  42. Seshia, S.S.; Abu-Arafeh, I.; Hershey, A.D. Tension-Type Headache in Children: The Cinderella of Headache Disorders! Can. J. Neurol. Sci. 2009, 36, 687–695.
  43. Hershey, A.D.; Powers, S.W.; Bentti, A.-L.; DeGrauw, T.J. Effectiveness of Amitriptyline in the Prophylactic Management of Childhood Headaches. Headache J. Head Face Pain 2000, 40, 539–549.
  44. Yurekli, V.A.; Akhan, G.; Kutluhan, S.; Uzar, E.; Koyuncuoglu, H.R.; Gultekin, F. The Effect of Sodium Valproate on Chronic Daily Headache and Its Subgroups. J. Headache Pain 2008, 9, 37–41.
  45. Grazzi, L.; Andrasik, F.; Usai, S.; Bussone, G. Magnesium as a Preventive Treatment for Paediatric Episodic Tension-Type Headache: Results at 1-Year Follow-Up. Neurol. Sci. Off. J. Ital. Neurol. Soc. Ital. Soc. Clin. Neurophysiol. 2007, 28, 148–150.
Subjects: Neurosciences
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to : , , , , ,
View Times: 213
Revisions: 2 times (View History)
Update Date: 22 Mar 2023