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Tension headache - Causes and pathogenesis

Alexey Kryvenko, medical expert
Last reviewed: 04.07.2025

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Triggers of tension headaches

The most important triggering factor for tension headache attacks is emotional stress (acute - for episodic, chronic - for chronic tension headaches). When distracted or with positive emotions, the pain may weaken or disappear completely, but then return again.

Another provoking factor is the so-called muscular factor: postural tension (prolonged forced position of the neck and head while working at a desk, driving a car), etc. It is necessary to emphasize that emotional stress itself can be a factor causing and maintaining dysfunction of the pericranial muscles.

Pathogenesis of tension headache

Although tension headache was initially considered a predominantly psychogenic disorder, studies conducted in recent years have confirmed its neurobiological nature. It is assumed that both peripheral and central nociceptive mechanisms are involved in the origin of tension headache. In the pathogenesis of chronic tension headache, the leading role is given to increased sensitivity (sensitization) of pain structures and insufficient function of the descending inhibitory pathways of the brainstem.

Classification of tension headaches

In ICHD-2, tension headaches are divided into episodic, occurring no more than 15 days within 1 month (or less than 180 days within a year), and chronic - more than 15 days per month (or more than 180 days within a year), and episodic tension headaches are divided into frequent and infrequent. On average, according to European data, episodic tension headaches occur in 50-60% of the population, chronic tension headaches - in 3-5%. Most often, a doctor has to deal with two varieties: frequent episodic and chronic tension headaches. In addition, both forms are subdivided (depending on the presence or absence of muscle dysfunction) into subtypes "with tension" and "without tension of pericranial muscles".

2. Tension headache (ICGB-2, 2004)

2.1 Infrequent episodic tension-type headache.
- 2.1.1. Infrequent episodic tension-type headache, combined with tension (pain) of the pericranial muscles.
- 2.1.2. Infrequent episodic tension-type headache not associated with tension of the pericranial muscles.
2.2 Frequent episodic tension-type headache.
- 2.2.1. Frequent episodic tension-type headache, combined with tension of the pericranial muscles.
- 2.2.2. Frequent episodic tension-type headache not associated with tension of the pericranial muscles.
2.3. Chronic tension headache.
- 2.3.1. Chronic tension headache, combined with tension of the pericranial muscles.
- 2.3.2. Chronic tension headache not associated with tension of the pericranial muscles.
2.4 Possible tension headache.
- 2.4.1. Possible infrequent episodic tension-type headache.
- 2.4.2. Possible frequent episodic tension-type headache.
- 2.4.3. Possible chronic tension headache.

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