2026 Volume 53 Issue 1 Pages 23-29
Chronic tension-type headache (CTTH) is a multifactorial chronic pain disorder characterized by the interplay between central sensitization, psychological factors, and musculoskeletal abnormalities that lead to headache. Although its prevalence is lower than that of episodic tension-type headache, CTTH imposes a substantial disease burden, with impairments in quality of life and daily functioning comparable to those observed in chronic migraine.
The pathophysiology of CTTH extends beyond peripheral nociceptive input from the pericranial muscles and involves dysfunction of central pain processing systems, including impaired descending inhibitory pathways and enhanced central sensitization. Neuroimaging studies have demonstrated structural and functional alterations in pain-related brain regions, such as the anterior cingulate cortex and insula, supporting the role of central mechanisms in symptom persistence. Furthermore, CTTH is frequently associated with psychiatric comorbidities, including depression and anxiety, and somatic conditions, such as fibromyalgia, irritable bowel syndrome, and sleep disorders. These overlapping conditions may share a common pathophysiological basis within the framework of the central sensitivity syndrome.
Clinically, CTTH often overlaps with migraine, and these conditions may exist along a continuum rather than as distinct entities. This overlap has important therapeutic implications, as migraine-oriented preventive strategies may also benefit patients with CTTH.
In terms of management, acute pharmacological treatment with simple analgesics or nonsteroidal anti-inflammatory drugs plays a limited role because of modest efficacy and the risk of medication overuse headache. Preventive therapy is the cornerstone of treatment, with tricyclic antidepressants, particularly amitriptyline, representing the first-line option, supported by strong evidence from randomized controlled trials. Other agents, such as mirtazapine and venlafaxine, may also be beneficial, whereas selective serotonin reuptake inhibitors have limited efficacy in treating CTTH.
Non-pharmacological interventions are essential for comprehensive management of the disease. Physical therapy, including posture correction, muscle relaxation, and trigger point interventions, can reduce peripheral nociceptive input and may contribute to modulating central pain processing. Cognitive behavioral therapy, relaxation techniques, and stress management strategies play critical roles in addressing maladaptive pain perception and psychological stress.
Given the complex and multifactorial nature of CTTH, a multidisciplinary treatment approach is indispensable, particularly in refractory cases. Collaborative care involving physicians, nurses, psychologists, physiotherapists, and pharmacists enables individualized and patient-centered management of patients with CTTH. Multidisciplinary case conferences facilitate comprehensive assessments and optimize treatment strategies.
In conclusion, CTTH should not be regarded as a benign or minor headache disorder but rather as a chronic pain condition that requires an integrated biopsychosocial approach to treatment. The early implementation of preventive strategies and multidisciplinary care is crucial for improving clinical outcomes.
