Link Found Between Tension Headaches and Anxiety, Depression

Patients with tension-type headaches had a significantly higher prevalence of anxiety and depression.

Researchers from Seoul, Korea found that patients with tension-type headaches (TTH) had a significantly higher prevalence of anxiety and depression compared with those without TTH. TTH symptoms were also worse in those who had anxiety or depression.

While previous clinic-based studies have found relationships between TTH and anxiety and depression,2,3 relationships between TTH and anxiety or depression from population-based studies are rare.

For this study, the researchers recruited 2695 participants aged 19-69 from the Korean Headache Sleep Study (KHSS), a cross-sectional, nationwide survey for headaches and symptoms of anxiety and depression among Korean people. They investigated the prevalence of TTH, anxiety, and depression in the general study population and in the 570 participants found to have TTH.

A diagnosis of TTH was based on criteria B through D for infrequent TTH (code 2.1) in the third edition beta version of the International Classification of Headache Disorders (ICHD-3 beta). Headache intensity was measured with the visual analogue scale (VAS) and the Headache Impact Test-6 (HIT-6). Anxiety was measured with the Goldberg Anxiety Scale (GAS) and depression was diagnosed with the Patient Health Questionnaire-9.

The researchers found that:

  • In the total study population, the rate of anxiety was 9.9%, the rate of depression was 4.3%, and the rate of TTH was 21.2%.
  • Among participants with TTH, 9.5% had anxiety, 4.2% had depression, and these rates were higher than in participants without headaches.
  • VAS scores for headache intensity and HIT-6 scores were significantly higher in participants with TTH as well as anxiety or depression compared with participants that had neither anxiety or depression.

“Our study revealed that a small but significant proportion of participants with TTH also had anxiety and depression, which was significantly higher than that of non-headache participants. Furthermore, prevalence of anxiety was increased in participants with more frequent TTH,” wrote Min Kyung Chu, MD, PhD, from the Department of Neurology at the Kangnam Sacred Heart Hospital, Hallym University College of Medicine, in Seoul, Korea, and colleagues. “Therefore, our study reaffirms [the] relationship between psychological disorders (anxiety or depression) and TTH.”

The researchers also noted that in this study, the prevalence of anxiety and depression in the total sample was slightly higher than the prevalence in participants with TTH. “Although we cannot suggest [the] exact cause for these discrepancies, relative high prevalence rate of anxiety and depression of migraine patients could affect our results,” they wrote.4

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The researchers concluded that their findings “suggest that the proper diagnosis and treatment of anxiety and depression are needed for the improved management of TTH.”

Limitations & Disclosures

  • TTH was diagnosed in face-to-face interviews using questionnaires. Although these diagnoses were validated by comparing the diagnoses made by neurologists in an additional phone interview, it is possible that some participants were misdiagnosed.
  • The lack of significant findings in subgroup analyses could be due to a limited sample size.
  • Variables such as employment status, occupation, social class, income, and marital status were not included or adjusted for in the analysis.
  • This study did not adjust for chronic pain disorders such as fibromyalgia. Because chronic pain disorders are potentially important confounding factors in psychiatric comorbidities, further research is necessary to study the relationship between chronic pain disorders and anxiety and/or depression in patients with headaches.


  1. Song T-J, Cho S-J, Kim W-J, Yang KI, Yun C-H, Chu MK. Anxiety and Depression in Tension-Type Headache: A Population-Based Study. PLoS ONE. 2016;11(10):e0165316. doi:10.1371/journal.pone.0165316.
  2. Puca F, Genco S, Prudenzano MP, Savarese M, Mussone G, D’Amico D, et al. Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy. The Italian Collaborative Group for the Study of Psychopathological Factors in Primary Headaches. Cephalalgia. 1999;19:159–164. doi:10.1046/j.1468-2982.1999.1903159.
  3. Holroyd KA, Stensland M, Lipchik GL, Hill KR, O’Donnell FS, Cordingley G. Psychosocial correlates and impact of chronic tension-type headaches. Headache. 2000;40:3–16. doi:10.1046/j.1526-4610.2000.00001.
  4. Song TJ, Cho SJ, Kim WJ, Yang KI, Yun CH, Chu MK. Anxiety and depression in probable migraine: A population-based study. Cephalalgia. 2016 Jun 1; doi:10.1177/0333102416653235.