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Tension-type headache (TTH) is the second most common condition worldwide (surpassed only by dental carries). As seen in migraine, TTH may progress to a chronic state. It is estimated that the incidence for chronic tension-type headache (CTTH) in the USA is 2.2%. Pericranial muscle tenderness is the most common finding in both episodic (ETTH) and CTTTH. The increased nociceptive CNS input from the cephalic and extracephalic musculature initiates a “feedback loop” that may lead to central sensitization by increasing the attention and emotional response to pain. Active and passive trigger points are frequently present in TTH. The presence of active trigger points has been shown to have a role in CTTH progression. As seen in other chronic pain states, in CTTH central mechanism of hyperexcitability and impaired inhibitory response have a role in pathogenesis.