Global, regional, and national burden and trends of tension-type headache among adolescents and young adults (15–39 years) from 1990 to 2021: findings from the Global Burden of Disease study 2021

Abstract

The prevalence of tension-type headache (TTH) is extremely high worldwide, but comprehensive global epidemiological studies targeting the specific age group of 15–39 years remain relatively limited. This study utilized data from the Global Burden of Disease 2021 (GBD 2021) study to analyze the incidence, prevalence, and disability-adjusted life years (DALYs) associated with TTH, and identified temporal trends using the estimated annual percentage change (EAPC). The study also investigated the association between the burden of TTH and the Socio-demographic Index (SDI). From 1990 to 2021, the global burden of TTH increased, with a 38% rise in prevalence cases and incidence cases. Across SDI regions, middle SDI region experienced the most significant growth in TTH cases, while high SDI regions showed a decline. Globally, the 35–39 age group faces a more severe disease burden, with prevalence cases at 188.27 (95% UI: 123.88–252.96) million, incidence cases at 61.82 (95% UI: 39.02–87.97) million, and DALYs cases at 461.94 (95% UI: 118.38–1494.8) thousand. From 1990 to 2021, the global epidemiological burden of TTH has shown a sustained increase. The most pronounced rise occurred in middle SDI regions, highlighting the urgent need for targeted public health strategies to enhance the quality of life among AYAs affected by TTH.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-02818-x.

Introduction

Tension-type headache (TTH) is the most common primary headache disorder, characterized by recurrent episodes of mild to moderate intensity headaches^1–3. The pain is typically bilateral, with a pressing or tightening quality, and does not worsen with routine physical activity^4,5. The pain of TTH is often described as a feeling of tightness around the head. Although the symptoms are not as severe and unbearable as migraines, the long-term persistence and recurrence have a significant negative impact on the physical and mental health of patients. The etiology of TTH is complex and is often associated with muscle tension, stress, and lifestyle factors. Although TTH is not life-threatening, its negative impact on the daily lives of patients significantly contributes to a decline in quality of life and a loss of productivity.

The prevalence of TTH is extremely high, with up to 78% of the general population having suffered from TTH at some point, and 3% suffering from chronic TTH⁶. The main difference between chronic and non-chronic TTH is that chronic TTH symptoms last longer, usually with headaches for more than 15 days per month and lasting at least 3 months⁷. The high prevalence of TTH directly leads to significant healthcare needs and associated costs. Therefore, understanding the global distribution and epidemiological characteristics of TTH is crucial for public health management, intervention, and resource allocation. Although some countries have begun to implement public health interventions for headaches, systematic long-term studies on TTH in the 15–39 age group are still lacking globally.

The Global Burden of Disease Study 2021 (GBD 2021) has developed a systematic framework by integrating disease data from 204 countries and territories worldwide between 1990 and 2021, aiming to analyze the global distribution patterns of TTH. Based on the GBD 2021 data, this study conducted a comprehensive analysis of the global trends in the incidence, prevalence, and disability-adjusted life years (DALYs) associated with TTH. The goal is to deepen the understanding of the global burden of this condition, provide strong support for public health policymakers in formulating effective strategies, and ultimately improve the quality of life for people around the world.

Methods

Data source and disease definition

The GBD 2021 integrated epidemiological data from 1990 to 2021 across 204 countries and territories^8–10. It provided estimates for the incidence, prevalence, mortality, and DALYs of 371 diseases and injuries, including TTH. In the GBD framework, TTH is defined as a persistent, non-pulsating, diffuse or band-like mild to moderate headache or neck pain (ICD-10 code G44.2) and is categorized within the level 4 cause classification system^11,12.

To ensure the reliability of burden estimation, the GBD employs a Bayesian statistical framework and Monte Carlo method to calculate 95% uncertainty intervals (UIs). The specific methodology includes:

1. Integrating data from multiple sources and performing stratified modeling using the DisMod-MR 2.1 model to adjust for data biases.

2. Conducting 500 random draws for each parameter to simulate the possible range of values.

3. Retaining and propagating uncertainties stemming from measurement error, model assumptions, and regional heterogeneity. Ultimately, UIs are generated using the 2.5th and 97.5th percentiles from 500 draws.

The 95% UIs indicates that there is a 95% probability that the true value lies within this interval. The width of the interval directly reflects the robustness of the estimate: a wide interval suggests data sparsity or high model uncertainty (commonly seen in low-income countries), whereas a narrow interval implies sufficient data and model stability. While UIs do not fully account for model structural biases or systematic data biases, they provide a transparent quantification of statistical uncertainty. This serves as a critical credibility assessment framework for global health decision-making, underscoring the importance of interpreting results cautiously by considering regional contexts and model assumptions¹³.

DALYs and estimated annual percentage change (EAPC)

DALYs quantify the impact of diseases on healthy life years, combining Years of Life Lost (YLL) due to premature death and Years Lived with Disability (YLD)¹⁴. It accounts for factors such as disease incidence, mortality, age at onset, duration, and disability weight (DW). The formula is DALY = YLL + YLD, where YLL reflects life years lost to early death, and YLD measures disability’s impact on quality of life. DALYs are essential in global burden studies, guiding public health policies and resource allocation. EAPC measures annual trends of disease indicators using linear regression of the natural logarithm of age-specific rates over time. Calculated as EAPC = 100 × (exp(β) − 1), where β is the regression coefficient, it provides detailed insights into time series changes. A negative EAPC indicates a decreasing trend, while a positive value signals an increase, offering critical data for targeted prevention and intervention strategies^15,16.

Results

Global level

From 1990 to 2021, the global epidemiological burden of TTH showed a continuous upward trend (Fig. 1A–E, Table1, Supplementary Tables 1 and 2). Specifically, the global prevalence cases increased from 694.26 million in 1990 to 961.45 million in 2021, with a percentage change of 38%, and the EAPC is 0.06 (95% CI: 0.04–0.08), indicating an annual increasing trend in prevalence rates. Similarly, incidence cases increased from 242.45 million in 1990 to 334.67 million in 2021, with an EAPC of 0.05 (95% CI: 0.04–0.07), and a percentage change of 38%. Furthermore, the global disease burden measured in DALYs increased from about 1428.5 thousand cases in 1990–1982.08 thousand cases in 2021, with an EAPC of 0.06 (95% CI: 0.04–0.08), and a percentage change of 39%.

Fig. 1.

Temporal trend of tension-type headache burden in adolescents and young adults in globally and 5 territories. (A) Percentage change in cases of prevalent, incident, and DALYs in 1990 and 2021. (B) The EAPC of prevalence, incidence, and DALY rates from 1990 to 2021. (C) The rates of prevalence from 1990 to 2021. (D) The rates of incidence from 1990 to 2021. (E) The rates of DALYs from 1990 to 2021.

Table 1.

The prevalence of tension-type headache cases and rates among adolescents and young adults in 1990 and 2021, and the trends from 1990 to 2021.

Location	1990_millions(95% UI)	2021_millions(95% UI)	Percentage change	1990_per 100 000(95% UI)	2021_per 100 000(95% UI)	EAPC (95% CI)
Global	694.26 (574.38–833.31)	961.45 (795.01–1159.26)	0.38	31,675.2 (26,205.79–38,019.67)	32,319.61 (26,724.73–38,969.07)	0.06 (0.04–0.08)
High SDI	143.44 (119.64–170.31)	143.82 (119.12–170.49)	0	41,341.38 (34,481.75–49,085.75)	40,715.08 (33,722.76–48,265.43)	− 0.09 (− 0.12–0.07)
High-middle SDI	138.27 (114.59–164.32)	139.61 (114.62–167.83)	0.01	30,555.34 (25,320.85–36,310.25)	31,710.14 (26,034.22–38,121.08)	0.13 (0.1–0.17)
Middle SDI	210.87 (174.39–253.17)	285.78 (235.26–343.65)	0.36	28,017.72 (23,170.68–33,637.8)	30,812.7 (25,365.75–37,052.12)	0.31 (0.29–0.32)
Low-middle SDI	146.33 (119.56–178.1)	260.05 (213.86–315.96)	0.78	32,274.49 (26,370.32–39,281.42)	32,404.69 (26,649.69–39,372.01)	− 0.01 (− 0.03–0.01)
Low SDI	54.65 (43.98–67.07)	131.44 (105.89–161.26)	1.41	29,653.82 (23,863.07–36,388.72)	29,268.97 (23,579.33–35,911.11)	− 0.06 (− 0.08–0.04)
Andean Latin America	3.73 (2.97–4.64)	6.84 (5.41–8.53)	0.83	24,122.42 (19,185.77–30,034.55)	25,268.78 (19,961.59–31,498.88)	0.19 (0.15–0.22)
Australasia	2.94 (2.4–3.55)	3.8 (3.09–4.59)	0.29	36,031.69 (29,381.94–43,553.8)	36,244.94 (29,538.14–43,795.39)	0 (0–0.01)
Caribbean	4.53 (3.55–5.67)	5.57 (4.37–6.97)	0.23	30,472.48 (23,855.02–38,121.93)	30,588.48 (24,034.9–38,294.65)	0 (0–0.01)
Central Asia	11.46 (9.18–13.87)	15.19 (12.24–18.53)	0.33	40,285.21 (32,278.46–48,747.8)	40,629.99 (32,736.21–49,557.86)	0.02 (0.01–0.04)
Central Europe	18.95 (15.6–22.86)	14.26 (11.64–17.2)	− 0.25	40,459.36 (33,309.5–48,798.36)	40,717.42 (33,232.49–49,102.55)	0.04 (0.03–0.04)
Central Latin America	21.53 (17.3–26.2)	32.02 (25.84–39.17)	0.49	31,540.31 (25,339.7–38,378.94)	31,654.29 (25,541.94–38,715.77)	0.01 (0–0.01)
Central Sub-Saharan Africa	6.25 (4.94–7.76)	16.3 (12.9–20.19)	1.61	30,105.73 (23,797.84–37,379.05)	30,128.61 (23,841.67–37,324.35)	0 (0–0)
East Asia	120.12 (99.37–145.34)	116.7 (95.01–142.96)	− 0.03	21,233.38 (17,564.93–25,692.19)	24,360.1 (19,832.77–29,842.26)	0.46 (0.38–0.53)
Eastern Europe	37.03 (31.12–43.5)	28.94 (24.28–33.95)	− 0.22	43,172.48 (36,285.85–50,722.47)	43,733.57 (36,692.59–51,309.02)	0.07 (0.04–0.11)
Eastern Sub-Saharan Africa	17.66 (14.05–21.93)	42.65 (33.94–52.47)	1.42	24,917.62 (19,819.37–30,940.76)	24,346.81 (19,376.51–29,948.75)	− 0.1 (− 0.12–0.08)
High-income Asia Pacific	26.14 (21.66–31.16)	19.97 (16.6–23.7)	− 0.24	38,722.73 (32,097.77–46,166.86)	39,522.91 (32,841.27–46,891.68)	0.11 (0.09–0.13)
High-income North America	53.34 (45.02–62.75)	56.27 (47.02–65.54)	0.05	47,075.52 (39,730.86–55,377.82)	45,679.65 (38,174–53,207.39)	− 0.14 (− 0.17–0.11)
North Africa and Middle East	39.63 (31.57–49.02)	76.38 (61.27–93.8)	0.93	29,615.36 (23,588.27–36,630.26)	30,040.82 (24,096.74–36,890.24)	0.07 (0.05–0.09)
Oceania	0.75 (0.59–0.93)	1.6 (1.26–1.99)	1.13	28,186.33 (22,130.35–35,099.4)	28,371.43 (22,378.24–35,368.75)	0.01 (0.01–0.02)
South Asia	142.68 (118.41–172.62)	262.4 (217.07–315.7)	0.84	33,056.93 (27,433.1–39,993.21)	33,175.79 (27,445.2–39,915.13)	− 0.02 (− 0.06–0.02)
Southeast Asia	63.59 (51.64–76.84)	90.58 (73.89–109.11)	0.42	32,277.04 (26,213.61–39,004.29)	32,663.24 (26,642.55–39,344.04)	0.04 (0.03–0.04)
Southern Latin America	6.66 (5.36–8.08)	9.12 (7.33–11.07)	0.37	34,906.84 (28,113.25–42,359.43)	35,369.38 (28,397.69–42,928.35)	0.05 (0.05–0.06)
Southern Sub-Saharan Africa	6.85 (5.62–8.24)	10.96 (8.98–13.17)	0.6	31,695.16 (26,002.82–38,117.03)	32,214.81 (26,381.84–38,699.82)	0.06 (0.05–0.07)
Tropical Latin America	24.2 (20.06–28.93)	32.82 (27.42–39.04)	0.36	37,623.47 (31,190.96–44,977.21)	37,160.25 (31,046.7–44,203.26)	− 0.15 (− 0.2–0.1)
Western Europe	63.09 (51.93–75.33)	57.45 (47.6–68.52)	− 0.09	43,775.21 (36,035.63–52,266.44)	44,272.86 (36,678.23–52,796.71)	0.05 (0.04–0.06)
Western Sub-Saharan Africa	23.12 (18.6–28.09)	61.62 (49.62–74.84)	1.67	32,305.37 (25,988.02–39,252.24)	32,227.51 (25,951.46–39,138.96)	− 0.02 (− 0.04–0)

SDI regional level

In different SDI regions, the epidemiological data for TTH in 2021 show significant differences (Table 1, Fig. 2A, Supplementary Figs. 1 and 2, Supplementary Tables 1 and 2). The absolute number of prevalent cases in the middle SDI region reached 285.78 (95% UI: 235.26–343.65) million in 2021, with an EAPC of 0.31 (95% CI: 0.29–0.32), which is the most significant increase among 5 SDI regions. In contrast, the prevalent cases in the high SDI region were 143.82 (95% UI: 119.12–170.49) million, with an EAPC of − 0.09 (95% CI: − 0.12 to − 0.07), indicating a downward trend. The low-middle SDI and low SDI regions had 260.05 (95% UI: 213.86–315.96) million and 131.44 (95% UI: 105.89–161.26) million, respectively, with EAPCs of − 0.01 (95% CI: − 0.03 to 0.01) and -0.06 (95% CI: − 0.08 to − 0.04), showing relatively stable changes.

Fig. 2.

Temporal trend of tension-type headache burden in adolescents and young adults in regions. (A) Prevalence rate per 100,000 population in 1990 and 2021. (B) Percentage change in cases of prevalent, incident, and DALYs in 1990 and 2021. (C) EAPC of rates of prevalent, incident, and DALYs from 1990 to 2021.

The high SDI and high-middle SDI regions had incident cases of 48.65 (95% UI: 39.13–59.52) million and 48.21 (95% UI: 39.31–59.04) million, respectively, with EAPCs of − 0.08 (95% CI: − 0.09 to − 0.06) and 0.09 (95% CI: 0.06–0.12), respectively, with the high SDI region showing a downward trend. Meanwhile, the middle SDI region had incident cases of 99.54 (95% UI: 81.36–121.09) million, with an EAPC of 0.27 (95% CI: 0.26–0.28), demonstrating significant growth. The middle SDI region reached 589.04 (95% UI: 155.66–2146.17) thousand cases in 2021, with an EAPC of 0.29 (95% CI: 0.28–0.30), which is also the most significant change among 5 SDI regions.

GBD regional level

Over the past 32 years, the prevalence cases, incidence cases, and DALYs cases of TTH have shown significant increasing trends in most regions (Fig. 2B,C). Particularly in Western Sub-Saharan Africa, Central Sub-Saharan Africa, and Eastern Sub-Saharan Africa, the percentage changes in prevalence cases are quite prominent, at 167%, 161%, and 142%, respectively. Notably, Central Europe has shown a significant downward trend in both prevalent and incident cases, with percentage changes of -25% for both.

Globally, the trend in DALYs for TTH is similar to that of prevalence. Most regions have seen an increase in DALYs, with Western Sub-Saharan Africa experiencing the highest increase, at a percentage change of 169%. However, Central Europe has seen a decrease in DALYs, with a percentage change of -23%. Regarding the EAPC, most regions show an upward trend in TTH prevalence, incidence, and DALYs, with East Asia having the highest increase. The EAPCs for East Asia are 0.46 (95% CI: 0.38–0.53) for prevalence, 0.37 (95% CI: 0.31–0.42) for incidence, and 0.27 (95% CI: 0.23–0.32) for DALYs, respectively.

Countries level

From 1990 to 2021, there were significant differences in the absolute number of prevalent cases, incident cases, and DALYs cases for TTH across different countries and regions (Fig. 3A, Supplementary Figs. 3 and 4, Supplementary Tables 3–5). Approximately 72% of countries saw an increase in prevalent cases during this period, while about 28% of countries experienced a decrease.

Fig. 3.

Temporal trend of tension-type headache burden in adolescents and young adults globally. (A) Percentage change in prevalent cases across 204 countries in 1990 and 2021. (B) EAPC in prevalent rates across 204 countries from 1990 to 2021.

Among the top five countries with the most significant increases in prevalent cases, incident cases, and DALYs cases, Qatar, Equatorial Guinea, United Arab Emirates, Afghanistan, and Jordan had percentage changes in prevalent cases of 607%, 361%, 331%, 293%, and 254%, respectively. The percentage changes in incident cases were 605%, 362%, 322%, 295%, and 252%, respectively, and the percentage changes in DALYs cases were 620%, 360%, 348%, 299%, and 262%, respectively. The top five countries with the most significant decreases in prevalent cases, incident cases, and DALYs cases were Bosnia and Herzegovina, Georgia, Latvia, Lithuania, and the United States Virgin Islands. The percentage changes in prevalent cases were − 47%, − 46%, − 43%, − 42%, and − 41%, respectively. The percentage changes in incident cases were − 47%, − 47%, − 44%, − 42%, and − 42%, respectively, and the percentage changes in DALYs cases were − 46%, − 46%, − 42%, − 41%, and − 41%, respectively (Fig. 3A).

Additionally, the prevalence, incidence, and DALYs rates for TTH in most countries worldwide show a relatively flat upward trend (Fig. 3B, Supplementary Figs. 5 and 6). However, China has the fastest increase in prevalence and incidence rates, with EAPC of 0.47 (95% CI: 0.39–0.55) and 0.38 (95% CI: 0.32–0.43), respectively. Spain has the fastest increase in DALYs rates, with an EAPC of 0.47 (95% CI: 0.38–0.57). Notably, as a developed country, Singapore still faces a relatively severe disease burden, with EAPCs for prevalence, incidence, and DALYs rates of 0.46 (95% CI: 0.34–0.58), 0.15 (95% CI: 0.11–0.19), and 0.43 (95% CI: 0.33–0.53), respectively. Ethiopia has the fastest decrease in prevalence, incidence, and DALYs rates, with EAPCs of -0.46 (95% CI: − 0.55 to − 0.37), − 0.41 (95% CI: − 0.49 to − 0.33), and − 0.45 (95% CI: − 0.54 to − 0.36), respectively (Fig. 3B).

Age patterns

From 1990 to 2021, the burden of TTH among individuals aged 15 to 39 showed significant age and regional differential trends (Table 2, Supplementary Tables 6 and 7). Overall, the prevalence cases, incidence cases, and DALYs cases of TTH among the global population aged 15 to 39 have been on the rise, but the specific changes vary between different age groups and regions (Fig. 4A–D, Supplementary Figs. 7 and 8).

Table 2.

The prevalence of tension-type headache cases and rates among adolescents and young adults in 1990 and 2021, and the trends in age patterns from 1990 to 2021.

Location	Age	1990_millions(95% UI)	2021_millions(95% UI)	Percentage change	1990_per 100 000(95% UI)	2021_per 100 000(95% UI)	EAPC (95% CI)
Global	15–19 years	148.72 (96.03–201.94)	182.63 (118.26–248.86)	0.23 (0.23–0.23)	28,632.61 (18,486.98–38,878)	29,268.61 (18,952.86–39,883.14)	0.04 (0.02–0.06)
Global	15–39 years	694.26 (574.38–833.31)	961.45 (795.01–1159.26)	0.38 (0.38–0.39)	31,675.2 (26,205.79–38,019.67)	32,319.61 (26,724.73–38,969.07)	0.06 (0.04–0.08)
Global	20–24 years	148.38 (107.25–203.47)	187.77 (135.94–260.07)	0.27 (0.27–0.28)	30,153.19 (21,795.03–41,348.24)	31,443.51 (22,765.14–43,551.55)	0.1 (0.08–0.13)
Global	25–29 years	143.67 (102.34–193.89)	194.23 (136.64–262.22)	0.35 (0.34–0.35)	32,458.47 (23,122.35–43,805.42)	33,013.58 (23,223.85–44,569.15)	0.09 (0.05–0.12)
Global	30–34 years	134.99 (94.49–179.26)	208.55 (145.97–277.95)	0.54 (0.54–0.55)	35,024.85 (24,515.99–46,510.78)	34,500.58 (24,148.31–45,981.3)	− 0.01 (− 0.06–0.04)
Global	35–39 years	118.49 (78.4–157.56)	188.27 (123.88–252.96)	0.59 (0.58–0.61)	33,638.73 (22,255.92–44,731.03)	33,568.18 (22,086.46–45,101.38)	− 0.02 (− 0.07–0.02)
Low SDI	15–19 years	13.35 (8.27–18.68)	32.28 (19.98–45.09)	1.42 (1.42–1.41)	26,341.08 (16,328.83–36,868.58)	26,032.47 (16,119.15–36,365.88)	− 0.05 (− 0.07–0.03)
Low SDI	15–39 years	54.65 (43.98–67.07)	131.44 (105.89–161.26)	1.41 (1.41–1.4)	29,653.82 (23,863.07–36,388.72)	29,268.97 (23,579.33–35,911.11)	− 0.06 (− 0.08–0.04)
Low SDI	20–24 years	12.41 (8.85–17.63)	29.85 (21.33–42.41)	1.41 (1.41–1.41)	29,119.3 (20,765.09–41,362.69)	28,624.62 (20,455.03–40,666.42)	− 0.08 (− 0.1–0.05)
Low SDI	25–29 years	11.13 (7.67–15.42)	26.42 (18.23–36.61)	1.37 (1.38–1.37)	31,076.76 (21,404–43,062.41)	30,673.99 (21,166.7–42,504.87)	− 0.07 (− 0.08–0.05)
Low SDI	30–34 years	9.68 (6.65–13.09)	23.32 (15.97–31.61)	1.41 (1.4–1.41)	32,588.27 (22,389.25–44,086.88)	32,216.73 (22,055.76–43,656.42)	− 0.06 (− 0.08–0.04)
Low SDI	35–39 years	8.09 (5.28–11.12)	19.56 (12.7–26.85)	1.42 (1.41–1.41)	31,711.92 (20,714.16–43,583.23)	31,421.31 (20,398.72–43,125.38)	− 0.05 (− 0.07–0.04)
Low-middle SDI	15–19 years	35.7 (22.94–48.64)	55.06 (35.56–74.98)	0.54 (0.55–0.54)	30,018.1 (19,292.11–40,907.3)	29,834.28 (19,267.17–40,627.71)	− 0.04 (− 0.05–0.03)
Low-middle SDI	15–39 years	146.33 (119.56–178.1)	260.05 (213.86–315.96)	0.78 (0.79–0.77)	32,274.49 (26,370.32–39,281.42)	32,404.69 (26,649.69–39,372.01)	− 0.01 (− 0.03–0.01)
Low-middle SDI	20–24 years	33.76 (24.33–46.71)	56.5 (40.75–78.05)	0.67 (0.67–0.67)	32,370.87 (23,330.54–44,789.24)	32,321.23 (23,311.6–44,649.26)	− 0.02 (− 0.04–0.01)
Low-middle SDI	25–29 years	29.79 (20.78–40.43)	53.96 (37.69–73.24)	0.81 (0.81–0.81)	33,232.29 (23,187.67–45,109.06)	33,336.68 (23,280.68–45,243.47)	− 0.01 (− 0.03–0.01)
Low-middle SDI	30–34 years	25.73 (17.74–34.65)	50.53 (34.93–68.21)	0.96 (0.97–0.97)	34,069.52 (23,492.11–45,890.93)	34,178.67 (23,626.4–46,138.28)	− 0.01 (− 0.03–0.02)
Low-middle SDI	35–39 years	21.37 (14.17–29.06)	44 (29.04–59.65)	1.06 (1.05–1.05)	32,841.21 (21,782.98–44,663.01)	32,973.03 (21,766.74–44,700.67)	− 0.01 (− 0.04–0.02)
Middle SDI	15–19 years	48.71 (31.58–66.11)	51.61 (33.88–69.88)	0.06 (0.07–0.06)	26,003.22 (16,858.65–35,288.08)	28,304.86 (18,582.12–38,325.61)	0.24 (0.21–0.26)
Middle SDI	15–39 years	210.87 (174.39–253.17)	285.78 (235.26–343.65)	0.36 (0.35–0.36)	28,017.72 (23,170.68–33,637.8)	30,812.7 (25,365.75–37,052.12)	0.31 (0.29–0.32)
Middle SDI	20–24 years	47.62 (34.73–66.29)	53.34 (38.95–73.92)	0.12 (0.12–0.12)	26,706.07 (19,475.67–37,175.62)	30,097.23 (21,976.4–41,705.57)	0.35 (0.31–0.4)
Middle SDI	25–29 years	43.47 (30.78–59.07)	57.81 (40.68–78.07)	0.33 (0.32–0.32)	28,795.86 (20,385.98–39,128.77)	31,453.85 (22,134.66–42,472.91)	0.34 (0.28–0.4)
Middle SDI	30–34 years	37.99 (26.12–51.41)	64.96 (45.24–87.31)	0.71 (0.73–0.7)	30,997.66 (21,315.28–41,949.49)	32,565.25 (22,676.34–43,767.44)	0.23 (0.17–0.29)
Middle SDI	35–39 years	33.07 (21.78–44.36)	58.05 (38.33–78.1)	0.76 (0.76–0.76)	29,150.93 (19,196.45–39,095.96)	31,444.31 (20,759.1–42,299.34)	0.23 (0.18–0.28)
High-middle SDI	15–19 years	26.63 (17.17–36.03)	21.1 (13.69–28.58)	− 0.21 (− 0.2–0.21)	27,587.3 (17,787.64–37,323)	29,117.98 (18,884.05–39,432.88)	0.13 (0.09–0.16)
High-middle SDI	15–39 years	138.27 (114.59–164.32)	139.61 (114.62–167.83)	0.01 (0–0.02)	30,555.34 (25,320.85–36,310.25)	31,710.14 (26,034.22–38,121.08)	0.13 (0.1–0.17)
High-middle SDI	20–24 years	27.27 (19.64–36.99)	22.28 (16.32–30.68)	− 0.18 (− 0.17–0.17)	27,951.07 (20,124.84–37,902.06)	29,723.62 (21,761.52–40,924.87)	0.12 (0.08–0.17)
High-middle SDI	25–29 years	28.72 (20.66–38.97)	26.68 (18.94–35.86)	− 0.07 (− 0.08–0.08)	30,907.02 (22,235.51–41,932.58)	31,505.38 (22,366.72–42,340.67)	0.15 (0.07–0.23)
High-middle SDI	30–34 years	29.3 (20.45–38.84)	35.98 (25.35–47.73)	0.23 (0.24–0.23)	34,371.86 (23,983.23–45,560.85)	33,719.88 (23,761.44–44,736.4)	0.05 (− 0.05–0.15)
High-middle SDI	35–39 years	26.34 (17.43–34.91)	33.56 (22.28–44.9)	0.27 (0.28–0.29)	32,831.32 (21,720.23–43,515.16)	33,087.36 (21,960.69–44,265.24)	0.05 (− 0.03–0.12)
High SDI	15–19 years	24.19 (15.97–32.02)	22.45 (14.87–29.73)	− 0.07 (− 0.07–0.07)	36,927.64 (24,375.55–48,869.25)	37,297.74 (24,707.83–49,392.85)	0.02 (− 0.01–0.06)
High SDI	15–39 years	143.44 (119.64–170.31)	143.82 (119.12–170.49)	0 (0–0)	41,341.38 (34,481.75–49,085.75)	40,715.08 (33,722.76–48,265.43)	− 0.09 (− 0.12–0.07)
High SDI	20–24 years	27.18 (19.75–36.73)	25.65 (18.85–34.88)	− 0.06 (− 0.05–0.05)	39,456.97 (28,664.55–53,326.82)	39,210.94 (28,823.53–53,335.48)	− 0.05 (− 0.09–0.02)
High SDI	25–29 years	30.42 (22.03–40.36)	29.2 (21.22–38.63)	− 0.04 (− 0.04–0.04)	41,732.72 (30,218.58–55,367.17)	40,904.76 (29,720.16–54,118.98)	− 0.12 (− 0.16–0.09)
High SDI	30–34 years	32.15 (23.11–41.45)	33.59 (24.07–43.55)	0.04 (0.04–0.05)	44,639.47 (32,083.15–57,541.28)	43,283.13 (31,009.66–56,114.73)	− 0.15 (− 0.17–0.13)
High SDI	35–39 years	29.49 (20.41–38.58)	32.94 (22.91–43.54)	0.12 (0.12–0.13)	43,601.17 (30,176.96–57,034.52)	41,874.67 (29,131.51–55,353.18)	− 0.15 (− 0.16–0.13)

Fig. 4.

Temporal trend of tension-type headache burden in adolescents and young adults by age pattern in different regions. (A) Prevalent cases of 5 age groups (15–39 years, 5-year intervals) from 1990 to 2021 globally and in 5 territories (low to high SDI). (B) The distribution of prevalent cases across 5 age groups as percentages globally, in 5 territories, and 21 GBD regions in 1990 and 2021. (C) Percentage change in prevalent cases of 5 age groups globally and in 5 territories in 1990 and 2021. (D) EAPC of prevalent rates of 5 age groups globally and in 5 territories from 1990 to 2021. E Analysis of the prevalence rates of tension-type headache disease burden by gender and age structure in 2021.

Over the past 32 years, the age group with the highest global disease burden has been the 35–39 age group. The prevalence cases, incidence cases, and DALYs cases for this age group were 188.27 million (95% UI: 123.88–252.96), 61.82 million (95% UI: 39.02–87.97), and 461.94 thousand (95% UI: 118.38–1494.8), respectively. During this period, the prevalence cases experienced a percentage change of 59%, the incidence cases saw a percentage change of 59%, and the DALYs cases had a percentage change of 57% (Fig. 4C, Supplementary Figs. 9 and 10). However, the 20–24 age group showed a significant upward trend in prevalence, incidence, and DALY rates, with EAPC of 0.1 (95% CI: 0.08–0.13), 0.1 (95% CI: 0.08–0.13), and 0.06 (95% CI: 0.04–0.08), respectively (Supplementary Figs. 11 and 12).

Among the 5 SDI regions, the low SDI region saw a significant increase in prevalence, incidence, and DALYs cases, with a substantial disease burden faced by each age group, averaging over 100% percentage change, but its EAPC showed a slow declining trend, suggesting that the burden of TTH in low SDI regions may ease in the future. Notably, the high-middle SDI region and the middle SDI region both showed a clear upward trend in EAPC for prevalence, incidence, and DALYs. Particularly, the 20–24 age group in the middle SDI region had the most significant increase in prevalence and incidence, with EAPCs of 0.35 (95% CI: 0.31–0.4) and 0.34 (95% CI: 0.29–0.38), respectively. The 25–29 age group had the highest increase in DALY rates, with an EAPC of 0.26 (95% CI: 0.22–0.3).

Over the past 32 years, the percentage distribution across each age group of AYAs has changed noticeably on a global scale. Compared to 1990, the proportion of prevalence cases, incidence cases, and DALYs cases in the 35–39 age group has increased by 3%, 2%, and 2%, respectively (Fig. 4B, Supplementary Figs. 13 and 14).

Gender difference

In terms of TTH prevalence cases and incidence cases, there is no significant difference between males and females (Supplementary Tables 8 and 9). However, females have a slightly higher number of DALYs cases than males. Additionally, the prevalence, incidence, and DALY rates for females are higher than those for males (Fig. 4E, Supplementary Figs. 15, 16, 17, 18, 19, and Supplementary Table S10).

The association between TTH burden and SDI

The incidence rates of TTH show a significant positive correlation with the SDI, with a correlation coefficient of 0.632, indicating that this correlation is statistically significant(Supplementary Fig. 20). The incidence rates remain relatively stable when the SDI value is within the range of 0.4 to 0.6. However, as the SDI value increases from 0.6 to 0.8, the incidence rates rise significantly. Moreover, the correlation between DALYs rates and SDI shows a pattern similar to that of incidence rates (Supplementary Fig. 21). However, the prevalence rates of TTH show a negative correlation with SDI, with a correlation coefficient of − 0.1 (Fig. 5).

Fig. 5.

The associations between the SDI and prevalent rates per 100,000 population of tension-type headache in adolescents and young adults across 21 GBD regions.

Discussion

This study delves into the global burden of TTH over the past 3 decades and reveals significant disparities across different regions and socioeconomic groups. From 1990 to 2021, the number of global TTH prevalence cases increased significantly, reaching 961 million people by 2021, with a growth rate of 38%. Concurrently, the incidence cases and DALYs cases also showed similar increasing trends. These data indicate that although TTH is not a fatal disease, it remains an important public health burden globally due to its negative impact on quality of life and productivity.

The etiology of TTH has not yet been fully elucidated. Current research suggests that TTH results from the interaction of multiple factors, including pain sensitivity, pain perception, and chemical substances in the brain such as neurotransmitters^3,17–19. Studies have indicated that patients with TTH may exhibit abnormalities in the central nervous system, which increase their sensitivity to pain²⁰. Moreover, compared to healthy individuals, TTH patients often show significantly more tenderness and stiffness in pericranial muscles, suggesting that muscle tension is a key contributing factor and is closely related to stress and anxiety. Work-related stress, anxiety, and symptoms of depression may further exacerbate TTH symptoms, creating a vicious cycle between pain and psychological issues. These findings highlight the importance of providing psychological support and stress management in the treatment of TTH. Future research should focus on exploring the neurobiological mechanisms of TTH, particularly how muscle tension may lead to pain hypersensitivity and chronic pain through the central nervous system.

From 1990 to 2021, the global epidemiological burden of TTH has been on the rise, with a 38% increase in incidence cases, and a 39% increase in the disease burden measured by DALYs cases. In different SDI regions, the epidemiological data for TTH in 2021 show significant differences, with the middle SDI region showing the most significant increase in the number of prevalent cases, while high SDI regions show a declining trend. At the GBD regional level, Western, Central, and Eastern Sub-Saharan Africa have seen significant increases in TTH prevalence cases and incidence cases, while Central Europe has seen a significant decline. These differences may be related to economic development, urbanization, lifestyle changes, health policies, and improvements in healthcare services. Therefore, targeted health policies and interventions need to be developed according to the specific circumstances of different regions to reduce the burden of TTH. More research is needed to understand the specific reasons for the increase in TTH and to evaluate the effectiveness of different interventions in order to develop more effective public health strategies. Given that TTH is a global issue, international cooperation is particularly important in sharing data, experiences, and resources to more effectively address the challenges of TTH.

Over the past 32 years, there have been significant differences in the number of prevalent cases, incident cases, and DALYs cases of TTH across different countries and regions worldwide. Approximately 72% of countries have seen an increase in prevalent cases during this period. Among the top five countries with the most significant increases, Qatar, Equatorial Guinea, the United Arab Emirates, Afghanistan, and Jordan have seen astonishingly high percentage changes in prevalent cases, incident cases, and DALYs cases. The prevalence, incidence, and DALY rates of TTH in most countries worldwide show a relatively flat upward trend, with China experiencing the fastest increase in prevalence and incidence rates, and Spain the fastest increase in DALY rates. Notably, as a developed country, Singapore still faces a severe disease burden, with high EAPC in prevalence, incidence, and DALY rates. These differences may be related to the economic level, healthcare services, lifestyle, and environmental factors of each country. Rapid economic growth, urbanization, and population aging may be the main factors leading to increased prevalence and incidence rates of TTH. For countries with declining trends, it may be related to improved health policies, enhanced healthcare services, and implementation of disease prevention measures. Countries should develop targeted public health policies and interventions based on their specific circumstances to reduce the prevalence and incidence of TTH. More cross-country research is needed to understand the global trends and risk factors of TTH and to evaluate the effectiveness of different interventions. In addition, long-term monitoring and evaluation of TTH trends are necessary to adjust public health strategies and interventions in a timely manner. Through these efforts, we can better understand the trends of TTH in different countries and regions worldwide and take corresponding measures to reduce its impact on public health.

The global burden of TTH between 1990 and 2021 shows an upward trend among the 15–39 age group, especially in the 30–34 and 35–39 age groups. There are significant differences in disease burden across regions. The burden of TTH has increased in low SDI regions, but the EAPC shows a declining trend, suggesting potential alleviation in the future. In contrast, the middle SDI and high-middle SDI regions show a significant upward trend in TTH burden. In terms of gender differences, women have higher prevalence, incidence, and DALY rates than men, and as age increases, women may face a more severe disease burden than men. These findings emphasize the need for differentiated health policies and interventions for different age groups, genders, and regions to reduce the burden of TTH.

This study systematically analyzed the epidemiological characteristics and public health impact of TTH among AYAs on a global scale. The findings reveal a continuously increasing burden of TTH, with particularly pronounced trends observed in regions with a middle SDI, highlighting an urgent need for increased attention from the public health sector. Specifically, the high and rising prevalence of TTH among AYAs poses a serious challenge to public health systems. On one hand, the chronic and recurrent nature of TTH significantly reduces patients’ quality of life, leading to decreased productivity in work and education and increased healthcare expenditures. On the other hand, the high incidence of TTH places additional strain on already burdened healthcare systems, with this impact being especially evident in middle SDI regions where medical resources are relatively limited. Notably, among different SDI regions, the middle SDI group showed the most significant increase in TTH prevalence cases, reaching 285.78 (95% UI: 235.26–343.65) million cases in 2021. The wide range of this UI reflects the heterogeneity of epidemiological data in middle SDI regions and underscores the need to interpret the data with caution. These findings provide critical evidence to support the development of targeted strategies for the prevention and control of TTH, particularly in resource-constrained settings.

TTH among AYAs is closely associated with a range of risk factors^21–23. First, psychosocial disorders—such as academic stress, social anxiety, and uncertainty about the future—can lead to emotional problems like anxiety and depression, which in turn cause sustained muscle tension, directly triggering headaches^24,25. Second, addiction-related issues, including chemical addiction (e.g., alcohol abuse and drug dependence) and digital addiction (e.g., excessive use of electronic devices and social media), can contribute to TTH through various mechanisms²⁶. Chemical addictions may cause physiological disruptions such as dehydration and sleep disorders, while digital addiction may indirectly provoke headaches by disrupting sleep, increasing eye strain, and encouraging sedentary behavior. Both types of addiction can also worsen anxiety and depression, creating a vicious cycle. Additionally, mild head trauma—often occurring during sports or accidents—although not resulting in severe brain injury, may trigger persistent headaches, dizziness, and attention difficulties, with symptoms lasting from weeks to months²⁷. Timely evaluation and intervention are essential to reduce the risk of TTH. In summary, social and psychological stress, addictive behaviors, and head trauma together constitute the multidimensional causes of TTH in AYAs. Effective prevention and control can be achieved through comprehensive interventions, such as psychological support, guidance on healthy behaviors, and management of trauma.

Public health intervention strategies targeting AYAs should encompass several key aspects. First, extensive health promotion campaigns should be conducted to raise awareness and understanding of TTH among this population. Second, the coverage and quality of primary healthcare services should be strengthened to enable early identification and management of TTH cases in AYAs. Third, given the close association between TTH and lifestyle factors—such as stress, insufficient sleep, and poor dietary habits—public health strategies should include the promotion of healthy lifestyles. Fourth, based on the findings of this study, the middle regions bear a heavier TTH burden and should therefore be prioritized in resource allocation to support relevant public health programs. Lastly, effective TTH management requires cross-sectoral collaboration, involving healthcare, education, labor, and social welfare sectors.

GBD assumptions and limitations

The GBD 2021 study relies on a series of core assumptions during its modeling process. First, it assumes that national data collection systems adequately capture the majority of the population, thereby overlooking urban–rural or subnational disparities, which may affect data precision. Second, the GBD assumes that disability weights for the same health condition are globally consistent, without fully accounting for cultural or economic variations that may influence quality-of-life assessments. Additionally, the model presumes that the effects of different risk factors are independent, which could underestimate potential interactions among these factors. Lastly, the long-term estimates of the GBD are based on the assumption of stable age-specific incidence rates, which may ignore the impact of unexpected public health events on population structure.

Nevertheless, the GBD study has several limitations. Although it integrates a vast amount of data, the coverage and accuracy may be limited in certain regions—particularly low- and middle-income countries—which can result in underestimation or overestimation of disease burden in those areas. Moreover, while assessing disease burden, the GBD may not fully capture all complex etiologies associated with TTH. For instance, psychological factors, lifestyle changes, and environmental influences may not be sufficiently considered in the models. Finally, the update of GBD data has a certain degree of delay, which means that the latest epidemiological trends may not be promptly reflected in the research results.

Conclusion

In summary, the global burden of TTH is generally on the rise, with significant variations between different regions and countries. Middle SDI regions are facing a severe disease burden, while high SDI regions have experienced a reduction in disease burden. Additionally, age and gender are important factors affecting the TTH burden. The relationship between SDI and TTH burden indicates that the impact of socio-economic development levels on TTH is complex, necessitating targeted public health strategies to address the needs of different regions.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

W.W. were responsible for identifying the topic and research concept. C.L.L. and Y.Z.W. were involved in study implementation and literature review. J.W. and C.K.M. analyzed the data and drafted the manuscript. M.L. and C.M. were involved in data interpretation and editing of the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by the Science and Technology Department of Jilin Province (No: 20230401085YY).

Data availability

The datasets presented in this study can be found in online (http://ghdx.healthdata.org/gbd-results-tool). Further information can be directed to the corresponding author.

Declarations

Competing interests

The authors declare no competing interests.