Sleep disturbances in tension-type headache: a systematic review and meta-analysis

Tension-type headache (TTH) is the most common primary headache, yet accompanying sleep disturbances have not been quantitatively synthesized.

PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to January 3, 2026, for observational studies reporting sleep outcomes in adults with TTH. The primary outcome was the prevalence of poor sleep quality assessed with the Pittsburgh sleep quality index (PSQI). Pooled estimates were calculated using random-effects models. Study quality was assessed with Joanna Briggs Institute checklists.

Twenty-seven studies were included. Pooled prevalence of poor sleep quality in TTH was 67% (95% CI 53-79%; I² = 97%), stable across sensitivity and trim-and-fill analyses. Heterogeneity appeared partly related to recruitment settings. In five studies with non-headache controls, the odds of poor sleep quality were elevated but not significant (OR = 2.39; 95% CI 0.83-6.86; p = 0.08). The pooled mean PSQI score was 9.48 and significantly higher than controls (MD = 3.77; 95% CI 2.32-5.22; p < 0.01). Mean sleep duration was 6.61 h and did not differ significantly from controls. Insomnia was reported in 37%, excessive daytime sleepiness in 13%, and high OSA risk or PSG-defined OSA in 26%, with imprecise estimates. PSQI scores correlated robustly with depression (r = 0.51; FDR q = 0.005), whereas correlations with headache frequency and intensity were nominal and exploratory.

Poor subjective sleep quality is common in TTH, particularly among patients presenting to clinical settings, and is associated with depressive symptoms, with exploratory associations with headache burden, supporting consideration of sleep assessment in the clinical evaluation of TTH.