Poor sleep quality is common in tension-type headache, linked to depression

The pooled prevalence of poor sleep quality—measured by the Pittsburgh Sleep Quality Index (PSQI)—was 67% (95% CI 53–79%), a finding that remained stable across sensitivity analyses and trim-and-fill tests for publication bias. When studies included non-headache control groups (n=5), the odds ratio for poor sleep quality in TTH patients was 2.39, though this did not reach statistical significance (95% CI 0.83–6.86). The pooled mean PSQI score in TTH patients was 9.48 and significantly higher than controls by 3.77 points (95% CI 2.32–5.22, p < 0.01). Sleep duration averaged 6.61 hours in TTH patients and did not differ meaningfully from controls. Among comorbid sleep conditions, insomnia was reported in 37% of patients, excessive daytime sleepiness in 13%, and high obstructive sleep apnea risk or PSG-confirmed OSA in 26%, though estimates were imprecise. A key finding emerged: PSQI scores correlated robustly with depressive symptoms (r = 0.51, p = 0.005), whereas associations with headache frequency and intensity were weak and exploratory.

The 67% prevalence estimate may overstate the population effect because the studies were drawn disproportionately from clinical settings (headache clinics, neurology practices), where patients with more severe or complex TTH—and potentially more sleep disturbance—tend to concentrate. When the meta-analysis examined only studies that recruited from the general population or non-clinical settings, heterogeneity (I² = 97%) was substantial, suggesting recruitment context drives reported associations. The robust correlation between PSQI and depression (r = 0.51, q-value 0.005 after multiple-testing correction) suggests that depressive symptoms may either precede poor sleep in TTH patients or reflect a shared underlying mechanism; the reverse correlation with headache burden was weak and exploratory, implying sleep disturbance is not a simple dose-response consequence of pain frequency or intensity. Insomnia (37%), excessive daytime sleepiness (13%), and OSA risk or diagnosis (26%) each carried wide confidence intervals, reflecting sparse or heterogeneous reporting across studies. The authors note that sleep assessment should be considered in clinical TTH evaluation, particularly because addressing sleep or depression may influence headache outcomes.