Tension Headache

How tension headaches happen

The exact cause is not fully understood, but research points to two mechanisms:

• Peripheral (muscle) factors: tender, tight muscles in the scalp, neck and shoulders, called pericranial tenderness. These are especially important in infrequent episodes.
• Central sensitization: in frequent and chronic tension headaches, the brain and spinal cord become more sensitive to pain signals, so normal sensations are felt as pain. This explains why muscle relaxants alone rarely help chronic cases.

Despite the name, a tension headache is not caused simply by "tension", and people without stress get them too.

For a quick guide to what tension headaches feel like and fast relief, see tension headache symptoms.

Symptoms

• dull, pressing or tightening pain, not throbbing
• usually on both sides of the head
• mild to moderate intensity
• not worsened by routine physical activity
• no nausea or vomiting
• may have mild sensitivity to light or sound, but not both
• tenderness of the scalp, neck and shoulder muscles

Causes and triggers

Types

The International Headache Society divides tension-type headache by frequency:

• Infrequent episodic: less than 1 day a month
• Frequent episodic: 1 to 14 days a month
• Chronic: 15 or more days a month for more than 3 months

The frequency determines the treatment approach. The page on tension-type headache explains the classification and long-term management of chronic forms in more detail.

Diagnosis

There is no test for tension headache. A doctor diagnoses it from your description and a normal examination. They will ask about the pain's location, quality, severity, duration and frequency, triggers, medicine use, sleep and mood, and check blood pressure, the eyes (including the back of the eye), neck and nervous system.

A headache diary for 4 to 8 weeks helps establish frequency, identify triggers and detect medication overuse.

Brain scans are not needed for typical tension headaches with a normal examination. They are used when there are warning signs, such as a new headache after 50, a change in pattern, neurological symptoms or headaches that worsen with straining.

Conditions doctors rule out

• Migraine, which can coexist
• Medication-overuse headache
• Cervicogenic headache from the neck
• Sleep apnea, high blood pressure crises, giant cell arteritis, raised pressure in the skull and, rarely, a brain tumor

Treatment

Treating an episode

• Ibuprofen, naproxen, aspirin or acetaminophen (paracetamol), following the label dose. Ibuprofen and aspirin are slightly more effective than acetaminophen in trials.
• Combination products with caffeine can add modest benefit.
• Avoid opioids and butalbital, which have little benefit and high risk of dependence and medication-overuse headache.
• Limit acute medicines to fewer than 10 to 15 days a month, depending on the drug, and ideally no more than 2 to 3 days a week.

Preventing frequent headaches

• Amitriptyline: a low-dose tricyclic antidepressant taken at night, the best-studied preventive medicine. It takes several weeks to work.
• Other options include mirtazapine and venlafaxine.
• Cognitive behavioral therapy, relaxation training and biofeedback have good evidence.
• Physical therapy focusing on posture, neck and shoulder exercises.
• Acupuncture may help some people with frequent episodes.

Lifestyle measures

• regular sleep, 7 to 9 hours
• regular meals and fluids
• regular aerobic exercise, such as 30 minutes of walking 5 days a week
• screen breaks every 30 to 60 minutes, and an eye test if you have not had one
• a night guard for teeth grinding
• stress management
• steady caffeine intake rather than large swings

Complications

The main complication is medication-overuse headache, which turns episodic headaches into daily ones. Chronic tension headaches are linked to anxiety, depression, disrupted sleep and reduced quality of life, which in turn worsen headaches.

Outlook

Most people have infrequent episodes that are easily treated. Frequent and chronic tension headaches can be harder to manage, but combining preventive medicine, therapy and lifestyle changes reduces frequency for most. Chronic tension headaches often improve over years.

Frequently asked questions

What causes tension headaches?

They come from a combination of tight, tender muscles in the head and neck and increased sensitivity of pain pathways in the nervous system. Stress, poor sleep, posture, eye strain, jaw clenching, skipped meals and caffeine withdrawal are common triggers.

How are tension headaches treated?

Occasional headaches respond to over-the-counter pain relievers such as ibuprofen or acetaminophen, plus rest, heat and stretching. Frequent headaches are treated with preventive approaches such as low-dose amitriptyline, CBT, relaxation techniques, physical therapy and regular exercise.

Can tension headaches be prevented?

Often, yes. Regular sleep and meals, staying hydrated, exercise, good posture, screen breaks and stress management reduce how often they happen. For frequent headaches, a doctor may suggest preventive medicine or therapy.

Are tension headaches dangerous?

No. Tension headaches are not caused by a serious disease and do not damage the brain. However, a headache that is sudden and severe, new after 50, or comes with neurological symptoms, fever or a stiff neck needs urgent medical assessment.

Is a tension headache the same as a tension-type headache?

Yes. Tension-type headache is the official medical name used in the International Classification of Headache Disorders. Tension headache and stress headache are common everyday names for the same condition.