Tension headache

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Tension headache
A woman experiencing a tension headache

Tension headache, also known as tension-type headache, is the most common type of primary headache. The pain can radiate from the lower back of the head, the neck, eyes or other muscle groups in the body typically affecting both sides of the head. Tension-type headaches account for nearly 90% of all headaches.

Pain medication, such as aspirin and ibuprofen, are effective for the treatment of tension headache.[1][2] Tricyclic antidepressants appear to be useful for prevention.[3] Evidence is poor for SSRIs, propranolol and muscle relaxants.[4][5]

As of 2013, tension headaches affect about 1.6 billion people (20.8% of the population)[6] and are more common in women than men (23% to 18% respectively).[7]

Signs and symptoms[edit]

Tension-type headache pain is often described as a constant pressure, as if the head were being squeezed in a vice. The pain is frequently present on both sides of the head at the same time. Tension-type headache pain is typically mild to moderate but may be severe.

According to the third edition of the International Classification of Headache Disorders,[8] the attacks must meet the following criteria:

  • A duration of between 30 minutes and 7 days.
  • At least two of the following four characteristics:
    • bilateral location
    • pressing or tightening (non-pulsating) quality
    • mild or moderate intensity
    • not aggravated by routine physical activity such as walking or climbing stairs
  • Both of the following:
    • no nausea or vomiting
    • no more than one of photophobia (sensitivity to bright light) or phonophobia (sensitivity to loud sounds)

Tension-type headaches may be accompanied by tenderness of the scalp on manual pressure during an attack.

Based on frequency, tension-type headaches can be sub-classified as

  • Infrequent episodic: occurring less than once per month on average, or less than 12 episodes a year;
  • Frequent episodic: occurring between 1-14 times per month on average for at least 3 months;
  • Chronic: occurring 15 times a month for at least 3 months (CTTH - chronic tension-type headache).


Various precipitating factors may cause tension-type headaches in susceptible individuals:[9]

  • Stress: usually occurs in the afternoon after long stressful work hours or after an exam
  • Sleep deprivation
  • Uncomfortable stressful position and/or bad posture
  • Irregular meal time (hunger)
  • Eyestrain[not in citation given]

Tension-type headaches may be caused by muscle tension around the head and neck.

Another theory is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information—for example from the temporal muscle or other muscles—and interprets this signal as pain. One of the main neurotransmitters that is probably involved is serotonin. Evidence for this theory comes from the fact that chronic tension-type headaches may be successfully treated with certain antidepressants such as nortriptyline. However, the analgesic effect of nortriptyline in chronic tension-type headache is not solely due to serotonin reuptake inhibition, and likely other mechanisms are involved. Recent studies of nitric oxide (NO) mechanisms suggest that NO may play a key role in the pathophysiology of CTTH.[10] The sensitization of pain pathways may be caused by or associated with activation of nitric oxide synthase (NOS) and the generation of NO. Patients with chronic tension-type headache have increased muscle and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain thresholds. Hyperexcitability of central nociceptive neurons (in trigeminal spinal nucleus, thalamus, and cerebral cortex) is believed to be involved in the pathophysiology of chronic tension-type headache.[11] Recent evidence for generalized increased pain sensitivity or hyperalgesia in CTTH strongly suggests that pain processing in the central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type headache.[12]

If other treatment is not working, a health care provider may use an MRI to confirm a more complicated diagnosis (e.g., new daily persistent headache).[13]



Drinking water and avoiding dehydration helps in preventing tension headache.[13] Using stress management and relaxing often makes headaches less likely.[13] Drinking alcohol can make headaches more likely or severe.[13] Good posture might prevent headaches if there is neck pain.[13] People who have jaw clenching might develop headaches, and getting treatment from a dentist might prevent those headaches.[13] Biofeedback techniques may also help.[14][15]


People who have 15 or more headaches in a month may be treated with certain types of daily antidepressants which act to prevent continued tension headaches from occurring.[13] In those who are predisposed to tension type headaches the first-line preventative treatment is amitriptyline, whereas mirtazapine and venlafaxine are second-line treatment options.[16] Tricyclic antidepressants appear to be useful for prevention.[3] Tricyclic antidepressants have been found to be more effective than SSRIs but have greater side effects.[3] Evidence is poor for the use of SSRIs, propranolol, and muscle relaxants for prevention of tension headaches.[4][5]


Treatment for a current tension headache is to drink water and confirm that there is no dehydration.[13] If symptoms do not resolve within an hour for a person who has had water, then stress reduction might resolve the issue.[13]


Over-the-counter drugs, like acetaminophen, aspirin, or ibuprofen, can be effective but tend to only be helpful as a treatment for a few times in a week at most.[1][13][17] Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache.[2][16]

Botulinum toxin does not appear to be helpful.[18]

Manual therapy[edit]

Current evidence for acupuncture is slight. A 2016 systematic review suggests better evidence among those with frequent tension headaches, but concludes that further trials comparing acupuncture with other treatment options are needed.[19]

People with tension-type headache often use spinal manipulation, soft tissue therapy, and myofascial trigger point treatment. Studies of effectiveness are mixed. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache.[20] A 2005 structured review found only weak evidence for the effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[21] A 2004 Cochrane review found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache.[22] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.[23] A 2012 systematic review of manual therapy found that hands-on work may reduce both the frequency and the intensity of chronic tension-type headaches.[24]


As of 2013 tension headaches affect about 1.6 billion people (20.8% of the population)[6] and are more common in women than men (23% to 18% respectively).[7] Despite its benign character, tension-type headache, especially in its chronic form, can impart significant disability on patients as well as burden on society at large.[25]


Tension headaches that do not occur as a symptom of another condition may be painful, but are not harmful. It is usually possible to receive relief through treatment. Tension headaches that occur as a symptom of another condition are usually relieved when the underlying condition is treated. Frequent use of pain medications in patients with tension-type headache may lead to the development of medication overuse headache or rebound headache.


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External links[edit]

External resources