Tension Headaches

Topic Overview

What is a tension headache?

Most headaches are tension headaches. These headaches tend to happen again and again, especially if you are under stress. They are not usually a sign of something serious. But they can be very painful and hard to live with.

What causes tension headaches?

Doctors don't know for sure what causes tension headaches. In the past experts thought that tension or spasms in the muscles of your neck, face, and head played a role. Now they think a change in brain chemicals may also be a cause.

What are the symptoms?

Symptoms of tension headaches include:

  • A headache that is constant, not throbbing. You usually feel the pain or pressure on both sides of your head.
  • Pressure that makes you feel like your head is in a vise.
  • Aching pain at your temples or the back of your head and neck.

This is different from migraine headaches, which usually cause throbbing pain and start on one side of your head.

Tension headaches tend to come back, especially when you are under stress. They can last from 30 minutes to several days.

Usually, pain from a tension headache is not severe and does not get in the way of your work or social life. But for some people the pain is very bad or lasts a long time. You have chronic tension headaches if they occur at least 15 days a month.

How are tension headaches diagnosed?

A doctor can usually diagnose tension headaches by asking you questions about your health and lifestyle and by examining you.

How are they treated?

Most people can treat their tension headaches with pain relievers that you buy without a prescription, like acetaminophen (such as Tylenol) or aspirin.

But if you take these pain relievers more than 3 times a week, you may get rebound headaches. Rebound headaches are different from tension headaches. They usually start after pain medicine has worn off, which leads you to take another dose. Eventually you get a headache whenever you stop taking the medicine.

Some people have chronic tension headaches. This means they often get headaches. Doctors may prescribe stronger pain medicine for these people.

Can tension headaches be prevented?

Even with treatment, most people still have some headaches. But with treatment, you will probably have them less often. And when you do get them, they probably won't be as bad.

Home treatment may help you avoid headaches. Learn how to handle stress. Make sure you sleep, exercise, and eat on a regular schedule. Check your posture. Don't strain your eyes when you use your computer. Get treatment for depression or anxiety.

Try keeping a headache diary. Every time you get a headache, write down the date, the hour, and what you were doing and feeling before your headache started. This may help you and your doctor find out what is causing your headaches so you can get the right treatment.

Frequently Asked Questions

Learning about tension headaches:

Being diagnosed:

Getting treatment:

Ongoing concerns:

Living with tension headaches:

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Decision Points focus on key medical care decisions that are important to many health problems. Decision Points focus on key medical care decisions that are important to many health problems.
  Headaches: Should I take prescription medicine for tension headaches?

Actionsets help people take an active role in managing a health condition. Actionsets are designed to help people take an active role in managing a health condition.
  Headaches: Identifying and avoiding triggers
  Headaches: Managing a headache

Cause

The cause of tension headaches is not clear. Experts believe there may be more than one factor that causes a tension headache. In the past, doctors believed that tension or spasms of the muscles of the neck, face, jaw, head, or scalp played a role in causing these headaches. Now they think a change in brain chemistry may also help cause a tension headache.

Symptoms

Symptoms of tension headaches include:

  • A constant headache that does not throb or pulse. You usually feel the pain or pressure on both sides of your head.
  • Tightness around your forehead that may feel like a "vise grip."
  • Aching pain at your temples or the back of your head and neck.

Unlike migraines, tension headaches do not often occur with nausea, vomiting, or sensitivity to both light and noise (but you may have one or the other), and they are not usually disabling. Episodes of tension headaches last from 30 minutes to several days. Tension headaches are considered chronic when they occur at least 15 days or more a month.

Chronic tension headaches frequently occur along with other conditions such as anxiety or depression. While not common, serious conditions such as tumors or infections may cause a headache.

What Happens

Tension headaches are one of the most common types of headaches. They can be triggered by stress, anxiety, depression, hunger, anger, fatigue, overexertion, poor posture, and muscle strain. Tension headaches may come on suddenly or gradually. Prolonged sitting, having poor posture, or eyestrain can also trigger tension headaches. The headache may disappear after you relax or take a nonprescription pain reliever, such as aspirin or ibuprofen.

Tension headaches can last anywhere from 30 minutes to 7 days. If you have a headache on 15 or more days each month over a 3-month period, you may have chronic tension headaches. Chronic headaches can lead to stress and depression, which in turn can prolong the cycle of headaches. Treatment is available to reduce the frequency or stop the occurrence of chronic tension headaches.

What Increases Your Risk

About 4 out of 100 people in the United States develop chronic tension headaches.1 Symptoms can start in childhood, but they are more likely to occur during middle age and be linked to stressful life events.

When To Call a Doctor

If you have a headache or have been diagnosed with tension headaches, use the following information to help you decide when to call your doctor.

Call 911 or other emergency services if:

  • You have a very sudden, severe, "thunderclap" headache that seems to come on instantly and is unlike any headache you have had before.
  • You have symptoms of a stroke:
    • Sudden numbness, paralysis, or weakness in your face, arm, or leg, especially on only one side of your body.
    • New problems with walking or balance.
    • Sudden vision changes.
    • New problems speaking or understanding simple statements, or feeling confused.
    • Drooling or slurred speech.
    • A sudden, severe headache that is different from past headaches.

Call your doctor now or go to the emergency room if:

  • You develop fever and a stiff neck.
  • You have new nausea and vomiting, or you cannot keep food or liquids down.

Watch closely for changes in your health, and be sure to contact your doctor if:

  • Your headache does not get better within 24 hours.
  • Your headache wakes you up at night.
  • Your headaches get worse or happen more often.
  • You start to have new symptoms.
  • You have any problems with your medicine.
  • You are older than 50 and have new or more frequent headaches.
  • Your headaches occur after physical exercise, sexual activity, coughing, or sneezing.
  • Your life is disrupted by your headaches (for example, you miss work or school regularly).

Watchful Waiting

Watchful waiting is a wait-and-see approach. If your headache gets better on its own, you won't need treatment. If it gets worse or your headaches become more frequent, you and your doctor will decide what to do next. Watchful waiting and using nonprescription pain relievers are appropriate if you have tension headaches that are not disabling. But if you have at least 15 tension headaches a month over a 6-month period, you may want to seek treatment for chronic tension headaches.

Who To See

Most health professionals can recognize and treat tension headaches. You may seek treatment from any of the following:

If you think your headaches are caused by depression or anxiety, seeking treatment from a psychiatrist, psychologist, or other licensed mental health counselor may help reduce the frequency or severity of your headaches, as well as relieve your symptoms of anxiety or depression.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Your doctor can usually diagnose tension headaches by asking you questions about your health and lifestyle and by examining you.

It is important to distinguish tension headaches from other headaches (such as migraines), because symptoms can be similar but treatment may vary. Usually migraine pain is felt on only one side of the head. Tension headaches usually cause pain on both sides of your head.

Your doctor may diagnose tension headaches if you have headaches with:

  • Constant pain that does not throb or pulse. You usually feel the pain or pressure on both sides of your head.
  • Tightness around your forehead that may feel like a "vise grip."
  • Aching pain at your temples or the back of your head and neck.

You might be sensitive to light or noise (but not both at the same time). But you will not usually feel nauseated. The pain does not get worse with activity.

Tension headaches can last from 30 minutes to 7 days. You may be diagnosed with chronic tension headaches if you have the same symptoms but have a headache on 15 or more days each month over a 3-month period.

In very rare cases, headaches can be caused by other, more serious medical conditions (such as brain tumors or aneurysms). Your doctor may order tests to rule out other causes. These tests may include:

  • A lumbar puncture, a test in which your doctor uses a needle to remove a small amount of fluid from your spinal canal. The fluid is then looked at for signs of infection.
  • An electroencephalogram (EEG), a test that measures and records the electrical activity of your brain by using sensors (electrodes) attached to your head and connected by wires to a computer.
  • An MRI scan of your brain, a test that uses a magnetic field and pulses of radio wave energy to provide pictures of your brain.
  • A CT scan of your head, a test in which a scanner directs a series of X-ray pulses through your head. This produces detailed pictures of structures inside the head.

Parents may become very concerned about headaches in children and feel that extensive testing is needed to rule out serious causes. But doctors often can evaluate children's headaches without using imaging tests. Children who have headaches will sometimes be monitored for 6 months or longer from the time of their first headache.

Treatment Overview

You can manage tension headaches by taking pain relievers that you can buy without a prescription, such as nonsteroidal anti-inflammatory drugs (NSAIDs) (for example, aspirin or ibuprofen). If you have chronic or severe tension headaches, you may need to take a prescription drug (such as an antidepressant) every day to reduce the pain and frequency of your headaches. You may also try complementary therapies (such as acupuncture, biofeedback, or meditation), to help lower stress, which may help reduce or prevent your headaches.

Initial treatment

When first treating tension headaches pain, you may try taking nonprescription drugs. These drugs usually have fewer side effects than prescription pain relievers. Also, you may be able to prevent or reduce tension headaches by learning what causes your headaches, such as stress or anxiety, and trying to avoid those triggers. For more information, see:

Click here to view an Actionset. Headaches: Identifying and avoiding triggers.

Nonprescription drugs. Medicines you can buy without a prescription usually work to stop the pain from tension headaches. Nonsteroidal anti-inflammatory drugs (NSAIDs) (such as aspirin or ibuprofen) and combination drugs (such as those that combine aspirin, acetaminophen, and caffeine) work best to stop tension headache pain. You can look at the back of the box or bottle to find the active ingredients. But try to avoid taking nonprescription drugs more than 3 times a week, because you may get rebound headaches. Rebound headaches are different from tension headaches. They are usually triggered after pain medicine has worn off, prompting you to take another dose. Eventually, you get a headache whenever you stop taking the medicine.

Prescription drugs. If the nonprescription medicines above don't work to stop your headaches, or if you take them more than 3 times a week or have a headache more than 15 days a month, your doctor may recommend you take a medicine every day to help prevent tension headaches. Your doctor may have you try one of more of the following medicines to help prevent your headaches:

In some cases your doctor may prescribe a medicine such as a barbiturate or narcotic to stop a headache if nonprescription medicines don't work. But these drugs can be habit-forming and should be used sparingly.

Click here to view a Decision Point. Should I take prescription drugs for tension headaches?

Stress management. Managing stress, anxiety, or depression may help reduce the frequency of tension headaches. The best approach to managing chronic tension headaches may be a combination of drugs and stress management therapies. Nonmedication methods for reducing stress may include:

It is important to have a good treatment plan for ongoing care of tension headaches, especially chronic tension headaches. You and your doctor will work together to find the best treatment to relieve or prevent your tension headaches. Typically, ongoing treatment includes using drugs to relieve your pain and practicing stress management techniques, such as relaxation exercises or meditation.

Treatment if the condition gets worse

If you continue to have tension headaches while you are getting treatment, you and your doctor may want to try another treatment plan. Changing drugs, trying a different type of pain reliever, or taking other drugs daily (such as antidepressants) may help improve your symptoms or reduce the number of tension headaches you develop. If you have already tried several different types of drugs, your doctor may order tests (such as an MRI or CT scan) to rule out other causes of your headaches.

What To Think About

Even with treatment, you will most likely continue to have some tension headaches. For most people, successful treatment means you get headaches less often and they are less severe when you do get them. It is rare for any treatment to be able to stop all tension headaches. Finding an effective drug may take some time and patience. It may take several attempts to find the drug that works best for you.

If you think your tension headaches could be related to depression or anxiety, be sure to let your doctor know. You may be able to stop or reduce the occurrence of tension headaches with proper treatment of these conditions.

Botulinum toxin type A (BTX-A) is sometimes injected into the muscles in the face and head, to reduce contractions or spasms that in the past were thought to produce tension headaches. But BTX-A injections do not seem to help with symptoms of tension headaches.1, 3 And BTX-A may cause weakness of the facial muscles and may affect swallowing.

Prevention

You may be able to prevent the frequency and severity of tension headaches by reducing muscle tension and by identifying and avoiding the triggers, such as stress, anxiety, fatigue, hunger, anger, poor posture, or overexertion.

For more information, see:

Click here to view an Actionset. Headaches: Identifying and avoiding triggers.

If you have tension headaches related to muscle tension in your neck, shoulders, and upper back, pay attention to your posture and position during your daily activities.

Your doctor may also prescribe medicine to help prevent tension headaches.

Home Treatment

There are many things you can do at home to reduce the frequency and severity of tension headaches. Reducing stress, getting regular exercise, eating right, and learning better ways to manage depression and anxiety may help.

Try the following:

  • Find healthy ways to deal with stress. You may be more likely to get tension headaches during stressful times.
  • Do relaxation exercises to reduce muscle tension and stress, which may help reduce the frequency and duration of tension headaches.
  • Take medicine as prescribed by your doctor to prevent and treat your tension headaches. This will also help you to avoid getting rebound headaches, which can be caused by overusing pain relievers.
  • Identify your headache triggers and determine whether your headaches are becoming more severe by keeping a headache diary(What is a PDF document?) .
  • Seek help if you think your tension headaches may be linked to depression or anxiety. Proper treatment of these conditions may reduce the frequency of your headaches, as well as relieve your symptoms of anxiety or depression.

For more information, see:

Click here to view an Actionset. Headaches: Identifying and avoiding triggers.
Click here to view an Actionset. Headaches: Managing headaches.

Tension headaches in children

If your child has tension headaches, they may be related to stress about school, such as tests, athletic events, dances, or peer pressure. They may also be related to lack of sleep. You may want to keep a diary of your child's headaches, to help identify his or her triggers. Talk to your doctor about the best treatment for your child's headaches. Be sure to let your doctor know if your child's headaches are not getting better.

Medications

Your doctor may recommend medicine to both treat and prevent tension headaches. He or she may first suggest you try a nonprescription drug, which usually has fewer side effects than prescription drugs. The type of tension headache that you have may help your doctor determine which drug to prescribe. You may have to try several different drugs or types of drugs before you find the one that is right for you. Good communication with your doctor is important in finding the most effective treatment for you.

Medication Choices

Nonprescription medicines you can use to stop a headache include:

  • Aspirin.
  • Ibuprofen (such as Advil or Motrin).
  • Naproxen (such as Aleve).
  • Acetaminophen (such as Tylenol).
  • A combination medicine that includes aspirin, acetaminophen, and caffeine (such as Excedrin).

If nonprescription medicines don't work, your doctor may prescribe a medicine such as a barbiturate or narcotic to stop a headache. But these drugs can be habit-forming and should be used sparingly.

If the nonprescription medicines above don't work to stop your headaches, or if you take them more than 3 times a week or have a headache more than 15 days a month, your doctor may recommend you take a prescription medicine every day to help prevent headaches. Medicines used to help prevent tension headaches include:

Click here to view a Decision Point. Should I take prescription drugs for tension headaches?

Botulinum toxin type A (BTX-A) is sometimes injected into the muscles in the face and head, to reduce contractions or spasms that in the past were thought to produce tension headaches. But BTX-A injections do not seem to help with symptoms of tension headaches.1, 3 And BTX-A may cause weakness of the facial muscles and may affect swallowing.

What To Think About

Try to avoid taking nonprescription drugs more than 3 times a week because you may get rebound headaches. Rebound headaches are different from tension headaches. They are usually triggered after pain medicine has worn off, prompting you to take another dose. Eventually, you get a headache whenever you stop taking the medicine.

Certain pain medicines interact poorly with other medicines. Before you begin taking pain medicines, be sure to let your doctor know about all of the drugs—both prescription and nonprescription, and other complementary therapies (such as herbs)—that you are taking.

Surgery

There is no surgical treatment for tension headaches.

Other Treatment

While you may use medicine to treat or prevent tension headaches, adding stress management therapies may help reduce the frequency of your tension headaches. Talk to your doctor about trying:

  • Biofeedback , a relaxation method to help you learn to control a body function that is not normally under conscious control, such as muscle tension.
  • A relaxation exercise during which you focus on relaxing each muscle group. Relaxation exercises can help with tension headaches.
  • Acupuncture , which involves putting very thin needles into the skin at certain points on the body. Current evidence shows that acupuncture can help prevent tension headaches.2
  • Transcutaneous electrical nerve stimulation (TENS) , which may help reduce pain.
  • Cognitive-behavioral therapy or problem-solving therapy during counseling sessions. Cognitive-behavioral therapy and problem-solving therapy can help with tension headaches.
  • Yoga.
  • Meditation .
  • Peppermint oil. There is some evidence that peppermint oil rubbed on the temples or on the tight muscles in the head, neck, and shoulders may help relieve tension headaches.

Other Places To Get Help

Organizations

National Institute of Neurological Disorders and Stroke
P.O. Box 5801
Bethesda, MD  20824
Phone: 1-800-352-9424
(301) 496-5751
TDD: (301) 468-5981
Web Address: www.ninds.nih.gov
 

The National Institute of Neurological Disorders and Stroke (NINDS), a part of the National Institutes of Health, is the leading U.S. federal government agency supporting research on brain and nervous system disorders. It provides the public with educational materials and information about these disorders.


American Headache Society Committee for Headache Education (ACHE)
19 Mantua Road
Mount Royal, NJ  08061
Phone: 1-800-255-2243
Fax: (856) 423-0082
E-mail: achehq@talley.com
Web Address: www.achenet.org
 

The American Headache Society Committee for Headache Education (ACHE) is a nonprofit partnership between health professionals and headache sufferers. ACHE provides resources and tools to health care professionals to help them help their headache patients. This Web site has many different educational resources for doctors, patients, families, schools, and employers. Resources include newsletters, articles on headaches, tools for both patients and doctors, and lists of certified headache doctors.


National Headache Foundation (NHF)
820 North Orleans
Suite 217
Chicago, IL  60610
Phone: 1-888-643-5552
(312) 274-2650
E-mail: info@headaches.org
Web Address: www.headaches.org
 

The National Headache Foundation is a nonprofit organization dedicated to three major goals: educating the public that headaches are serious disorders and that sufferers need understanding and continuity of care; promoting research into potential headache causes and treatments; and serving as an information resource for sufferers, their families, and doctors who treat them. The NHF can provide lists of local doctors specializing in headache treatment. It also has a monthly newsletter and many pamphlets on a variety of topics related to the different headache syndromes.


References

Citations

  1. Silver N (2006). Headache (chronic tension-type), search date October 2005. Online version of Clinical Evidence (15).
  2. Linde K, et al. (2009). Acupuncture for tension-type headache. Cochrane Database of Systematic Reviews (1).
  3. Naumann M, et al. (2008). Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 70(19): 1707–1714.

Other Works Consulted

  • Moja L, et al. (2005). Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. Cochrane Database of Systematic Reviews (3).
  • Ropper AH, Samuels MA (2009). Tension headache section of Headache and other craniofacial pains. In Adams and Victor's Principles of Neurology, 9th ed., pp. 176–177. New York: McGraw-Hill.

Credits

Author Monica Rhodes
Editor Kathleen M. Ariss, MS
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer Colin Chalk, MD, CM, FRCPC - Neurology
Last Updated July 22, 2009

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