A tension headache is pain or discomfort in the head, scalp, or neck, usually associated with muscle tightness in these areas.
Muscle contraction headache; Headache - benign; Headache - tension; Chronic headaches - tension; Rebound headaches - tension
Causes, incidence, and risk factors
Tension headaches are one of the most common forms of headaches. They may occur at any age, but are most common in adults and adolescents.
If a headache occurs two or more times a week for several months or longer, the condition is considered chronic. Chronic daily headaches can result from the under- or over-treatment of a primary headache. For example, patients who take pain medication more than 3 days a week on a regular basis can develop rebound headaches.
Tension headaches can occur when the patient also has a migraine.
Tension headaches occur when neck and scalp muscles become tense, or contract. The muscle contractions can be a response to stress, depression, a head injury, or anxiety.
Any activity that causes the head to be held in one position for a long time without moving can cause a headache. Such activities include typing or other computer work, fine work with the hands, and using a microscope. Sleeping in a cold room or sleeping with the neck in an abnormal position may also trigger a tension headache.
Other triggers of tension headaches include:
Tension headaches are not associated with structural changes in the brain.
The headache pain may be described as:
- Dull, pressure-like (not throbbing)
- A tight band or vise on the head
- All over (not just in one point or one side)
- Worse in the scalp, temples, or back of the neck, and possibly in the shoulders
The pain may occur as an isolated event, constantly, or daily. Pain may last for 30 minutes to 7 days. It may be triggered by or get worse with stress, fatigue, noise, or glare.
There may be difficulty sleeping. Tension headaches usually do not cause nausea or vomiting.
People with tension headaches tend to try to relieve pain by massaging their scalp, temples, or the bottom of the neck.
Signs and tests
A headache that is mild to moderate, not accompanied by other symptoms, and responds to home treatment within a few hours may not need further examination or testing, especially if it has occurred in the past. A tension headache reveals no abnormal findings on a neurological exam. However, tender points (trigger points) in the muscles are often seen in the neck and shoulder areas.
The health care provider should be consulted -- to rule out other disorders that can cause headache -- if the headache is severe, persistent (does not go away), or if other symptoms are present with the headache.
Headaches that disturb sleep, occur whenever you are active, or that are recurrent or chronic may require examination and treatment by a health care provider.
Understanding your headache triggers can help you avoid situations that cause your headaches. A headache diary can help you identify your headache triggers. When you get a headache, write down the day and time the pain began. The diary should include notes about what you ate and drank in the last 24 hours, how much you slept and when, and what was going on in your life immediately before the pain started. For example, were you under any unusual stress? Also include information about how long the headache lasted, and what made it stop.
Hot or cold showers or baths may relieve a headache for some people. You may need to make lifestyle changes if you have chronic tension headaches. This may include changing your sleep habits (usually to get more sleep), increasing exercise, and stretching the neck and back muscles. In some situations, you may need to change your job or recreational habits.
Over-the-counter painkillers such as aspirin, ibuprofen, or acetaminophen may relieve pain if relaxation techniques do not work. If you are planning to take part in an activity that you know will trigger a headache, taking one of these painkillers beforehand may be helpful.
Narcotic pain relievers are sometimes prescribed. Remember that pain medications only relieve headache symptoms for a short period of time. After a while, they do not work as well or the help they provide does not last as long. Regular, overuse of pain medications can lead to rebound headaches.
Other prescription treatments may include:
- Muscle relaxants such as tizanidine
- Selective serotonin-reuptake inhibitors (SSRIs) such as paroxetine (Paxil) or citalopram (Celexa) taken daily to help prevent or decrease the number of headaches
- Tricyclic antidepressants such as amitriptyline, nortriptyline, or doxepin taken daily to help prevent or decrease the number of headaches
Combining drug treatment with relaxation or stress-management training, biofeedback, cognitive behavioral therapy, or acupuncture may provide better relief for chronic headaches.
Botox (botulinum toxin) is becoming popular as a treatment for chronic daily headaches, including tension headaches. However, it is currently not approved for such use.
Tension headaches usually respond well to treatment without residual effects.
Although they are not medically dangerous, chronic tension headaches can have a negative impact on the quality of life and work productivity.
Rebound headaches -- headaches that keep coming back -- may occur from overuse of painkillers.
It's important to see a doctor if you have chronic headaches. In some cases, the headache may be a symptom of a more serious disorder.
Calling your health care provider
Call 911 if:
- You are experiencing "the worst headache of your life"
- You have speech, vision, or movement problems or loss of balance, especially if you have not had these symptoms with a headache before
- Your headaches are more severe when lying down
- The headache starts very suddenly
Also, call your doctor if:
- Your headache patterns or pain change
- Treatments that once worked are no longer helpful
- You have side effects from medication, including irregular heartbeat, pale or blue skin, extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain, cramps, dry mouth, or extreme thirst
- You are pregnant or could become pregnant -- some medications should not be taken when pregnant
See the general article on headaches for more emergency headache symptoms
Learn and practice stress management. Some people find relaxation exercises or meditation helpful. Biofeedback may improve relaxation exercises and may be helpful for chronic tension headache.
Tips to prevent tension headaches:
- Keep warm if the headache is associated with cold.
- Use a different pillow or change sleeping positions.
- Practice good posture when reading, working, or doing other activities.
- Exercise the neck and shoulders frequently when typing, working on computers, or doing other close work.
- Get plenty of sleep and rest.
Massaging sore muscles may also help.
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Naumann M, So Y, Argoff CE, Childers MK, Dykstra DD, Gronseth GS, et al. 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. 2008;70(19):1707-1714.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2009;(1):CD007587.
Kevin Sheth, MD, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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