Things to Know About Tension Headaches
Tension headaches mainly hurt in the forehead, temples, or the back of the head and/or neck. Tension headaches may cause a dull, aching pain on both sides of the head or a “vice-like” tightening in the head and neck.
- More than 10 million people a year visit a doctor or an emergency department because of headaches.
- Tension headache is the most common type of headache.
- A majority of men and women develop a tension headache sometime during their lives.
- Tension headache can occur at any age but most commonly begins during adolescence or young adulthood, with the highest frequency among those aged 20-50 years.
- More than 300 known medical disorders can produce headaches. In 1988, the International Headache Society developed a classification system for headaches. Thirteen categories of headaches are subdivided into 129 subtypes. Headache types are described as primary or secondary.
- Primary headaches include migraine, tension-type, and cluster headaches. Most people who see a doctor for headache pain have one of these types. Primary headaches are usually harmless, but they may come back again and again.
- Secondary headaches are often the result of some underlying disease, of which head pain is a symptom.
- The International Headache Society further divides tension headaches into episodic or chronic and on the presence or absence of pericranial muscle tenderness (pain on the outside of the skull).
- People with episodic tension-type headaches have at least 10 previous headache episodes lasting from 30 minutes to 7 days and occurring fewer than 180 times a year. The headache must have at least 2 of the following characteristics:
- Pressing/tightening (non-pulsating) quality, located on both sides of the head
- Mild or moderate intensity
- Not aggravated by routine physical activity
- No nausea or vomiting
- Possible sensitivity to light or sound but not both
- People with chronic tension-type headaches have an average headache frequency of 15 days a month or 180 days a year for 6 months and must also meet the criteria for episodic tension-type headaches. In addition, people with chronic tension-type headaches must not have another disorder as shown by physical and neurologic examination.
What Causes Tension Headaches?
- Many people associate the onset of tension-type headacheadachesstress or upsetting emotional situations. However, these factors have not been shown to lead to muscle contraction or reduced blood flow. Although people may have tenderness of the muscles surrounding the head, tension-type headache is not the result of sustained muscle contraction.
- The most compelling and current evidence points to central nervous system dysfunction as the underlying cause of tension-type headaches. Thus, the muscle ache of tension-type headache is thought to be a result of increased sensitivity of the nervous system and pain from occasional or long-term imbalances in brain chemicals known as neurotransmitters (serotonin, dopamine, norepinephrine, and enkephalins).
- Studies show that some people with primary headache disorders respond to medications that specifically target and influence serotonin. These are mostly people who have migraine or cluster headaches. Most of those who do not have migraine or cluster headaches do not respond to serotonin-targeted drugs.
- People with chronic tension-type headaches may also have imbalances in neurochemicals. Depression may be an underlying cause in some people with chronic tension headaches. Depression and some sleep disorders are linked to serotonin.
What Are the Signs and Symptoms of a Tension Headache?
In general, a tension-type headache may cause diffuse (spread out, not in one place) pressure or tightness. Sometimes, muscles surrounding the head are tender.
- The pain may be on both sides of the head, or it may cause an aching or squeezing sensation located in the forehead, temples, or back of the head with radiation to the neck and shoulders. Pain is usually moderate in intensity, not severely disabling, and not associated with the typical symptoms of migraine, such as nausea, vomiting, or sensitivity to sound or light.
- The onset of pain is usually gradual and not associated with any prodrome or period in which a person can feel a headache coming on.
- People may associate the onset of a tension-type headache with periods during or after stress and usually toward the latter part of the day.
- If the tension-type headache is present for more than 15 days a month or longer than 6 months, it is considered chronic rather than episodic.
When to Seek Medical Care for a Tension Headache
When to call the doctor
- People with episodic or chronic tension-type headaches who experience a change in severity or frequency should consult with a doctor.
- People without a history of headaches who are older than 50 years and who experience pain in the temporal region (near the temple on the head) should see a doctor to be evaluated for temporal arteritis. In addition, those older than 50 years with new-onset headaches should be evaluated for possible malignancy.
- When a headache is associated with signs of infection, such as fever, rash, or stiff neck, a doctor should be seen to rule out conditions like meningitis, encephalitis, or Lyme disease.
- Persons with new-onset headaches who either have risk factors for HIV infection, or who have HIV infection or cancer, may need imaging studies to rule out meningitis, brain abscess, or the spread of cancer.
When to go to the hospital
Certain headaches may indicate a more serious underlying problem. In these cases, the person should seek immediate medical attention at a hospital emergency department.
- People who may or may not have a history of headaches and feel they are experiencing the worst headache of their life should seek emergency help, especially if the headache feels "explosive" and came on suddenly. This may suggest bleeding within or around the brain. The sudden onset, not necessarily the severity of the pain, is a signal that people with such headaches should be checked.
- People with headaches and other associated symptoms, such as loss of vision in one eye, weakness on one side of the body, slurring or garbled speech, or inability to understand and follow commands, should be evaluated at once.
- Any person, but especially an elderly person, who sustains any form of trauma associated with the onset of headaches must be evaluated in an emergency department.
How Is a Tension Headache Diagnosed?
Most tension-type headaches are diagnosed based on a complete and comprehensive history and physical examination. No further diagnostic studies are needed for people who have normal neurological examination findings and are otherwise healthy.
In contrast, people with chronic tension-type headaches, regardless of whether they have normal neurological examination findings, should have a CT scan and MRI. Although this sophisticated imaging does not diagnose a specific type of headache syndrome, it may prove invaluable in excluding other causes of headaches. Thyroid function studies, complete blood cell count, and metabolic screening should also be performed.
What Natural or Home Remedies Help Soothe and Cure Tension Headaches?
Most people with tension-type headaches find relief with over-the-counter medications such as aspirin, acetaminophen (Tylenol and many others), and other nonsteroidal anti-inflammatory drugs (NSAIDs).
- Certain people may require prescription-strength pain relievers for particularly severe episodes.
- Frequent use of medications to treat symptoms of headaches may actually cause episodic tension-type headaches to become chronic in nature.
What Over-The-Counter Medications Soothe and Treat Tension Headaches?
Doctors will suggest over-the-counter pain relievers such as aspirin, acetaminophen, and other NSAIDs. These provide relief for most people with tension-type headaches.
What Prescription Medications Treat Tension Headaches?
Prescription-strength pain relievers may be given once the doctor has a better understanding of a person's headache and other coexisting medical conditions. Doctors are careful, however, to prevent people from becoming dependent on strong narcotic drugs, especially when headaches come back again and again.
For headache pain that cannot be controlled with pain relievers, doctors may prescribe preventive therapy such as antidepressants, beta-blockers, or anticonvulsants.
Do I Need to Follow Up With My Doctor After Being Diagnosed With Tension Headache?
People with the diagnosis of tension-type headache should take medications as directed and arrange a return visit to the doctor in 1-2 weeks. At that time, the doctor can make medication adjustments or provide further diagnostic work if the diagnosis remains uncertain.
- Medical attention should be sought immediately if new symptoms or a profound change in symptoms are experienced.
- If a person has depression or anxiety disorders, or if he or she simply overuses medications, detoxification is necessary before effective treatment can begin. Some people with very complex situations may benefit from combinations of medications. In these cases, the doctor may make referrals to neurologists, psychiatrists, or anesthesiologists.
Can Tension Headaches Be Prevented?
Medications used for the prevention of tension-type headaches include antidepressants, beta-blockers, and anticonvulsants. These medications are usually worth trying, but they are more likely to be effective if the person also has migraine or cluster headaches. Most doctors choose to start with the newer generation antidepressants, which have fewer side effects, and gradually increase the dose to reach a therapeutic effect. Antidepressants may have to be tried for 1-2 months to determine if they help.
What’s the Outlook for a Person Who Suffers From Tension Headaches?
Tension-type headache is a harmless medical condition that responds well to over-the-counter pain relievers taken when an occasional headache strikes. Some people with episodic tension-type headache overuse medications and causing headaches to progress into chronic tension-type headaches.
At present, no studies associate tension-type headaches with the development of more severe or life-threatening medical conditions. Additionally, no studies specifically evaluate chronic tension-type headaches. The outlook for people with chronic tension-type headaches is not well understood.
Reviewed on 10/14/2022
Medically reviewed by Joseph Carcione, DO; American board of Psychiatry and Neurology
Taylor, F. R., MD. "Tension-type headache in adults: Acute treatment." UpToDate. Updated Mar 10, 2015.