Tension Headache

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the website Patient UK, authored by Dr Colin Tidy (see below), reviewed by Prof Cathy Jackson. Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Tension headache is the most common form of headache. Painkillers taken only when needed for the pain, work well in most cases. Attention to lifestyle factors, such as stress, posture and exercise, may help to prevent headaches. Medication to prevent headaches may help those who have frequent tension-type headaches.

What is tension headache and who it affected by it?

Tension headache is the most common type of headache people experience. It's difficult to say precisely how common, as estimates from different studies have varied wildly, but most people will have a tension headache at some point in their lives.

Those studies which have tried to determine how many people experience tension headaches suggest that:

Somewhere around half of adults experience tension headaches at least every month, and about 1 in 30 adults experience chronic tension headaches (headaches on more than half of the days for three months or more) - although some of these cases may be medication-overuse headaches (medication-induced headaches) and it may therefore be an overestimation.

Tension headaches are called episodic tension headaches if they occur on less than half of the days in a month. They are called chronic tension headaches if they occur more than half of the time.

Symptoms

What are the symptoms of a tension headache?

• Tension headaches are usually felt as a band of pain across the forehead. They can last for anything from a few hours to several days, although a few hours is most common. They can be uncomfortable and tiring, but they do not usually disturb sleep. Most people can carry on working with a tension headache. They are not usually made worse by physical activity, although it's not unusual to be a bit sensitive to bright light or noise.
• Tension headaches tend to come on during the day and worsen as the day goes on; they are often mildest in the morning. (An exception to this would be a headache caused by sleeping in an awkward position, causing a sore neck, or an ache in the face and jaw due to tooth grinding.)
• The pain is usually moderate or mild but sometimes it can be severe.
• Tension headaches are usually felt on both sides of the head - most often the front. Typically, the pain is like a tightness around the hat-band area. Some people feel a squeezing or pressure on their head.
• Tension headaches can interrupt concentration but are usually not bad enough to send you to bed. Most people can work through a tension headache if they really need to.
• Tension headaches can be caused by tightness in the muscles at the back of the neck and over the scalp. The underlying causes include anything which makes those muscles tense, including poor posture, stress and sleeping on too many pillows.
• Tiredness, anxiety and hunger can also make them worse. Working long hours hunched over a computer may also trigger them.
• Some people get tension headaches if they drink too much caffeine or alcohol, if they don't drink enough water or if they go for a long time between meals.

There are usually no other symptoms. Some people don't like bright lights or loud noises, and don't feel like eating much when they have a tension headache.

Causes

What causes tension headaches?

The cause is not clear. Some may be due to muscular tension; however, many tension headaches develop for no apparent reason.

Some may be triggered by things such as:

• Emotional tension, anxiety, tiredness or stress.
• Physical tension in the muscles of the scalp and neck.
• Eye strain.
• Hunger.
• Physical factors such as bright sunlight, cold, heat, noise, etc.

Your genetic make-up may also be a factor. So, some people may inherit a tendency to be more prone to develop tension headaches more easily than others when stressed or anxious.

Tension headache is a primary headache - which means that it is not caused by other conditions. So, if you have a tension-type headache, a doctor's examination will be normal apart from the muscles around the head perhaps being a little tender when a doctor presses on them. Any tests that may be done will also be normal.

Are any other headaches similar to tension headache?

Some common conditions can cause a headache similar to a tension headache. These include a high temperature (fever), which may cause a similar headache. A similar headache is also common if you don't have caffeine for a while when you were used to drinking lots of caffeine-rich drinks, such as a lot of coffee. This is a caffeine withdrawal headache.

What is the risk of developing medication-overuse headache if I have tension headache?

Medication-overuse headache is caused by taking painkillers (or triptan medicines) too often for tension headaches or migraine attacks. The body responds to this by increasing the number of pain receptors in the head, so that the head becomes excessively sensitive and pain is felt all the time. If you find that you are having headaches on most days then this may be a cause. Speak with a doctor for advice.

How can I be sure it is not a more serious type of headache?

With tension headaches, you are normally well between headaches, and have no other ongoing symptoms. A doctor diagnoses that headaches are the tension type by their description. Also, there is nothing abnormal to find if a doctor examines you (apart from some tenderness of the muscles around the head when a headache is present). Tests are not needed unless you have unusual symptoms, or something other than tension headache is suspected.

The kind of symptoms that might make a doctor wish to do further tests to make absolutely sure your headache is not serious include:

• You have had a significant head injury in the previous three months.
• Your headaches are worsening and accompanied by high temperature (fever).
• Your headaches start extremely suddenly.
• You have developed problems with speech and balance as well as headache.
• You have developed problems with your memory or changes in your behaviour or personality as well as headache.
• You are confused or muddled with your headache.
• Your headache started when you coughed, sneezed or strained.
• Your headache is worse when you sit or stand.
• Your headache is associated with red or painful eyes.
• Your headaches are not like anything you have ever experienced before.
• You have unexplained sickness (vomiting) with the headache.
• You have low immunity - for example, if you have HIV, or are on oral steroid medication or medicines which suppress the immune system.
• You have or have had a type of cancer that can spread through the body.

Treatment

What are the treatments for tension headache?

Lifestyle

The best approach is to try to work out what triggers your headache. Changes in lifestyle can also help. A walk, some exercise, or simply taking a break from the normal routine may help. A neck and shoulder massage may help. A hot flannel on your neck or a warm bath may also help. Try to drink less caffeine and more water. Try to have a sensible diet where you eat regularly and have a good balance of slow-release energy foods, rather than lots of sugars.

Reducing the number of pillows you sleep on can sometimes help, particularly if you sleep on more than two pillows. Sleeping on your side on high pillows means that your neck is bent which can cause tension and then headaches.

Other ways to avoid tension headaches are by having plenty of sleep and avoiding excessive noise.

Occasionally tension headaches are caused by reading in low light for long periods.

Painkillers

Painkillers often work well to ease a tension headache. Note: you should not take painkillers for headache for more than a couple of days at a time. Also, on average, do not take them for more than two days in any week for headaches. See a doctor if you need painkillers for headaches more often than this. If you take them more often, you may develop medication-overuse headache (medication-induced headache). Do not take painkillers to prevent headaches. Take each day as it comes.

Painkillers that are used include:

• Paracetamol, which often works well. It is best to take a full dose as soon as a headache starts. This may ward off the headache better than treating it after it has fully developed. You can take a second dose after four hours if necessary.
• Anti-inflammatory painkillers are alternatives to paracetamol. These include ibuprofen which you can buy at pharmacies. You need a prescription for other types, such as diclofenac and naproxen. Typically, anti-inflammatory painkillers, rather than paracetamol, probably ease the pain in more people with headaches. However, some people develop side-effects such as stomach problems, and paracetamol does work in a lot of people. So, it is probably best to see how you get on with paracetamol first before trying an anti-inflammatory painkiller. Always read the leaflet which comes with the medicine packet for a list of possible side-effects and cautions. For example, if you are pregnant or breastfeeding, there are some restrictions on the use of anti-inflammatory painkillers.
• Some doctors do not recommend aspirin, as it has an even higher risk of causing stomach side-effects than anti-inflammatory painkillers have. Bearing this in mind, you may wish to try aspirin if you do not tend to get much relief from paracetamol or anti-inflammatory painkillers. Read the leaflet which comes with the medicine packet for a list of possible side-effects and cautions. Note: teenagers and children under the age of 16 years should not take aspirin.
• Opiate painkillers such as codeine, dihydrocodeine and morphine are not normally recommended for tension headaches. This includes combination tablets that contain paracetamol and codeine, such as co-codamol. The reason is because opiate painkillers can make you drowsy. They are also the most likely type of painkiller to cause medication-overuse headache if used regularly (described earlier). People who take opiate painkillers are also at increased risk of developing chronic tension headache.

Prevention

How can I prevent frequent/chronic tension headaches?

Diary

It may help to keep a diary if you have frequent headaches. Note when, where and how bad each headache is, and how long each headache lasts. Also note anything that may have caused it. A pattern may emerge and you may find a trigger to avoid. For example, hunger, eye strain, bad posture, stress, anger, etc. Also try to take note of things that made it better, and things that were different on the days you were well, which may help point to a clue regarding what was wrong.

Stress

Stress is a trigger for some people who develop tension headaches. Avoid stressful situations whenever possible. Sometimes a stressful job or situation cannot be avoided. Learning to cope with stress and to relax may help. Breathing and relaxation exercises, or coping strategies, may ease anxiety in stressful situations and prevent a possible headache. There are books and tapes which can help you to relax. Sometimes a referral to a counsellor or psychologist may be advised.

Regular exercise

Some people with frequent headaches say that they have fewer headaches if they exercise regularly. If you do not do much exercise, it may be worth trying some regular activities like brisk walking, jogging, cycling, swimming, etc. (This will have other health benefits too apart from helping with headaches.) It is not clear how exercise may help. It may be that exercise helps to ease stress and tension, which can have a knock-on effect of reducing tension headaches. It may also improve posture and neck muscle tension.

Medication

Amitriptyline is the medicine most commonly used to prevent tension headaches. This is not a painkiller and so does not take away a headache if a headache develops. It is an antidepressant medicine and you have to take it every day with the aim of preventing headaches. (One effect of some antidepressants is to ease pain and prevent headaches even in people who are not depressed. So, although amitriptyline is classed as an antidepressant, it is not used here to treat depression.) A low dose is started at first and may need to be increased over time, as the dose has to be built up slowly in order to avoid side-effects. Once the headaches have been reduced for 4-6 months, the amitriptyline can be stopped. Treatment can be resumed if headaches return (recur). Other medicines are sometimes tried if amitriptyline is not suitable or does not help.

The time to consider taking medication for the prevention of headaches is not clear. If you are regularly having tension headaches more than four times a month then preventative treatment is best before headaches become very frequent. This may prevent frequent episodic tension headaches from becoming chronic tension headaches.

The goals of preventative treatment are to reduce the frequency and intensity of headaches. So, with treatment, the headaches may not go completely, but they will often develop less often and be less severe. Any headache that does occur whilst taking preventative medication may also be eased better than previously by a painkiller.

It is often difficult in retrospect to say how well a preventative treatment has worked. Therefore, it is best to keep a headache diary for a couple of weeks or so before starting preventative medication. This is to record when and how severe each headache was, and also how well it was eased by a painkiller. Then, keep the diary going as you take the preventative medicine to see how well things improve. The headaches are unlikely to go completely but the diary may show a marked improvement.

About the author

Dr Colin Tidy

MBBS, MRCGP, MRCP, DCH

Dr Colin Tidy qualified as a doctor in 1983 and he has been writing for Patient since 2004. Dr Tidy has 25 years’ experience as a General Practitioner. He now works as a GP in Oxfordshire, with a special interest in teaching doctors and nurses, as well as medical students.  In addition to writing many leaflets and articles for Patient, Dr Tidy has also contributed to medical journals and written a number of educational articles for General Practitioner magazines.

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