Tension headaches, the most common type of headache, produce a dull and pressure-like pain in the head, neck and scalp. They are usually mild but can become debilitating in some people.

Head pain associated with a tension headache is usually generalized, with areas of more intense pain in the scalp, forehead, temples or the back of the neck. In addition, the condition can cause pressure that is similar to the sensation of having a vice or a tight band on the head or around the neck. The severity of a tension headache varies from patient to patient, as well as from headache to headache in the same person. In many people, tension headaches are accompanied by other symptoms including neck or jaw discomfort and tenderness in the scalp, neck and shoulder muscles.

Tension headaches may occur occasionally or as frequently as every day. Tension headaches that occur on fewer than 15 days a month are referred to as episodic, and those occurring on 15 days a month or more for at least six months may be described as chronic. Each episode may last anywhere from 30 minutes to a week. During this time, the intensity of the pain may fluctuate. This type of headache typically develops early in the day, often after a person wakes up.

The exact cause of tension headaches remains unknown. For many years, experts have believed the condition is triggered by the contraction of neck and scalp muscles. More recently, some experts have investigated the theory that the condition results from changes in brain chemicals. Researchers, however, have been able to identify a number of factors that may trigger a tension headache. These include stress, depression and anxiety.

Although tension headaches can interfere with a patient’s daily life, they are usually not a symptom of an underlying disease. In some cases, however, a number of serious conditions (e.g., brain tumor, aneurysm) can cause headaches that may be mistaken for tension headaches. A physician evaluates the patient by taking a medical history and performing a physical examination. Imaging studies such as MRI or CAT scan may be performed to rule out other conditions.

Tension headaches cannot be cured. However, there are a number of methods used to control symptoms and prevent future episodes. These include such headache medications as analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs). Other pain management methods, such as acupuncture, may also be used. Patients may also prevent tension headaches by altering their lifestyle to avoid factors that trigger the headaches. 

The American Pain Foundation estimates that tension headaches account for 90 percent of headaches not due to disease. Although they can occur at any age, tension headaches are most common in patients in their 30s and in women.   

Patients should seek emergency medical treatment when a headache is accompanied by symptoms not experienced with previous tension headaches (e.g., speech problems, vision abnormalities) as it may indicate a more serious medical condition.

A tension headache is characterized by a dull, achy pain in the head, neck or scalp. It is the most common form of headache.

According to the American Pain Foundation, tension headaches account for 90 percent of headaches not due to disease. The headaches typically cause pain on both sides of the head as well as the back of the neck and at the base of the skull. They may also produce a sensation of tightness in the forehead or at the temples. Many patients compare the pressure of a tension headache to the sensation produced by wearing a tight band around the head or neck.

The level of pain associated with a tension headache may fluctuate throughout the course of the headache. This pain, which may be mild or moderate, may last anywhere from 30 minutes to a week. The severity of the pain varies from patient to patient, as well as from episode to episode in the same person. The frequency of the headaches also varies. Though some patients may experience them often, others may experience tension headaches only occasionally. In most cases, the pain develops early in the day, usually soon after a patient wakes up.

Tension headaches can interfere with a patient’s daily life. The pain associated with the condition often prevents a person from attending work and social activities. Although they are bothersome, tension headaches are not usually a symptom of an underlying disease. In some cases, however, head pain may indicate a more serious underlying condition such as a brain tumor, stroke or aneurysm.

Patients should discuss all severe, persistent or recurring headaches with their physician and seek medical attention when a headache:

• Disturbs sleep
• Occurs with activity
• Does not improve with treatment
• Changes in pattern or intensity
• Is accompanied by other symptoms, such as drowsiness, nausea and vomiting, vision changes, changes in movement or sensation or changes in alertness

Patients should seek emergency medical treatment when:

• A headache is accompanied by unusual symptoms not experienced with previous headaches, including:
  
  
• Speech problems
• Vision abnormalities, such as double vision
• Numbness, weakness or loss of balance
• Fever
• Stiff neck
• Rash
• Seizures
• Mental confusion
  
  
• A severe headache occurs abruptly
  
  
• A headache occurs after a head injury
  
  
• A chronic headache intensifies with coughing, exertion, straining or sudden movement
  
  
• A new type of headache pain occurs (in those over age 50 or younger than 8)

Tension headaches can be classified into two groups based on frequency:

• Episodic. This type of tension headache occurs on fewer than 15 days a month. They usually last anywhere from 30 minutes up to seven days. The presenting symptom is bilateral  (affecting both sides) tightness around the head, which is not increased with physical activity and not associated with nausea or vomiting.  
  
  
• Chronic. Tension headaches occurring on 15 days a month or more for at least six months may be described as chronic. Twice as many women as men have this form of headache. For many people with this type of headache, the pain is daily or continuous. A tension headache occurring at least six days a week is known as a chronic daily headache. Chronic headaches may persist for many years. When compared to people who do not experience headaches, people with this type of headache are more likely to experience anxiety and depression.

Chronic tension headaches are less common then episodic tension headaches. The severity and duration of chronic and episodic headaches are similar. In addition, either type may be accompanied by scalp tenderness.

A tension headache may also be described as a coexisting migraine and tension-type headache. This term is used to describe the combination of a daily, chronic tension headache and a recurrent migraine. This type of headache is also known as transformed migraine or chronic migraine. In most cases, patients with this condition have a personal history of migraine headaches that can be traced back to adolescence or early adulthood.

The exact cause of tension headaches is unknown. Researchers have developed a number of theories.

For many years, researchers believed tension headaches were caused by the contraction of neck and scalp muscles. Recent research, however, has cast doubt over the accuracy of this theory. A test known as electromyography has been used to record electrical currents produced by muscle activity in people diagnosed with tension headache. The test has been unable to identify increased muscle tension in these people. This indicates that muscle tension may not be the main cause of tension headaches. As a result of these findings, the International Headache Society has begun to refer to tension headaches as “tension–type headaches.”  

A new theory that has emerged suggests that tension headaches are the result of changes in brain chemicals responsible for communication between nerves (e.g., serotonin, endorphins). Although scientists do not understand why these chemical changes take place, they believe the process stimulates pain pathways to the brain and hinders the brain’s ability to suppress pain.

Nitric oxide (a substance involved in the transmission of nerve impulses) is another chemical linked to tension headaches. Researchers believe overproduction of nitric oxide is related to chronic tension headaches. In addition, substances that prevent the production of nitric oxide have been linked to a reduction in the muscle tightness associated with tension headaches.

The chemical changes related to tension headaches are similar to those associated with migraines. As a result, some experts believe the two types of headaches are related. Although the connection is unclear, some researchers believe migraines result from the regular occurrence of tension headaches. As the tension headache–related pain increases in intensity, the characteristics associated with a migraine appear. Another theory is that mild migraines are a form of tension headache.

A number of factors may trigger a tension headache, including:

• Body positioning. Poor posture and ergonomics, working in awkward positions, holding one position for an extended period of time, keeping the head or neck in an unnatural position.
  
  
• Lack of physical activity.
  
  
• Fatigue.
  
  
• Lack of sleep or changes in sleep patterns.
  
  
• Sleeping in a cold room.
  
  
• Skipping meals.
  
  
• Eye strain or close work under poor lighting conditions.
  
  
• Psychological conditions such as stress, depression or anxiety.
  
  
• Hormonal changes such as those caused by menstruation, pregnancy, menopause or hormone use.
  
  
• Medications. These include antidepressants, antihypertensives (drugs for high blood pressure) or frequent use of analgesics (creating rebound withdrawal headaches). However, research has shown that antihypertensives can also prevent headaches in some cases.
  
  
• Other illnesses. Arthritis, sinus infection, nasal congestion, colds or influenza.
  
  
• Physical abnormalities. Neck muscle, bone or intervertebral disc abnormalities or misalignment of the teeth or jaw.
  
  
• Sensory stimulus such as light or noise.
  
  
• Stimulants such as alcohol, nicotine or caffeine.
  
  
• Overexertion.

In addition, a number of factors appear to make a person more likely to develop tension headaches. These risk factors include:

• Age. Although tension headaches can occur at any age, they are most common in patients between the ages of 30 and 39.
  
  
• Sex. Tension headaches are more common in women than men.
  
  
• Family history. Tension headaches are more likely to occur in people with tension headache sufferers in their immediate family (parents, siblings, children). This may be the result of an inherited susceptibility.
  
  
• History of migraines. Most migraine sufferers also get tension-type headaches.

The main symptom of a tension headache is a dull and pressure-like pain in the head. The pain is typically generalized, with areas of more intense pain in the scalp, forehead, temples or the back of the neck. The headache may also produce a feeling of pressure similar to the sensation caused by the placement of a vice or a tight band on the head and/or around the neck.    

Tension headaches may be accompanied by a number of other symptoms including:

• Neck pain or jaw discomfort  
• A clicking sound when opening the jaw
• Tenderness in the scalp, neck or shoulder muscles
• Insomnia (difficulty sleeping)
• Fatigue
• Irritability
• Loss of appetite
• Difficulty concentrating

In addition to these symptoms, tension headache sufferers may also experience a number of symptoms related to migraines, including an increased sensitivity to light or sound. However, this is rare.

Headaches that are mild to moderate in intensity, not accompanied by other symptoms and responsive to treatment within a few hours do not usually require medical attention. However, headaches that are severe, recurrent or chronic should be brought to a physician’s attention. Headaches that interfere with sleep, occur with activity or present with additional symptoms also require examination by a physician.     

During an evaluation for tension headaches, physicians take the patient’s medical history and perform a physical examination. Information provided during these steps can help physicians determine whether a patient’s symptoms are the result of a tension headache or an underlying medical condition (e.g., brain tumor, aneurysm).

While collecting a patient’s medical history, physicians may ask the patient about symptoms. Questions in a pain assessment may focus on the characteristics of the pain, including its severity, location, frequency and duration. It is also common for musculoskeletal tenderness to be discovered during the physical examination.

Correct diagnosis is important because researchers have found that some people who are diagnosed with tension headaches actually have another condition, such as TMJ disorder.

There is no particular test to diagnose tension headaches, so medical history and physical examination are the only way to diagnose this condition.  Other tests may be performed to rule out other serious causes of headaches.  Physicians may use a number of methods to determine the cause of the head pain. These include:   

• MRI (magnetic resonance imaging). MRIs use a powerful magnetic field to create images of structures and organs within the body, allowing a computer to produce clear cross-sectional or three-dimensional images. This test may be ordered to examine the brain and rule out aneurysm and a number of other serious causes.
  
  
• CAT scan (computed axial tomography).  This test allows for multiple x-rays to be taken from different angles around the patient. A computer analyzes the "slices" or cross-sectional images. Frequently after the first set of images is taken, the patient receives an intravenous (I.V.) injection of a contrast agent (dye) to better outline the body parts. Then a second set of images is taken. This test may be ordered to examine the brain and rule out aneurysm and a number of other serious causes.  

There are a number of treatment options available for tension headaches. Although tension headaches cannot be cured, treatments aim to control the symptoms and prevent future episodes.

Although they do not cure headaches, prescription and over-the-counter medications may also be used to prevent tension headaches, stop the progression of tension headaches and relieve symptoms.

In what is known as acute therapy, a number of headache medications are used to stop or reduce the pain of an existing tension headache. These include:

• Analgesics (e.g., acetaminophen). These pain relievers are often effective in relieving headache pain.
  
  
• Nonsteroidal anti-inflammatory drugs (NSAIDs, including aspirin, ibuprofen and naproxen). These drugs are often used to relieve headache pain.
  
  
• Combination medications. Certain medications (e.g., aspirin, acetaminophen) may be combined with caffeine or a sedative into a single drug. Available over the counter and by prescription, these combination drugs are sometimes more effective at relieving pain than pure analgesics.
  
  
• Triptans (serotonin receptor agonists). These drugs may be recommended for patients who experience migraines as well as episodic tension headaches.
  
  
• Opiates. In rare cases, opiates may be prescribed to relieve pain associated with tension headaches. They are not commonly used because they carry a risk for dependence. They also cause a number of negative side effects, such as sedation, nausea and constipation.

Medications used to reduce the frequency and severity of tension headaches include:

• Antidepressants. Normally prescribed to relieve depression, these drugs can prevent tension headaches by stabilizing the levels of serotonin and other brain chemicals. Commonly prescribed antidepressants include:
  
  
  • Tricyclic antidepressants. These are commonly used to prevent chronic and episodic tension headaches.
    
    
  • Selective serotonin reuptake inhibitors (SSRIs). This type of antidepressant is favorable because it often causes fewer side effects than tricyclic antidepressants. However, SSRIs are usually less effective in preventing tension headaches.

Antidepressants may increase the risk of suicidal thinking and behavior in children and adolescents. The U.S. Food and Drug Administration (FDA) has issued an advisory that people being treated with these drugs should be closely monitored for unusual changes in behavior.

• NSAIDs. In addition to their role as acute therapy, daily use of NSAIDs may manage chronic tension headaches in many people.
  
  
• Anticonvulsants. Usually used to control seizures, these medications may be prescribed to prevent tension headaches.
  
  
• Muscle relaxants. In some cases, muscle relaxants are recommended for the prevention of tension headaches, even though the research has shown that muscle relaxants work centrally and cause sedation.  

Patients experiencing tension headaches with the features of a migraine may benefit from taking antihypertensives such as beta blockers or calcium channel blockers. These drugs, commonly used to treat migraines, may be used alone or in combination with antidepressants to reduce the frequency of tension headaches. A recent analysis of 94 clinical trials involving more than 24,000 patients found that four leading classes of antihypertensives (thiazide diuretics, beta blockers, ACE inhibitors, angiotensin II receptor antagonists) can significantly reduce the risk of headaches.

In order to be effective, drugs used to reduce the frequency and severity of tension headaches need to be taken at regular intervals. They are frequently recommended for patients wh

• Experience three or more headaches a week
• Do not find relief from acute or nondrug therapy
• Have headaches lasting longer than three to four hours
• Have severe pain that becomes disabling 
• Have severe pain that causes overuse of acute medication
• Cannot take acute medication because of unrelated medical conditions

Because preventive medication may take several weeks to build up in the nervous system and take effect, patients taking preventive medications may not notice improvement for a couple of months or more. Some patients may require a combination of medications to achieve the greatest effectiveness.

Physicians will closely monitor a patient’s treatment to determine its effectiveness. Once the headaches are under control, physicians may begin gradually reducing the medication dose.

Medications can provide temporary relief from head pain. However, they may also lose their effectiveness over time. In addition, medications used to treat tension headaches have a number of negative side effects. Patients are encouraged to discuss with their physician the risks of all over-the-counter and prescription drugs taken regularly for the treatment of headache pain.

Overuse of prescription and over-the-counter pain medications can lead to rebound headaches and the development of chronic daily headaches. To prevent these conditions, patients should take over-the-counter pain medication only when it is necessary. When the medication is used, patients should take the smallest dose needed to provide relief. Ideally, patients should not take over-the-counter pain medication more than two times a week. Patients taking prescription pain medication should not exceed the physician-recommended dosage.

Men may be undertreated for tension headaches. A recently completed nine-year British study involving more than 400,000 patients found that women are more likely to seek medical attention for headaches and to receive prescriptions. Other recent research indicates many adolescents with chronic headaches are not being treated. Anyone suffering from tension headaches or other headaches is advised to take the initiative in seeking help.

Additional treatment methods include:

• Acupuncture. During this procedure, fine needles are inserted into specific points in the body to control pain.
  
  
• Essential oils. A salve (an oil-based herbal solution) made from ginger, peppermint and wintergreen oils may be used to relieve tension headaches. Patients may benefit from smelling the salve or rubbing it on their temples and the nape of their neck.

In addition to taking medications, patients may reduce the frequency of tension headaches by avoiding factors that trigger the headaches. Patients may identify these triggers by keeping a headache diary for at least two months. To compile this journal, patients should record certain information after each headache occurs, including:

• When the headache occurred
• Severity of the headache
• Where the headache was located
• How long the headache lasted
• Medications taken
• Events prior to the headache
• What was eaten 24 hours before the headache occurred
• Sleep patterns and amount of sleep
• Level of stress

Patients may benefit most from using lifestyle changes to prevent and relieve tension headaches. Such treatment methods include:

• Exercising regularly. Patients can reduce the frequency and severity of tension headaches by participating in regular aerobic exercise (e.g., walking, swimming, bicycling). Such activity helps to relax the muscles and increase the levels of the body’s natural stress relievers. Exercise can also relieve the pain of an existing headache. Patients should discuss physical activity with their physician before starting an exercise routine.
  
  
• Managing stress. Patients may use a number of relaxation techniques, including deep breathing, yoga, and meditation to relieve stress, a common trigger of tension headaches. Organizing daily activities ahead of time can also reduce stress. Biofeedback may also be recommended. During this procedure, electronic monitoring devices are used to teach people how to consciously regulate their bodily functions through relaxation or imagery. Cognitive behavioral therapy may also be used to reduce stress in patients with depression or anxiety.
  
  
• Muscle relaxation. Some tension headaches patients may benefit from relaxing the muscles. Methods used to relieve muscle tension include thermotherapy (e.g., heating pad, hot-water bottle, warm compress, hot towel, hot bath or shower) and cryotherapy (e.g., ice pack, cold shower or bath). Massage therapy for the head, neck and shoulders can reduce stress and relieve tension. 
  
  
• Improving posture. Good posture and ergonomics can prevent muscle tension. There are a number of techniques a person can use to perfect their posture, including:
  
  
  • Hold the shoulders back and the head high when standing. Also pull the abdomen and buttocks in and tuck in the chin.
    
    
  • When in a sitting position, the thighs should be parallel to the ground and the head should not be slumped forward.
    
    
  • Avoid sitting, standing or working in one position for an extended period of time.
    
    
  • Avoid wearing high heels or shoes that do not fit properly.
    
    
  • Regularly perform stretching and strengthening exercises for the neck and shoulders.
    
    
  • Place weight on both feet when standing. When standing in place for an extended period of time, elevate one foot on a stool. Change to the other foot periodically.
    
    
  • When sitting for an extended period of time, use a footstool to elevate the feet. Get up and move around every 30 minutes.
    
    
  • Sit in straight-back chairs and keep the head supported.
    
    
  • Avoid carrying shoulder bags or purses weighing more than 2 pounds (1 kilogram).

Other common prevention methods include:

• Avoiding cigarette smoking
• Avoiding excess caffeine
• Avoiding alcohol
• Maintaining a regular, healthy diet
• Maintaining a regular sleep pattern and getting plenty of sleep and rest
• Keeping warm if the headache is triggered by the cold
• Using a different pillow
• Using a new sleeping position

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about tension headaches:

1. How can I tell if my headache is a tension headache or another type?
   
   
2. What may be causing my tension headaches?
   
   
3. How can I determine the cause of my tension headaches?
   
   
4. What symptoms should I watch for?
   
   
5. How can I relieve my tension headaches?
   
   
6. What is the best over–the–counter drug for tension headaches?
   
   
7. Can heat therapy, cold therapy or other treatments help?
   
   
8. How can I prevent tension headaches?
   
   
9. What type of exercise will benefit me?
   
   
10. Can changes to my diet or other habits help?