A tension headache is pain or discomfort in the head, scalp, or neck, usually associated with muscle tightness in these areas.A.D.A.M.

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.

Rebound headaches are headaches that keep coming back. They may occur if you overuse painkillers.

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, and 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:

• Alcohol use
• Caffeine (too much or withdrawal)
• Colds, the flu, or a sinus infection
• Dental problems such as jaw clenching or teeth grinding
• Eye strain
• Excessive smoking
• Fatigue or overexertion 

Tension headaches can occur when you also have a migraine. Tension headaches are not associated with brain diseases.

Symptoms

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.

Treatment

The goal is to treat your headache symptoms right away, and to prevent headaches by avoiding or changing your triggers. A key step in doing this involves learning to manage your tension headaches at home by:

• Keeping a headache diary to help you identify your headache triggers. Then you and your doctor can make changes in your lifestyle to reduce the number of headaches you get.
• Learning what to do to relieve a headache when it starts
• Learning how to take your headache medicines the correct way

Medicines that may relieve a tension headache include:

• Over-the-counter painkillers such as aspirin, ibuprofen, or acetaminophen
• Narcotic pain relievers
• Muscle relaxants such as tizanidine

Remember that pain medications only relieve headache symptoms for a short period of time. After a while, they do not work as well or they do not relieve headaches for as long. Overuse of pain medications during most weeks can lead to rebound headaches -- headaches that keep coming back.

You may take some medicines daily to help prevent or decrease the number of headaches. These medicines are normally used to treat depression, but they can also help prevent tension headaches. They include:

• SSRIs such as paroxetine (Paxil) or citalopram (Celexa)
• Tricyclic antidepressants such as amitriptyline, nortriptyline, or doxepin

Ask your health care provider about relaxation or stress-management training, biofeedback, cognitive behavioral therapy, or acupuncture, which may help relieve chronic headaches.

Botox (botulinum toxin) is becoming popular as a treatment for chronic daily headaches, including tension headaches. However, it is not approved by all insurance companies. Botox works by preventing spasms in the muscles where it is injected.

Expectations (prognosis)

Tension headaches often respond well to treatment, and do not cause serious medical problems. However, chronic tension headaches can have a negative impact on the quality of life and work.

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
• The headache starts very suddenly
• The headache occurs with repeated vomiting
• You have a high fever

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

Prevention

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.

References

1. Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. 2008:7(1):70-83. [PubMed: 18093564]
2. 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. [PubMed: 18458231]
3. Jackson JL, Shimeall W, Sessums L, Dezee KJ, Becher D, Diemer M, et al. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ. 2010. 341:c5222. doi: 10.1136/bmj.c5222. [PMC free article: PMC2958257] [PubMed: 20961988]
4. Halker RB, Hastriter EV, Dodick DW. Chronic daily headache: an evidence-based and systematic approach to a challenging problem. Neurology. 2011;76(7 suppl 2):S37-S43. [PubMed: 21321350]
5. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2009;(1):CD007587. [PMC free article: PMC3099266] [PubMed: 19160338]

Review Date: 11/2/2012.

Reviewed by: Luc Jasmin, MD, PhD, Department of Neurosurgery, Cedars Sinai Medical Center, Los Angeles and Department of Anatomy, University of California, San Francisco, CA. Review provided by VeriMed Healthcare Network. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, David R. Eltz, and Stephanie Slon.