What Is a Tension Headache

Introduction

Headaches are very common; most individuals will experience some type of headache in their lives. There are different types of headaches, and this article focuses on a subtype called tension headaches.

A tension headache is a recurring form of headache with episodes that last from minutes to days. It is known by many names, tension-type headache, muscle contraction headache, stress headache or psychomyogenic headaches. It is the most common kind of primary headache (defined as headaches with no known cause).¹

Tension headache (TH) affects nearly half of the entire UK population at least once in their lifetime. In some other countries, 89% of their population reported experiencing tension headaches at least once in their lifetime. It is common in adults between the ages of 30-39 and is slightly more common in women than men with a ratio of 5:4.²

Although most people do not visit their GP for these headaches, it frequently disrupts the lives of individuals as they might need to stay off their daily routine and activities to recover from their symptoms. At other times, it can cause severe symptoms necessitating a visit to the hospital.

Categories of tension headache

Tension headache is divided into 2 different categories based on the number and duration of attacks in a year. The categories are episodic tension headache and chronic tension headache. Episodic tension headache occurs less than 180 days in a year while chronic tension headache is present for more than 180 days in a year.¹ Episodic tension headache is also divided into 2, infrequent and frequent. The table below explains the categories of tension headaches.

Characteristics of tension headache

How do we know the difference between a tension headache and any other kind of headache? We can tell the difference because tension headaches have characteristics that are somewhat easy to recognize. 

The characteristics of Tension headache are as follows:

• Tension headache is band-like, described as a pain that is similar to a rubber band around the head
• The headache feels tight or compressing. There is no throbbing sensation
• The intensity of the headache is mild to moderate
• It is not worsened by movement or chores
• It is not associated with nausea or vomiting although loss of appetite can occur
• There is either phonophobia or photophobia. Photophobia and phonophobia are sensitivity of light and loud sounds because they aggravate the headaches
• Tension headache usually lasts for about 30 minutes to 7 days but could be longer in some cases²

Aetiology

Although several studies have been done on tension headaches, no cause has been found. Some contributory factors may increase the likelihood of getting a tension headache or worsen the headache. It is proposed that the cause of episodic tension headache has more to do with the muscles around the head and neck while the cause of chronic tension headache is related to persistent pain signals sent to the brain.²

Episodic tension headache has been linked to spasms of the muscles of the head, face, and neck. Some experts believe that posture may also be a factor when it comes to this category of tension headache as a bad posture – bending over a phone for instance – may lead to improper compensatory positions of neck and shoulder muscles creating muscular spasms that could cause episodic tension headaches.^3.4

Chronic tension headaches could develop from episodic tension headaches. Pain signals are sent to the brain during muscular spasms. When the muscle spasms are persistent, the pain signals are also persistent, and this causes a kind of hypersensitivity to pain. The brain becomes overly sensitive and may perceive normal signals as pain which leads to prolonged episodes of tension headaches.^1,2

Some studies have also implicated Vitamin deficiencies such as Vitamin D and B12 as likely causes of tension headaches. Stress is another factor associated with tension headaches.³

Diagnosis and evaluation

A doctor makes a diagnosis of tension headaches by asking specific questions and doing some relevant examinations. Rarely do tests need to be done for a diagnosis of tension headache. The questions asked are usually related to the characteristics of tension headaches earlier discussed in this article. The doctor would ask about the site of the headache, how long it lasts, how often it happens and if there are some associated symptoms like nausea, vomiting, photophobia or phonophobia.

To diagnose tension headache, there must be at least 2 of the following symptoms present

• Band-like headache
• Tightening or non-throbbing headache
• Pain is of mild to moderate severity
• Headache does not limit normal daily activities or chores

Sometimes, a person can have both a migraine and a tension headache at the same time. A migraine is another type of primary headache that may be mistaken for a tension headache but usually, the symptoms of a migraine are different. A migraine would be associated with nausea and vomiting, and the headache is usually one-sided.

If a person has symptoms of tension headache as well as nausea and vomiting, they likely have both a migraine and a tension headache at the same time as there is no nausea or vomiting with tension headaches.

It is important to ensure that there is no other cause of these headaches. A doctor does this by ruling out other causes of headaches through his questions and examinations.

Management

Management is divided into pharmacological and non-pharmacological management. Both strategies can be used for episodic and chronic tension headaches and can also be used for treatment and prevention.

Non-pharmacological management can be used for those who prefer not to take medications or in addition to medications. These non-pharmacological treatments include lifestyle modifications and psychological strategies.

Examples of lifestyle modification are relaxation, better sleep, healthy balanced diets, exercise programs, and improvement of posture. Since stress has been implicated in tension headaches, measures to reduce stress such could be very helpful in the management of tension headaches. Massages, cold or hot packs or even acupuncture can give some relief from the headaches.^1,3

Psychological strategies work by training the body and mind to identify triggers that could cause or worsen a tension headache and consciously reduce those triggers. Relaxation training is a form of psychological strategy, and it involves deliberately relaxing the shoulder, neck, and head muscles to prevent or reduce tension headaches since spasms in the above-mentioned muscles have been associated with tension headaches. Cognitive behavioural therapy (CBT) works by teaching an individual to identify thoughts or beliefs that could worsen or cause headaches and figure out solutions to those triggering thoughts.¹

Pharmacological management is done using medications. Episodic and Chronic tension headaches are treated differently with specific medications for both types of tension headaches.

Episodic tension headache is treated mainly with NSAIDs. They are very effective in relieving tension headaches. Sometimes, acetaminophen can be used in addition to NSAIDs as they have a stronger effect on tension headaches when used together.

Other pain-relieving medications like opioids, sedatives or caffeine are not advised as they can be addictive and can may lead to a chronic tension headache. Over-use of pain-relieving medications can cause what is known as a medication overuse headache so these medications should be taken only when required.^1,3

Chronic tension headache is treated with a tricyclic antidepressant called amitriptyline. It is usually started on a low dose and increased as required. Improvement should be obvious in 3-4 weeks when on amitriptyline. Usually, treatment lasts 6 months and then it is slowly stopped. Sometimes, headaches begin again after stopping amitriptyline and in those cases, the medication is given continuously. Other antidepressants have been used in the management of chronic tension headaches, but none has been as effective as amitriptyline.^1,3

The role of medications such as muscle relaxants in the management of chronic tension headaches is still being debated. There hasn’t been substantial proof showing that they work. Botulinum toxin type A (Botox) is another medication being explored. It is not usually recommended but in cases where nothing works, Botox could be tried.³

The lifestyle modifications and psychological treatments earlier discussed are effective measures for preventing tension headaches. Amitriptyline is also used as a prevention therapy because of its efficacy.

Prognosis

Tension headaches are usually resolved over time. Complete resolution is more common in people with infrequent episodic tension headaches. A study done in Denmark monitoring people with frequent episodic and chronic tension headaches revealed that almost half of those with frequent episodic tension headaches stopped experiencing headaches, while just about 16% of them developed chronic tension headaches.^1,3

Summary

Tension headache is a common type of headache seen in the general population. The symptoms of this headache are usually severe enough to cause disruptions in an individual’s life. Fortunately, there are lifestyle modifications, psychological therapies and medications that are very effective in the management of this illness.