Tension-type Headache

The Basics

Tension-type headaches are the most common form of headache, occurring in about three-quarters of the general population. They can range from the occasional mild headache to daily disabling headaches in some cases.

Tension-type headaches have been called by various names over the years, including tension headache, muscle contraction headache, psychomyogenic headache, stress headache, ordinary headache, essential headache, idiopathic headache, and psychogenic headache. Of those names, only “tension headaches” is still fairly frequently used.

As you can see from the names that tension-type headache has been known by, it was at one time thought that the cause of tension-type headache was primarily psychological, caused by the mind or emotions. There have now been studies that strongly suggest a physical (neurobiological) cause.

Symptoms

Tension-type headaches most commonly last from 30 minutes to seven days. The pain is commonly described on both sides of the head (bilateral), as “a band around the head” or vice-like. The pain is generally mild to moderate and is not worse with routine physical activity, which means that most people with tension-type headache continue about their normal daily activities despite having their headache.

A tension-type headache is not accompanied by nausea or vomiting. It may be accompanied by increased sensitivity to light or sound, but not both. It may be associated with tenderness of the pericranial (head and neck) muscles, particularly with increased frequency of tension-type headache attacks.

Please refer to the International Classification of Headache Disorders 3rd edition (beta version) website for more information on the criteria used to diagnosis tension-type headache: https://www.ichd-3.org/2-tension-type-headache/

Types of Tension-type headache

Tension-type headache is broken down into three types:

  • Infrequent episodic type tension-type headache: one or fewer episodes per month.
  • Frequent episodic type tension-type headache: more than one, but fewer than 15 episodes per month for three or more months.
  • Chronic tension-type headache: more than 15 episodes per month for three or more months. There may be mild nausea with this type of tension-type headache.

Diagnosing Tension-type headache

There are no diagnostic tests to confirm tension-type headache. Diagnosis is accomplished by reviewing the patient’s personal and family medical history, studying their symptoms, and conducting an examination. Because of the association of tension-type headache-like symptoms with secondary headaches (due to an underlying cause or condition), doctors should consider the possibility of a secondary headache disorder when people present with presumed tension-type headache. This is particularly important if someone develops new/different headaches or has progressive headaches that are increasing in frequency. Examples of secondary causes include medication overuse or structural brain lesions.

At times, it can be difficult to distinguish between tension-type headache and a migraine attack. Tension-type headache is not made worse by physical activity. It is not accompanied by vomiting, and if nausea is present, it is mild. A migraine attack may be accompanied by increased sensitivity to both light and sound; one or neither accompanies tension-type headache. It is, however, possible for a tension-type headache to trigger a migraine attack.

Treatment of Tension-type headache

Infrequent episodic tension-type headache needs only treatment for the individual episodes (acute treatment). Simple analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin, are reasonable choices. Sometimes combination analgesics including caffeine can be more effective; but with frequent use, side effects such as rebound headache may emerge. Use of combination therapies containing either butalbital or opioids for treatment of tension-type headache is generally not recommended because of the risk of tolerance, dependency, toxicity, and the development of medication overuse headache. Acute treatments should be limited to no more than twice per week, otherwise they can produce medication overuse headache and may cause undesirable effects on the liver, kidneys, stomach and other organs.

If tension-type headaches are frequent, long lasting, or associated with a significant amount of disability, then preventive treatment is recommended. Commonly used preventive strategies include medications such as amitriptyline and non-medication treatments for headache such as biofeedback, relaxation, and cognitive-behavioral therapy, acupuncture, massage therapy or physical therapy.

Summary

Unless they become frequent, tension-type headaches are usually more an annoyance than a big problem. They can often be treated with an over-the-counter medication and a bit of rest. Still to be on the safe side, a doctor should always diagnose headaches. More frequent tension-type headaches may require daily preventive medications or complementary therapies to restore health and quality of life.

Resources:

The International Headache Society. https://www.ichd-3.org/2-tension-type-headache/

Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache – report of an EFNS task force. Eur J Neurol 2010; 17:1318.