What is a tension-type headache?
A tension-type headache is a recurring headache that can last for anything from a few minutes to several weeks1.
It is one of the most common types of headache2 and typically presents with pain that spreads in a band-like fashion from both sides of the forehead to the back of the head3.
In the past, this type of headache was known by other names, such as “stress headache” and “muscle contraction headache”, but, in 1988, the International Classification of Headache Disorders (ICHD) officially labelled it “tension-type headache”1,4. Many people, however, simply refer to tension-type headaches as “normal headaches” and just take over-the-counter painkillers instead of seeing their healthcare provider1,4. However, taking painkillers more than twice a week can put one at risk of developing chronic daily medication overuse headaches1,3.
Classification of tension-type headaches
Tension-type headaches are classified into two main types based on frequency1:
Episodic
An episodic tension-type headache can last from as little as half an hour to a week5. Episodic tension-type headaches can further be subdivided into infrequent and frequent1. Infrequent episodic tension-type headaches occur fewer than 12 days per year (in other words once a month), while frequent types occur more than 12 days but fewer than 180 days per year1.
Chronic
Chronic tension-type headaches occur more than 180 days per year or more than 15 days a month for at least 3 months1.
Symptoms and signs
Symptoms of episodic and chronic tension-type headaches are the same, except for frequency1.
Characteristic features include the following1,2,3,4,5:
- A dull, pressing sensation that feels like a tight band wrapped around the head.
- The pain is of non-pulsating quality and occurs on both sides of the head.
- The pain is of mild to moderate intensity and is not made worse by routine physical activities.
- Neck and scalp muscles may feel painful or tender.
- The pain is less severe than with a migraine.
- There is mostly no throbbing, nausea or vomiting, auras, or sensitivity to light and noise as frequently seen with a migraine.
Causes
Even though tension-type headaches are the most common type of headache, not much is known about them and researchers still do not fully understand what causes them4,5.
Environment
Infrequent episodic tension-type headaches seem to be precipitated mainly by environmental factors, which may include stress, mental tension, smoking and weather changes6.
Genetics
Frequent episodic and chronic tension-type headaches may at least partly be caused by genetic factors6.
Precipitating or aggravating factors
Stress is the most common trigger reported by people who suffer from tension-type headaches5. Other reported triggers for tension-type headaches include:
- Not eating on time
- Lack of sleep
- Oestrogen-containing medication, such as combined oral contraceptives or hormonal replacement therapy
- Menstruation
- Alcohol
- Medication overuse1.
Diagnosis
Any person with frequent or severe headaches should consult a medical professional to rule out the possibility that there is a serious underlying condition3.
It is also important to rule out other types of headache as well as co-occurring medical conditions1,2. Lastly, care is required to detect whether the headaches are aggravated by overuse of medications1.
Your healthcare practitioner will likely:
- Take a detailed history1.
- Ask you to describe the nature of pain, in other words whether it is constant, pulsating, or throbbing. He/she may also ask about factors that aggravate your symptoms. With a tension-type headache, physical activity usually does not make it worse, while a migraine feels worse when one performs routine physical activities1,2.
- Ask about other symptoms. Nausea and vomiting or sensitivity to both light and loud noises point towards migraine rather than tension-type headache1,5.
- Perform a physical examination. He/she may feel your scalp and neck muscles to identify tender and/or trigger points. Tender points are areas where manual pressure induces local pain. Trigger points are areas of localized deep tenderness where sustained pressure will cause referred pain in another area in the region1.
Neuroimaging [such as MRI (magnetic resonance imaging), CT (computed tomography), fMRI (functional MRI) or PET (positron emission tomography) scans] is usually not necessary unless your healthcare practitioner picks up something concerning during the initial examination3,7.
Treatment
If you suffer from tension-type headaches, you should not lose hope1. A combination of medical and non-medical treatment options are available to control your symptoms2.
Episodic tension-type headache
Simple painkillers (analgesics), such as paracetamol, and non-steroidal anti-inflammatory drugs (NSAIDs) form the cornerstones of treatment for episodic tension-type headaches1,8.
Painkillers or NSAIDs are sometimes combined with caffeine or with opiates (such as codeine). Combination with opiates is generally not advised due to the risk of developing chronic daily headache or other adverse effects (dependency, abuse, or addiction)1,3,8. Painkillers or NSAIDS may also be combined with antihistamines with sedating properties or with antiemetics (to treat nausea and vomiting) as these medicines may enhance the pain-relieving effects of standard analgesics3.
Chronic tension-type headache
Chronic tension-type headaches may be best treated with a combination of medical and non-medical treatments1.
It is also important to recognise and treat co-occurring conditions such as anxiety or depression1.
The tricyclic antidepressant amitriptyline has been shown to be effective in treating chronic tension-type headaches1. It is usually prescribed continuously for 6 months after which withdrawal may be attempted. Some patients may continue to remain free from headaches, while others may experience recurrence. These patients will usually require ongoing treatment over the long-term1.
Non-medical treatments
Other common treatments for tension-type headaches include:
- Biofeedback – a technique that teaches the body to control certain responses to help reduce pain3,5. For example, a person may be able to learn how to reduce muscle tension or to slow his/her heart rate or breathing5.
- Relaxation training, which may take the form of yoga, meditation and breathing exercises3,5.
- Self-hypnosis3.
- Cognitive behavioural therapy – a talk therapy that may help a person to learn how to manage stress, and in doing so, may help to reduce the frequency and severity of the headaches3,5.
- Physiotherapy2.
- Massage2.
- Acupuncture2.
Prevention
A combination of stress-management techniques and medication works better than one of these treatments in isolation5. Tricyclic antidepressants (e.g., amitriptyline) are the best medication for prevention4.
Helpful tools
Keeping a headache diary may be beneficial.
In it, note details of headache episodes, their severity, and any medication you take. This can provide helpful insight for your healthcare practitioner, who may be able to pick up triggers or whether you may be experiencing symptoms of medication overuse1.
Healthy habits to help prevent headaches
- Get enough sleep at night
- Don’t smoke
- Do regular exercise
- Eat a balanced diet
- Drink enough water
- Have less alcohol, caffeine, and sugar5.
