Signs and Symptoms

• Headache starts at the back of your head and spreads forward
• Dull pressure or a squeezing pain, often described as a tight band around the head
• Muscles in your neck, shoulders, and jaw can feel tight and sore
• Affects both sides of your head equally
• May have difficulty sleeping or eating

Causes

Researchers aren't clear what causes a tension headache. For years, scientists thought that it was caused by tightening the muscles in your shoulders, neck, scalp, and jaw when you are tense. But new tests that measure muscle tension show that the muscles of people with tension headaches aren’t any tighter. Newer theories suggest tension headaches are caused by changes in brain chemicals called neurotransmitters (including serotonin), similar to what happens with a migraine. Scientists don’t know why the levels of neurotransmitters go up and down, but they think it activates pain pathways in the brain. Tight muscles may help trigger the changes in neurotransmitters, or muscle tightness may be a result of changing levels of brain chemicals.

Triggers may include:

• Stress
• Depression
• Anxiety
• Holding your head in one position for a long time (like using a computer)
• Sleeping in an awkward position or in a cold room
• Eye strain
• Drugs or alcohol
• Fatigue
• Overexertion
• Skipping meals
• Head or neck injury, even years after the injury
• Clenching your jaw or grinding your teeth (bruxism)
• Medications, including some headache medications (leading to rebound headaches)
• Arthritis
• Hormonal changes (primarily among women)

Certain foods or food additives may also be a trigger for some people (see Nutrition and Dietary Supplements section)

Pain that originates from other areas, such as your sinuses, can also trigger tension headaches, or a combined sinus-tension headache

Risk Factors

• Gender -- women tend to have more headaches than men
• Changes in estrogen levels during a woman’s period or at menopause
• Premenstrual syndrome
• Stress
• Chronic overwork
• Too much or too little sleep
• Missing meals
• Alcohol or drug use

Diagnosis

Your doctor will take a detailed history to distinguish tension headaches from other headaches, such as migraines. Your doctor will ask questions about when your headaches occur, how long they last, how frequently they come on, the location of the pain, and any symptoms that accompany the headaches. Sometimes it helps to keep a diary about your headaches before seeing the doctor, so you have an accurate recording of how often they happen.

Your doctor will examine your head, neck, eyes, and sinuses, and do a neurologic examination. Your doctor may ask you some questions to test your short-term memory, and examine your neck and scalp to determine if they are tender.

If you have unusual symptoms, your doctor may order these tests:

• Computed tomography (CT) scan or magnetic resonance imaging (MRI), to rule out a tumor or aneurysm, or to check for sinusitis
• X-ray of the neck to look for arthritis or spinal problems; x-ray of the sinuses to look for sinusitis
• Electroencephalogram (EEG), a brain wave study, to look for seizure activity

Treatment Approach

A comprehensive treatment plan, including relaxation, exercise, lifestyle changes, and occasional medication can be very effective in reducing the frequency and intensity of tension headaches.

Biofeedback, yoga, and relaxation techniques, for example, can help relieve pain and lower the number of headaches you have. Regular exercise helps, too.

Lifestyle

Keeping a headache diary can help identify the source of your tension headaches and how you can change your environment and habits to avoid them. When a headache starts, write down the date and time it began. Note what you ate for the preceding 24 hours, how long you slept the night before, what you were doing just before the headache, any unusual stress in your life, how long the headache lasted, and what you did to make it stop.

Good health habits may help reduce stress and tension headaches:

• Get enough sleep
• Eat a healthy diet
• Get regular exercise
• Quit smoking
• Use relaxation techniques

Medications

Medications are used both to relieve pain and to prevent headaches if you have chronic tension headaches.

To relieve pain:

Over-the-counter (OTC) analgesics -- are usually effective. Do not take these medications for more than a few days without calling your doctor, and take only the amount recommended on the package. Talk to your doctor about which of these is best for you.

• Acetaminophen (Tylenol) -- can cause liver damage if used in high doses or over a long period of time
• Aspirin -- can cause stomach upset and bleeding
• Ibuprofen (Advil, Motrin) -- can cause stomach upset and bleeding, and increase the risk of heart problems
• Naproxen (Aleve) -- can cause stomach upset and bleeding, and raise risk of heart problems
• A combination of acetaminophen, aspirin, and caffeine (Excedrin, other brands) -- can cause liver damage if used in high doses or over a long period of time; may increase the risk of bleeding

Prescription analgesics -- may be needed if your headaches don't respond to OTC medications. They include

• Naproxen (Naprosyn) -- can cause stomach upset and bleeding, and increase the risk of heart problems
• Indomethacin (Indocin) -- can cause stomach upset and bleeding, and increase the risk of heart problems
• Piroxicam (Feldene) -- can cause stomach upset and bleeding, and increase the risk of heart problems

In some cases, your physician may recommend botulinum toxin A (Botox) injections to relieve tension headaches. Preliminary studies suggest that botulinum toxin A relieves neuromuscular pain. Repeat injections may be required. More research is needed.

Rarely, if your headaches are very severe and nothing else relieves the pain, your physician may consider prescribing narcotics such as codeine plus acetaminophen (Tylenol with Codeine No. 3) or hydrocodone with acetaminophen (Vicodin).

To prevent chronic tension headaches:

Tricyclic antidepressants -- Tricyclic antidepressants are helpful in preventing all kinds of headaches, including migraines and tension headaches. Tricyclic antidepressants include:

• Amitriptyline (Elavil)
• Nortriptyline (Pamelor)
• Doxepin (Sinequan)
• Imipramine (Tofranil)

Selective serotonin reuptake inhibitors (SSRIs) -- another type of antidepressant that may not work as well as tricyclics in preventing headaches, but tend to have fewer side effects. They include:

• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Citalopram (Celexa)
• Sertraline (Zoloft)

Anticonvulsants -- Some anti-seizure drugs help prevent migraines and tension headaches, although researchers aren't sure why:

• Divalproex sodium (Depakote)
• Gabapentin (Neurontin)
• Topiramate (Topamax)

Nutrition and Dietary Supplements

Diet

Certain foods can trigger tension headaches, including:

• Chocolate
• Cheese
• Monosodium glutamate (MSG), a flavor enhancer often found in Chinese food
• Foods containing the amino acid tyramine, found in red wine, aged cheese, smoked fish, chicken livers, figs, and some beans
• Nuts
• Peanut butter
• Some fruits, like avocado, banana, and citrus
• Onions
• Dairy products
• Meats containing nitrates -- bacon, hot dogs, salami, cured meats
• Fermented or pickled foods
• Foods and drinks containing caffeine

If you suspect that any of these foods cause your headaches, you could follow an elimination diet, eliminating all the items on this list from your diet and then reintroducing them one at a time. Pay close attention to whether the number of headaches increases after eating particular foods. Then you know which trigger foods to avoid.

5-hydroxytryptophan (5-HTP, 400 to 600 mg per day) -- Your body makes the amino acid 5-HTP and converts it into serotonin, an important brain chemical. Researchers think changes in brain chemicals may be related to tension headaches, and some of the drugs used to treat headaches work by affecting serotonin. Based on that thinking, 5-HTP has been proposed as a treatment for tension headaches. Several studies indicate that 5-HTP may be effective for migraines. But the evidence is mixed for tension headaches. One study found that 5-HTP did not reduce the number of headaches people had. But it did allow them to reduce their use of other painkillers. More studies are needed to tell whether 5-HTP helps treat tension headaches. If you take an antidepressant, sedatives, psychotropic medications, sleep aids, cough medicine that contains dextromethorphan, pain medications, or supplements, such as St. John's wort or SAMe, you should not take 5-HTP unless closely supervised by your physician. If you are pregnant or breastfeeding, do not take 5-HTP without first asking your doctor. People with Down Syndrome may have an increased risk of seizures with the use of 5-HTP.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. However, herbs can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care practitioner.

• Peppermint ( Mentha x piperita ) -- Peppermint oil, applied topically to the forehead, has shown some promise in very early studies. In one study, applying a 10% peppermint oil solution to the temples relieved pain about as well as acetaminophen (Tylenol). More research is needed to know for sure if peppermint oil is effective. Be careful not to get peppermint oil or any essential oil into the eyes.
• Tiger Balm (contains various oils including camphor, menthol, cassia oil, and clove oil) -- Tiger Balm is an over-the-counter topical ointment used for muscle pain. One study found that applying Tiger Balm to the forehead helped relieve headache pain better than placebo and about as well as acetaminophen (Tylenol).
• Butterbur ( Petasites hybridus, 50 to 75 mg of a standardized extract 2 times per day) -- A few studies suggest that butterbur may help reduce both the frequency and duration of migraine attacks. It has also been proposed as a treatment for tension headaches. However, so far no studies have been done to see whether it works for tension headaches. If you want to try butterbur for your headaches, ask your doctor about a safe extract and dose. Some butterbur may contain a chemical that may cause liver damage, so use a trusted brand. Butterbur may interact with several medications. Women who are pregnant or breastfeeding should not take butterbur.
• Feverfew ( Tanacetum parthenium, 50 to 80 mg per day) -- Feverfew has been used traditionally to treat headaches, and several well-designed studies have found that it may help prevent and treat migraines. However, not all studies agree, and it has not been studied to see if it can prevent or treat tension headaches. Feverfew can increase the risk of bleeding, and should not be taken with blood thinners, such as warfarin (Coumadin) or clopidogrel (Plavix). If you are allergic to ragweed you may also be allergic to feverfew. Women who are pregnant or breastfeeding should not take feverfew.

Although there are no scientific studies showing that these herbs work, they are sometimes suggested to treat tension headaches and other types of headaches. People who take blood-thinning medications or who have bleeding disorders should not take these herbs:

• Dong quai (Angelica sinensis) -- People who have a history of hormone-sensitive conditions should take particular care, as some experts believe Don quai has an estrogen-like effect.
• Ginger (Zingiber officinale).
• Willow bark (Salix spp.) -- People who are sensitive to aspirin should not take willow bark.

Acupuncture

Scientific studies investigating the use of acupuncture to treat tension headaches have found mixed results. Researchers agree that acupuncture appears safe and that it may be effective for some people. Acupuncturists diagnose tension headaches by paying careful attention to the kidney and its associated meridians (energy pathways in the body), as well as liver and gallbladder meridians. The physical location of the headache also helps the acupuncturist create a treatment plan, which may include lifestyle/dietary changes or herbal remedies. Other studies suggest acupuncture is best used as a preventive treatment for tension headaches, and that electro-acupuncture is more effective than manual acupuncture.

Chiropractic

Several clinical trials indicate that spinal manipulation therapy may help treat tension headaches, especially ones that start in the neck. One study compared spinal manipulation to Elavil and found that people in both groups got better, while those in the spinal manipulation group had less side effects. The benefits of spinal manipulation lasted longer: One month after treatment, the chiropractic group still showed improvement, while the Elavil group did not. Another study found a 50% reduction of headache severity after a single 10-minute spinal manipulation session. However, other studies comparing chiropractic to a sham treatment plus massage found no benefit.

Massage and Physical Therapy

Regular massage may help relieve stress and pain in people with chronic tension headaches, according to one preliminary study. Doing stretches for your head and neck (taught by a physical therapist) may also help. Practicing proper posture is another important factor in reducing the number of headaches. A physical therapist can teach you.

Reflexology is a technique that places pressure on specific "reflex points" on the hands and feet that are believed to correspond to areas throughout the body. Some early studies suggest it may relieve pain and allow people with migraines to take less pain medication. However, more research is needed. Practitioners believe reflexology helps you become more aware of your own body signals, which might help you sense the subtle signals that indicate a migraine is about to occur (before pain starts). They also believe reflexology helps improve general well-being and energy level.

Homeopathy

Studies indicate that homeopathy may be no more effective than placebo in relieving tension headaches. Interestingly, one of the most common reasons people seek homeopathic care is to relieve the pain associated with chronic headaches. Many homeopaths report that homeopathy helps treat and prevent recurrent tension headaches. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

The following remedies are commonly prescribed for tension headaches:

• Belladonna -- for throbbing headaches that come on suddenly; symptoms tend to worsen with motion and light, but are partially relieved by pressure, standing, sitting, or leaning backwards.
• Bryonia -- for headaches with a steady, sharp pain that occurs most often in the forehead, but may radiate to the back of the head; symptoms tend to worsen with movement and light touch, but firm pressure alleviates the pain; the person for whom this remedy is most appropriate is usually irritable and may experience nausea, vomiting, and constipation.
• Gelsemium -- for pain that extends around the head and feels like a tight band of constriction; pain usually originates in the back of the head and may be relieved following urination; this remedy is most appropriate for individuals who feel extremely weak and have difficulty keeping their eyes open.
• Ignatia -- for pain that may be described as a feeling of something being driven into the skull; these types of headaches tend to be triggered by emotion, including grief or anxiety, and the treatment is appropriate for both children and adults
• Iris versicolor -- for throbbing headaches that occur on one side of the head, especially after eating sweets; visual disturbances may also occur; these headaches are worse in the early morning, during spring and fall, and symptoms tend to worsen with vomiting.
• Lachesis -- for headaches that tend to occur on the left side of the head; symptoms are typically worse in the mornings, before menstruation, and with exposure to warmth and sunlight; symptoms tend to improve with open air and firm pressure.
• Nux vomica -- for headaches associated with hangovers, overindulgence in foods or alcohol, and overwork; these types of headaches are often accompanied by nausea and/or dizziness; this remedy is most appropriate for individuals who tend to be constipated and irritable.
• Pulsatilla -- for headaches triggered by eating rich, fatty foods, particularly ice cream; pain tends to move but may be concentrated in the forehead or on one side of the head and may be accompanied by digestive problems or occur around the time of menstruation; children for whom this remedy is appropriate often develop these symptoms while at school.
• Sanguinaria -- for right-sided headaches that begin in the neck and move upwards, recur in a predictable pattern (such as every seven days); pain is aggravated by motion, light, or sun exposure, odors, and noise; this remedy is appropriate for children who may have a craving for spicy or acidic foods, despite having a general aversion to eating due to the headache.
• Spigelia -- for stinging, burning, or throbbing sinus pain that often occurs on the left side of the head; symptoms tend to worsen with cold weather and motion, but may be temporarily relieved by cold compresses and lying on the right side with the head propped up.

Mind-Body Medicine

You can do many things to avoid tension headaches or relieve the pain:

• Biofeedback to control muscle tension.
• Learn to meditate, breathe deeply, or try other relaxation exercises, such as yoga or hypnotherapy.
• Develop a daily relaxation routine that focuses on the muscles of the head, neck, and on improving your posture.

Other relaxation techniques that may be helpful include:

• Guided imagery
• Hypnosis

Other Considerations

Pregnancy

Some women who are prone to headaches may get them more often when they are pregnant. However, other women may have fewer headaches during pregnancy, especially during the second trimester.

Warnings and Precautions

Use medications only as directed. Using some medications on a regular basis can cause rebound headaches.

Call your doctor if you have a new headache, a change in quality of a previous headache or headache pattern, or if a medication that usually takes away the pain no longer works.

Prognosis and Complications

It's rare to have a serious underlying condition due to headaches, like a tumor or a stroke. You should go to the emergency room if you experience the following:

• Sudden and severe headache that persists or increases in intensity over 24 hours
• A sudden, severe headache that you describe as "your worst ever," even if you are prone to headaches
• Chronic or severe headaches that begin after age 50
• Headaches accompanied by memory loss, confusion, loss of balance, change in speech or vision, or loss of strength in, or numbness or tingling, in any one of your limbs
• Headaches after a head injury, especially if you also feel drowsy or nauseated
• Headaches accompanied by fever, stiff neck, nausea, and vomiting (may indicate meningitis)
• Severe headache localized to one eye, accompanied by redness of the eye (may indicate acute glaucoma)

More than 90% of people with tension headaches can get significant relief from a combination of lifestyle changes, relaxation, and medication.

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