Tension Headaches

Topic Overview

What is a tension headache?

Most headaches are tension headaches. These headaches tend to happen again and again, especially if you are under stress. They are not usually a sign of something serious. But they can be very painful and hard to live with.

What causes tension headaches?

Doctors don't know for sure what causes tension headaches. Experts once thought that tension or spasms in the muscles of your neck, face, and head played a role. Now they think a change in brain chemicals may also be a cause.

What are the symptoms?

Symptoms of tension headaches include:

• A headache that is constant, not throbbing. You usually feel the pain or pressure on both sides of your head.
• Pressure that makes you feel like your head is in a vise.
• Aching pain at your temples or the back of your head and neck.

This is different than migraine headaches, which usually cause throbbing pain and start on one side of your head.

Tension headaches tend to come back, especially when you are under stress. They can last from 30 minutes to several days.

Usually, pain from a tension headache is not severe and does not get in the way of your work or social life. But for some people the pain is very bad or lasts a long time. You have chronic tension headaches if they occur at least 15 days a month.

How are tension headaches diagnosed?

A doctor can usually diagnose tension headaches by asking you questions about your health and lifestyle and by examining you.

How are they treated?

Most people can treat their tension headaches with pain relievers that you buy without a prescription, like acetaminophen (such as Tylenol) or aspirin.

But if you take these pain relievers more than 3 times a week, you may get rebound headaches. Rebound headaches are different from tension headaches. They usually start after pain medicine has worn off, which leads you to take another dose. Eventually you get a headache whenever you stop taking the medicine.

Some people have chronic tension headaches. This means they often get headaches. Doctors may prescribe stronger pain medicine for these people.

Can tension headaches be prevented?

Even with treatment, most people still have some headaches. But with treatment, you will probably have them less often. And when you do get them, they probably won't be as bad.

Home treatment may help you avoid headaches. Learn how to handle stress. Make sure you sleep, exercise, and eat on a regular schedule. Check your posture. Don't strain your eyes when you use your computer. Get treatment for depression or anxiety.

Try keeping a headache diary. Every time you get a headache, write down the date, the hour, and what you were doing and feeling before your headache started. This may help you and your doctor find out what is causing your headaches so you can get the right treatment.

Frequently Asked Questions

Health Tools

Health Tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I take prescription drugs for tension headaches?
	Actionsets are designed to help people take an active role in managing a health condition.
	Headaches: Identifying and avoiding triggers
	Headaches: Managing a headache

Cause

The cause of tension headaches is not clear. Experts believe there may be more than one factor that causes a tension headache. In the past, doctors believed that tension or spasms of the muscles of the neck, face, jaw, head, or scalp played a role in causing these headaches. Now they think a change in brain chemistry may also help cause a tension headache.

Symptoms

Symptoms of tension headaches include:

• A constant headache that does not throb or pulse. You usually feel the pain or pressure on both sides of your head.
• Tightness around your forehead that may feel like a "vise grip."
• Aching pain at your temples or the back of your head and neck.

Unlike migraines, tension headaches do not often occur with nausea, vomiting, or sensitivity to both light and noise (but you may have one or the other), and they are not usually disabling. Episodes of tension headaches last from 30 minutes to several days. Tension headaches are considered chronic when they occur at least 15 days or more a month.

Chronic tension headaches frequently occur along with other conditions such as anxiety or depression. While not common, serious conditions such as tumors or infections may cause a headache.

What Happens

Tension headaches are one of the most common types of headaches. They can be triggered by stress, anxiety, depression, hunger, anger, fatigue, overexertion, poor posture, and muscle strain. Tension headaches may come on suddenly or gradually. Prolonged sitting, having poor posture, or eyestrain can also trigger tension headaches. The headache may disappear after you relax or take a nonprescription pain reliever, such as aspirin or ibuprofen.

Tension headaches can last anywhere from 30 minutes to 7 days. If you have at least 15 tension headaches a month over a 6-month period, you may have chronic tension headaches. Chronic headaches can lead to stress and depression, which in turn can prolong the cycle of headaches. Treatment is available to reduce the frequency or stop the occurrence of chronic tension headaches.

What Increases Your Risk

About 4 out of 100 people in the United States develop chronic tension headaches.¹ Symptoms can start in childhood, but they are more likely to occur during middle age and be linked to stressful life events.²

When To Call a Doctor

If you have a headache or have been diagnosed with tension headaches, use the following information to help you decide when to call your doctor.

Call 911 or other emergency servicesif:

• You have a very sudden, severe, "thunderclap" headache that seems to come on instantly and is unlike any headache you have had before.
• You have symptoms of a stroke, which may include:
  • Sudden numbness, paralysis, or weakness in your face, arm, or leg, especially on only one side of your body.
  • Feeling dizzy or clumsy, or having trouble walking or standing.
  • Sudden changes in vision.
  • New and sudden problems speaking or understanding simple statements.

Call your doctor now or go to the emergency room if:

• You develop fever and a stiff neck.
• You have new nausea and vomiting, or you cannot keep food or liquids down.

Watch closely for changes in your health, and be sure to contact your doctor if:

• Your headache is not better within 1 to 2 days, or if it wakes you up at night.
• Your headaches get worse or happen more often.
• You start to have new symptoms.
• You have any problems with your medicine.
• You are older than 50 and have new or more frequent headaches.
• Your headaches occur after physical exercise, sexual activity, coughing, or sneezing.
• Your life is disrupted by your headaches (for example, you miss work or school regularly).

Watchful Waiting

Watchful waiting is a wait-and-see approach. If your headache gets better on its own, you won't need treatment. If it gets worse or your headaches become more frequent, you and your doctor will decide what to do next. Watchful waiting and using nonprescription pain relievers are appropriate if you have tension headaches that are not disabling. But if you have at least 15 tension headaches a month over a 6-month period, you may want to seek treatment for chronic tension headaches.

Who To See

Most health professionals can recognize and treat tension headaches. You may seek treatment from any of the following:

• General practitioner
• Family medicine physician
• Internist
• Nurse practitioner (NP)
• Physician assistant (PA)
• Neurologist, if your headaches are severe or do not get better with treatment

If you think your headaches are caused by depression or anxiety, seeking treatment from a psychiatrist, psychologist, or other licensed mental health counselor may help reduce the frequency or severity of your headaches, as well as relieve your symptoms of anxiety or depression.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Your doctor can usually diagnose tension headaches by asking you questions about your health and lifestyle and by examining you.

It is important to distinguish tension headaches from other headaches (such as migraines) because symptoms can be similar, but treatment may vary. Usually migraine pain is felt on only one side of the head. Tension headaches usually cause pain on both sides of your head.

Your doctor may diagnose tension headaches if you have headaches with:

• Constant pain that does not throb or pulse. You usually feel the pain or pressure on both sides of your head.
• Tightness around your forehead that may feel like a "vise grip."
• Aching pain at your temples or the back of your head and neck.

You might be sensitive to light or noise (but not both at the same time), but you will not usually feel nauseated. The pain does not get worse with activity.

Tension headaches can last any length of time from 30 minutes to 7 days. You may be diagnosed with chronic tension headaches if you have the same symptoms but have at least 15 of these headaches a month over a 6-month period.

In very rare cases, headaches can be caused by other, more serious medical conditions (such as brain tumors or aneurysms). Your doctor may order tests to rule out other causes. These tests may include:

• A lumbar puncture, a test in which your doctor uses a needle to remove a small amount of fluid from your spinal canal. The fluid is then looked at for signs of infection.
• An electroencephalogram (EEG), a test that measures and records the electrical activity of your brain by using sensors (electrodes) attached to your head and connected by wires to a computer.
• An MRI scan of your brain, a test that uses a magnetic field and pulses of radio wave energy to provide pictures of your brain.
• A CT scan of your head, a test in which a scanner directs a series of X-ray pulses through your head. This produces detailed pictures of structures inside the head.

Parents may become very concerned about headaches in children and feel that extensive testing is needed to rule out serious causes. But doctors often can evaluate children's headaches without using imaging tests. Children who have headaches will sometimes be monitored for 6 months or longer from the time of their first headache.

Treatment Overview

You can manage tension headaches by taking pain relievers that you can buy without a prescription, such as nonsteroidal anti-inflammatory drugs (NSAIDs) (for example, aspirin or ibuprofen). If you have chronic or severe tension headaches, you may need to take a prescription drug (such as an antidepressant) every day to reduce the pain and frequency of your headaches. You may also try complementary therapies (such as acupuncture, biofeedback, or meditation), to help lower stress, which may help reduce or prevent your headaches.

Initial treatment

When first treating tension headaches pain, you may try taking nonprescription drugs. These drugs usually have fewer side effects than prescription pain relievers. Also, you may be able to prevent or reduce tension headaches by learning what causes your headaches, such as stress or anxiety, and trying to avoid those triggers. For more information, see:

Headaches: Identifying and avoiding triggers.

Nonprescription drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, usually reduce the pain you get with a tension headache. But try to avoid taking nonprescription drugs more than 3 times a week, because you may get rebound headaches. Rebound headaches are different from tension headaches. They are usually triggered after pain medicine has worn off, prompting you to take another dose. Eventually, you get a headache whenever you stop taking the medicine.

Prescription drugs. If nonprescription drugs do not relieve your headache, your doctor may prescribe stronger medicine to treat your pain. You may be prescribed:

• Antidepressants such as mirtazapine (Remeron) and the tricyclic antidepressant amitriptyline. When taken daily, these medicines can help reduce how often tension headaches occur and how long they last.¹
• Seizure medicines or antianxiety drugs. These medicines are not often used to treat tension headaches.

In some cases your doctor may prescribe drugs such as barbiturates or narcotics when other drugs are ineffective. But these drugs can be habit-forming and should be used sparingly.

Should I take prescription drugs for tension headaches?

Stress management. Managing stress, anxiety, or depression may help reduce the frequency of tension headaches. The best approach to managing chronic tension headaches may be a combination of drugs and stress management therapies. Nonmedication methods for reducing stress may include:

• Biofeedback, a relaxation method to help you learn to control a body function that is not normally under conscious control, such as muscle tension.
• A relaxation exercise during which you focus on relaxing each muscle group. Relaxation exercises can help with tension headaches. When relaxation exercises and antidepressants are used together as treatment, the results are even better.³
• Acupuncture, which involves putting very thin needles into the skin at certain points on the body to produce energy flow along the body's meridians. Evidence specifically for tension headaches shows that acupuncture is no better than sham acupuncture (when needles are put into the skin, but not at the right points).⁴
• Transcutaneous electrical nerve stimulation (TENS), which may help reduce pain.
• Cognitive-behavioral therapy or problem-solving therapy during counseling sessions. Cognitive-behavioral therapy and problem-solving therapy can help with tension headaches. When cognitive-behavioral therapy or problem-solving therapy and antidepressants are used together as treatment, the results are even better.³
• Yoga.
• Meditation.

Ongoing treatment

It is important to have a good treatment plan for ongoing care of tension headaches, especially chronic tension headaches. You and your doctor will work together to find the best treatment to relieve or prevent your tension headaches. Generally, ongoing treatment includes using drugs to relieve your pain and practicing stress management techniques, such as relaxation exercises or meditation.

Ongoing treatment may involve finding the right drug for your headache, identifying and avoiding tension headache triggers, and avoiding rebound headaches that are caused by overusing pain relievers.

Headaches: Identifying and avoiding triggers

Nonprescription drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, are often all you need to reduce the pain you get with a tension headache. But try to avoid taking nonprescription drugs more than 3 times a week, because you may get rebound headaches. Rebound headaches are different from tension headaches. They are usually triggered after pain medicine has worn off, prompting you to take another dose. Eventually, you get a headache whenever you stop taking the medicine.

Prescription drugs. If nonprescription drugs do not relieve your headache, your doctor may prescribe stronger medicine to treat your pain. You may be prescribed:

• Antidepressants such as mirtazapine (Remeron) and the tricyclic antidepressant amitriptyline. When taken daily, these medicines can help to reduce how often tension headaches occur and how long they last.¹
• Seizure medicines or antianxiety drugs. These medicines are not often used to treat tension headaches.

In some cases your doctor may prescribe drugs such as barbiturates or narcotics when other drugs are ineffective. But these drugs can be habit-forming and should be used sparingly.

Should I take prescription drugs for tension headaches?

Stress management. Managing stress, anxiety, or depression may help reduce how often tension headaches occur. The best approach to managing chronic tension headaches may be a combination of drug and stress management therapies. Methods of reducing stress may include:

• Biofeedback, a relaxation method to help you learn to control a body function that is not normally under conscious control, such as muscle tension.
• A relaxation exercise during which you focus on relaxing each muscle group. Relaxation exercises can help with tension headaches. When relaxation exercises and antidepressants are used together as treatment, the results are even better.³
• Acupuncture, which involves putting very thin needles into the skin at certain points on the body to produce energy flow along the body's meridians. Evidence specifically for tension headaches shows that acupuncture is no better than sham acupuncture (when needles are put into the skin, but not at the right points).⁴
• Transcutaneous electrical nerve stimulation (TENS), which may help reduce pain.
• Cognitive-behavioral therapy or problem-solving therapy during counseling sessions. Cognitive-behavioral therapy and problem-solving therapy can help with tension headaches. When cognitive-behavioral therapy or problem-solving therapy and antidepressants are used together as treatment, the results are even better.³
• Yoga.
• Meditation.

Treatment if the condition gets worse

If you continue to have tension headaches while you are getting treatment, you and your doctor may want to try another treatment plan. Changing drugs, trying a different type of pain reliever, or taking other drugs daily (such as antidepressants) may help improve your symptoms or reduce the number of tension headaches you develop. If you have already tried several different types of drugs, your doctor may order tests (such as an MRI or CT scan) to rule out other causes of your headaches.

What To Think About

Even with treatment, you will most likely continue to have some tension headaches. For most people, successful treatment means you get headaches less often and they are less severe when you do get them. It is rare for any treatment to be able to stop all tension headaches. Finding an effective drug may take some time and patience. It may take several attempts to find the drug that works best for you.

If you think your tension headaches could be related to depression or anxiety, be sure to let your doctor know. You may be able to stop or reduce the occurrence of tension headaches with proper treatment of these conditions.

Botulinum toxin type A (BTX-A) is sometimes injected into the muscles in the face and head, to reduce contractions or spasms that in the past were thought to produce tension headaches. But BTX-A injections do not seem to help with symptoms of tension headaches.^{1, 5} And BTX-A may cause weakness of the facial muscles and may affect swallowing.

Prevention

You may be able to prevent the frequency and severity of tension headaches by reducing muscle tension and by identifying and avoiding the triggers, such as stress, anxiety, fatigue, hunger, anger, poor posture, or overexertion.

For more information, see:

Headaches: Identifying and avoiding triggers.

If you have tension headaches related to muscle tension in your neck, shoulders, and upper back, pay attention to your posture and position during your daily activities.

Home Treatment

There are many things you can do at home to reduce the frequency and severity of tension headaches. Reducing stress, getting regular exercise, eating right, and learning better ways to manage depression and anxiety may help.

Try the following:

• Find healthy ways to deal with stress. You may be more likely to get tension headaches during stressful times.
• Do relaxation exercises to reduce muscle tension and stress, which may help reduce the frequency and duration of tension headaches.
• Take medicine as prescribed by your doctor to prevent and treat your tension headaches. This will also help you to avoid getting rebound headaches, which can be caused by overusing pain relievers.
• Identify your headache triggers and determine whether your headaches are becoming more severe, by keeping a headache diary (What is a PDF document?) .
• Seek help if you think your tension headaches may be linked to depression or anxiety. Proper treatment of these conditions may reduce the frequency of your headaches, as well as relieve your symptoms of anxiety or depression.

For more information, see:

Headaches: Identifying and avoiding triggers.

Headaches: Managing headaches.

Tension headaches in children

If your child has tension headaches, they may be related to stress about school, such as tests, athletic events, dances, or peer pressure. They may also be related to lack of sleep. You may want to keep a diary of your child's headaches, to help identify his or her triggers. Talk to your doctor about the best treatment for your child's headaches. Be sure to let your doctor know if your child's headaches are not getting better.

Medications

Your doctor may prescribe medicine to both treat and prevent tension headaches. He or she may first suggest you try a nonprescription drug, which usually has fewer side effects than prescription drugs. The type of tension headache that you have may help your doctor determine which drug to prescribe. You may have to try several different drugs or types of drugs before you find the one that is right for you. Good communication with your doctor is important in finding the most effective treatment for you.

Medication Choices

Medicines you may be given to treat or prevent tension headaches include:

• Antidepressants such as mirtazapine (Remeron) and the tricyclic antidepressant amitriptyline. When taken daily, these medicines can help reduce how often tension headaches occur and how long they last.¹
• Seizure medicines or antianxiety drugs. These medicines are not often used to treat tension headaches.

In some cases your doctor may prescribe drugs such as barbiturates or narcotics when other drugs are ineffective. But these drugs can be habit-forming and should be used sparingly.

Should I take prescription drugs for tension headaches?

Botulinum toxin type A (BTX-A) is sometimes injected into the muscles in the face and head, to reduce contractions or spasms that in the past were thought to produce tension headaches. But BTX-A injections do not seem to help with symptoms of tension headaches.^{1, 5} And BTX-A may cause weakness of the facial muscles and may affect swallowing.

What To Think About

Try to avoid taking nonprescription drugs more than 3 times a week because you may get rebound headaches. Rebound headaches are different from tension headaches. They are usually triggered after pain medicine has worn off, prompting you to take another dose. Eventually, you get a headache whenever you stop taking the medicine.

Certain pain medicines interact poorly with other medicines. Before you begin taking pain medicines, be sure to let your doctor know about all of the drugs-both prescription and nonprescription, and other complementary therapies (such as herbs)-that you are taking.

Surgery

There is no surgical treatment for tension headaches.

Other Treatment

While you may use medicine to treat or prevent tension headaches, adding stress management therapies may help reduce the frequency of your tension headaches. Talk to your doctor about trying:

• Biofeedback, a relaxation method to help you learn to control a body function that is not normally under conscious control, such as muscle tension.
• A relaxation exercise during which you focus on relaxing each muscle group. Relaxation exercises can help with tension headaches. When relaxation exercises and antidepressants are used together as treatment, the results are even better.³
• Acupuncture, which involves putting very thin needles into the skin at certain points on the body to produce energy flow along the body's meridians. Evidence specifically for tension headaches shows that acupuncture is no better than sham acupuncture (when needles are put into the skin, but not at the right points).⁴
• Transcutaneous electrical nerve stimulation (TENS), which may help reduce pain.
• Cognitive-behavioral therapy or problem-solving therapy during counseling sessions. Cognitive-behavioral therapy and problem-solving therapy can help with tension headaches. When cognitive-behavioral therapy or problem-solving therapy and antidepressants are used together as treatment, the results are even better.³
• Yoga.
• Meditation.
• Peppermint oil. There is some evidence that peppermint oil rubbed on the temples or on the tight muscles in the head, neck, and shoulders may help relieve tension headaches.

Other Places To Get Help

Organizations

Related Information

• Anxiety
• Cluster Headaches
• Depression
• Headaches
• Migraine Headaches
• Sinusitis
• Stress Management

References

Citations

1. Silver N (2006). Headache (chronic tension-type), search date October 2005. Online version of Clinical Evidence (15).

2. Ropper AH, Brown RH (2005). Tension headache section of Headache and other craniofacial pains. In Adams and Victor's Principles of Neurology, 8th ed., p. 157. New York: McGraw-Hill.

3. Holroyd KA, et al. (2001). Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination. JAMA, 285(17): 2208-2215.

4. Melchart D, et al. (2006). Acupuncture for idiopathic headache. Cochrane Database of Systematic Reviews (4).

5. Naumann M, et al. (2008). 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, 70(19): 1707-1714.

Other Works Consulted

• Diamond ML (2002). The role of concomitant headache types and non-headache co-morbidities in the underdiagnosis of migraine. Neurology, 58: S3-S9.

Credits