Tension headache

Date Updated: 09/29/2021

Overview

A tension-type headache (TTH) is generally a mild to moderate pain that's often described as feeling like a tight band around the head. A tension-type headache is the most common type of headache, yet its causes aren't well understood.

Treatments for tension-type headaches are available. Managing a tension-type headache is often a balance between practicing healthy habits, finding effective nondrug treatments and using medications appropriately.

Symptoms

Signs and symptoms of a tension-type headache include:

Dull, aching head pain
Sensation of tightness or pressure across the forehead or on the sides and back of the head
Tenderness in the scalp, neck and shoulder muscles

Tension-type headaches are divided into two main categories — episodic and chronic.

Episodic tension-type headaches

Episodic tension-type headaches can last from 30 minutes to a week. Frequent episodic tension-type headaches occur less than 15 days a month for at least three months. Frequent episodic tension-type headaches may become chronic.

Chronic tension-type headaches

This type of tension-type headache lasts hours and may be continuous. If your headaches occur 15 or more days a month for at least three months, they're considered chronic.

Tension-type headaches versus migraines

Tension-type headaches can be difficult to distinguish from migraines. Plus, if you have frequent episodic tension-type headaches, you can also have migraines.

Unlike some forms of migraine, tension-type headaches usually aren't associated with visual disturbances, nausea or vomiting. Although physical activity typically aggravates migraine pain, it doesn't make tension-type headache pain worse. An increased sensitivity to either light or sound can occur with a tension-type headache, but this symptom isn't common.

When to see a doctor

Make an appointment with your doctor

If tension-type headaches disrupt your life or you need to take medication for your headaches more than twice a week, see your doctor.

Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different. Occasionally, headaches may indicate a serious medical condition, such as a brain tumor or rupture of a weakened blood vessel (aneurysm).

When to seek emergency help

If you have any of these signs or symptoms, seek emergency care:

Abrupt, severe headache
Headache with a fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or speaking difficulties
Headache after a head injury, especially if the headache gets worse

Causes

The cause of tension-type headaches is not known. Experts used to think tension-type headaches stemmed from muscle contractions in the face, neck and scalp, perhaps as a result of heightened emotions, tension or stress. But research suggests that muscle contraction isn't the cause.

The most common theory supports a heightened sensitivity to pain in people who have tension-type headaches. Increased muscle tenderness, a common symptom of tension-type headaches, may result from a sensitized pain system.

Triggers

Stress is the most commonly reported trigger for tension-type headaches.

Complications

Because tension-type headaches are so common, their effect on job productivity and overall quality of life is considerable, particularly if they're chronic. The frequent pain may render you unable to attend activities. You might need to stay home from work, or if you do go to your job, your ability to function may be impaired.

Prevention

In addition to regular exercise, techniques such as biofeedback training and relaxation therapy can help reduce stress.

Biofeedback training. This technique teaches you to control certain body responses that help reduce pain. During a biofeedback session, you're connected to devices that monitor and give you feedback on body functions such as muscle tension, heart rate and blood pressure. You then learn how to reduce muscle tension and slow your heart rate and breathing yourself.
Cognitive behavioral therapy. This type of talk therapy may help you learn to manage stress and may help reduce the frequency and severity of your headaches.
Other relaxation techniques. Anything that helps you relax, including deep breathing, yoga, meditation and progressive muscle relaxation, may help your headaches. You can learn relaxation techniques in classes or at home using books, videos or apps.

Using medications in conjunction with stress management techniques may be more effective than either treatment alone in reducing your tension-type headaches.

Additionally, living a healthy lifestyle may help prevent headaches:

Get enough, but not too much, sleep.
Don't smoke.
Exercise regularly.
Eat regular, balanced meals.
Drink plenty of water.
Limit alcohol, caffeine and sugar.

Diagnosis

If you have chronic or recurrent headaches, your doctor may conduct physical and neurological exams, then try to pinpoint the type and cause of your headaches using these approaches:

Your pain description

Your doctor can learn a lot about your headaches from a description of your pain. Be sure to include these details:

Pain characteristics. Does your pain pulsate? Or is it constant and dull or sharp or stabbing?
Pain intensity. A good indicator of the severity of your headache is how much you're able to function while you have it. Are you able to work? Do your headaches wake you or prevent you from sleeping?
Pain location. Do you feel pain all over your head, on only one side of your head, or just on your forehead or behind your eyes?

Imaging tests

If you have unusual or complicated headaches, your doctor may order tests to rule out serious causes of head pain, such as a tumor. Two common tests that can be used to image your brain include:

Magnetic resonance imaging (MRI). An MRI scan combines a magnetic field, radio waves and computer technology to produce clear images.
Computerized tomography (CT). A CT scan is a diagnostic imaging procedure that uses a series of computer-directed X-rays to provide a comprehensive view of your brain.

Treatment

Some people with tension-type headaches don't seek medical attention and try to treat the pain on their own. Unfortunately, repeated use of pain relievers that are available without a prescription can actually cause another type of headache, medication overuse headache.

Acute medications

A variety of medications, both nonprescription and prescription, are available to reduce the pain of a headache, including:

Pain relievers. Simple pain relievers available without a prescription are usually the first line of treatment for reducing headache pain. These include the drugs aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve).
Combination medications. Aspirin or acetaminophen (Tylenol, others) or both are often combined with caffeine or a sedative drug in a single medication. Combination drugs may be more effective than single-ingredient pain relievers. Many combination drugs are available without a prescription.
Triptans and narcotics. For people who experience both migraines and episodic tension-type headaches, a triptan can effectively relieve the pain of both headaches. Opioids, or narcotics, are rarely used because of their side effects and potential for dependency.

Preventive medications

Your doctor may prescribe medications to reduce the frequency and severity of attacks, especially if you have frequent or chronic headaches that aren't relieved by pain medication and other therapies.

Preventive medications may include:

Tricyclic antidepressants. Tricyclic antidepressants, including amitriptyline and protriptyline, are the most commonly used medications to prevent tension-type headaches. Side effects of these medications may include constipation, drowsiness and dry mouth.
Other antidepressants. Evidence also supports the use of the antidepressants venlafaxine (Effexor XR) and mirtazapine (Remeron).
Anticonvulsants and muscle relaxants. Other medications that may prevent tension-type headaches include anticonvulsants, such as gabapentin and topiramate (Topamax, Qsymia, others). More study is needed.

Preventive medications may require several weeks or more to build up in your system before they take effect. So don't get frustrated if you haven't seen improvements shortly after you begin taking a drug.

Your doctor will monitor your treatment to see how the preventive medication is working. In the meantime, overuse of pain relievers for your headaches may interfere with the effects of the preventive drugs. Ask your doctor about how often to use pain relievers while you’re taking preventive medication.

Lifestyle and home remedies

Rest, ice packs or a long, hot shower may be all you need to relieve a tension-type headache. A variety of strategies can help you reduce the severity and frequency of chronic tension-type headaches without using medicine. Try some of the following:

Manage your stress level. One way to help reduce stress is by planning ahead and organizing your day. Another way is to allow more time to relax. And if you're caught in a stressful situation, consider stepping back.
Go hot or cold. Applying heat or ice — whichever you prefer — to sore muscles may ease a tension-type headache. For heat, use a heating pad set on low, a hot-water bottle, a warm compress or a hot towel. A hot bath or shower also may help. For cold, wrap ice, an ice pack or frozen vegetables in a cloth to protect your skin.
Perfect your posture. Good posture can help keep your muscles from tensing. When standing, hold your shoulders back and your head level. Pull in your abdomen and buttocks. When sitting, make sure your thighs are parallel to the ground and your head isn't slumped forward.

Alternative medicine

The following nontraditional therapies may help if you have tension-type headache pain:

Acupuncture. Acupuncture may provide temporary relief from chronic headache pain. Acupuncture practitioners treat you using extremely thin, disposable needles that generally cause little pain or discomfort. Acupuncture is typically safe when performed by an experienced acupuncturist who follows safety guidelines and uses sterile needles.
Massage. Massage can help reduce stress and relieve tension. It's especially effective for relieving tight, tender muscles in the back of your head, neck and shoulders. For some people, it may also provide relief from headache pain.
Deep breathing, biofeedback and behavior therapies. A variety of relaxation therapies are useful in coping with tension-type headaches, including deep breathing and biofeedback.

Coping and support

Living with chronic pain can be difficult. Chronic pain can make you anxious or depressed and affect your relationships, your productivity and the quality of your life.

Here are some suggestions:

Talk to a counselor or therapist. Talk therapy may help you cope with the effects of chronic pain.
Join a support group. Support groups can be good sources of information. Group members often know about the latest treatments. Your doctor may be able to recommend a group in your area.