Tension headaches are very common, affecting as many as 40% of teenagers and
adults. They tend to start at the back of your head and move forward, involving
your neck, scalp, and head (for example, the temporal regions on either side of
your forehead and the occiput, which is at the base of your head just above the
neck). The pain, which is due to contraction (tightness) of the neck and scalp
muscles, can ultimately cover your entire head. Such muscle contraction is
commonly caused by stress - thus, the name "tension."
Headaches originating from tightness in the neck muscles are often called
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 or
vice around the head
Muscles in your neck, shoulders, and jaw can feel tight and sore
Bilateral - meaning that it affects both
sides of your head equally
May have difficulty sleeping
When you feel tense, the muscles in your shoulders, neck, scalp, and jaw
tighten up, creating pain. Causes include the following:
Any acitivity (like using a computer, typing, fine work with your
hands, or using a microcope) that causes the head to be held in one position for
a long time without moving
Sleeping in an abnormal position or in a cold room
Head or neck injury, even years after the injury
Clenching your jaw or grinding your teeth, which can cause a condition
known as Temporomandibular Joint (TMJ) Dysfunction, can also cause muscle
contraction around the temples, neck, and shoulders, spreading to the head and
resembling tension headaches
Pain that originates from other areas, such as your sinuses, can also
trigger tension headaches or a combined sinus/tension headache
Women tend to have more headaches than men (although, prior to
adolescence, boys may get more headaches than girls)
Changes in estrogen levels such as menstruation and menopause
Too much or too little sleep
Missed or delayed meals
Alcohol or drug use
Certain foods or food additives may also be a trigger for some people
Nutrition and Dietary Supplements
When you see your health care provider, he or she will take a detailed
history in order to distinguish tension headaches from headaches of other
causes, such as migraines. Your health care provider 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 prior to seeing the doctor; this
way, you'll have an accurate recording of how often they happen and you won't
forget the details related to your headaches.
When you do see your physician, the physical exam will include assessing your
head, neck, eyes, and sinuses as well as performance of a neurologic
examination. Don't be surprised if the doctor asks you some questions to test
your short term memory. On exam, the physician is likely to find musculoskeletal
tenderness around your neck and scalp.
Tests that your doctor may order, depending on your symptoms and exam,
CT scan or MRI to look for a mass or other brain disorder or to check
Xray of the neck to look for arthritis or spinal problems; xray of the
sinuses to look for sinusitis
Electroencephalogram (EEG) - a brain wave
study , looking for any seizure activity
Lumbar puncture - a "spinal tap" done for
different reasons, including to rule out any infection like meningitis
Unfortunately, as many as 60% of people with tension headaches do not seek
the advice of their physician and simply resort to taking over the counter
medications for the pain. This is too bad because a comprehensive treatment plan
including relaxation (see
Mind/Body Medicine), exercise and
lifestyle changes, and occasional
medication can be very effective in
significantly reducing the frequency and intensity of tension headaches.
Many of the medications used to prevent or treat tension headaches, however,
have risks and side effects. Therefore, using methods that do not include
medications are preferred if you are able to achieve successful pain control and
reduce the frequency of your headaches. Biofeedback, yoga, and relaxation
techniques, for example, can be quite effective for both acute relief and
decreased headache frequency. Regular exercise can also reduce how often you get
a tension headache.
Keeping a headache diary, particularly when you first begin to experience
headaches, can help identify the source of your tension headaches and how to
modify your environment and habits to avoid headaches. When a headache occurs,
write down the date and time the headache began. Note what you ate for the
preceding 24 hours, how long you slept the night before, what you were
experiencing 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, as listed below, are important for helping to lessen
stress and tension headaches:
Eating a healthy
Choose from a variety of relaxation techniques (see
Mind/Body Medicine section)
Medications are used both to treat the pain from a headache at the time that
you have it (acute therapy) and to prevent the headaches from coming if you are
a person who gets them frequently (chronic therapy).
Acute pain control:
Over-the-counter (OTC) pain relievers are usually effective temporary
remedies. Talk to your doctor about which of these is best for you.
If over the counter medications are not adequate for pain control, a
physician may prescribe a more potent version of non-steroidal anti-inflammatory
drug (NSAID) such as naproxen, ibuprofen, diclofenac, tolmetin, or ketoprofen.
Another medication that your doctor might consider is called isometheptene.
Rarely, if your headaches are very severe and nothing else relieves the pain,
your physician may consider prescribing opiods like codeine or hydrocodone.
Prevention of chronic, recurrent tension headaches:
Tricyclic antidepressants, such as amitriptyline, imipramine,
desipramine, and nortriptyline, may be used; generally, relaxation techniques
and cognitive behavioral therapy (see
Mind/Body Medicine) are encouraged
first, before this class of medication is considered as an adjunct to these
techniques, especially in children.
Other antidepressants may be considered by your doctor as well,
including monoamine oxidase inhibitors (MAOIs such as phenelzine and
tranylcypromine), selective serotonin-reuptake inhibitors (SSRIs like
fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram), bupropion,
nefazodone, or venlafaxine.
Anti-anxiety agents, like alprazolam or clonazepam, might be
prescribed for a short period of time to decrease muscle tension or to treat
anxiety symptoms during periods of extreme stress.
Surgery and Other Procedures
If an injury or problem in the cervical spine is contributing to tension
headaches, a nerve block, using a steroid to reduce inflammation and muscle
contraction, may be considered to lessen the head pain.
Nutrition and Dietary Supplements
Certain foods can trigger tension headaches; these include:
Monosodium glutamate (MSG), a flavor enhancer
On the other hand, following a diet that is rich in fruits and vegetables,
whole grains, and uses fish and soy for protein instead of red meat may help
lessen the frequency and intensity of your headaches.
Magnesium levels tend to be lower in those with headaches, both migraines and
tension types. In the case of tension headaches, this may be due to the fact
that low levels of magnesium may trigger muscle tightness and pain. Therefore,
if you suffer from frequent tension headaches, consider, together with your
physician, taking magnesium supplements and carefully keeping track of whether
your headaches happen less often or are less severe.
Vitamin B Complex
Vitamin B complex is considered to be an anti-stress agent and, therefore,
potentially helpful to take if you experience tension headaches.
5-hydroxytryptophan (5-HTP) is an amino acid. The body makes 5-HTP from
tryptophan (another amino acid that is obtained from the diet) and converts it
to an important brain chemical known as serotonin. 5-HTP dietary supplements
help raise serotonin levels in the brain, which may have a positive effect on
sleep, mood, anxiety, aggression, appetite, temperature, sexual behavior, and
pain sensation. Some studies suggest that 5-HTP supplements may be effective in
children and adults with various types of headaches including tension, but more
research is needed before knowing its safety and
The use of herbs is a time-honored approach to strengthening the body and
treating disease. Herbs, however, contain active substances that can trigger
side effects and interact with other herbs, supplements, or medications. For
these reasons, herbs should be taken with care and only under the supervision of
a practitioner knowledgeable in the field of herbal medicine.
Cayenne (Capsicum frutescens/Capsicum spp.)
Capsaicin, a substance found in cayenne pepper, has powerful pain-relieving
properties when applied topically. To relieve chronic, recurrent headaches,
including tension and cluster headaches (a severe one-sided headache that tends
to occur in clusters, happening repeatedly every day at the same time for
possibly several weeks), capsaicin is placed inside the nose.
Peppermint (Mentha x piperita) When applied topically
to the forehead and temples, peppermint has the ability to relieve tension
headaches and may be comparable to acetaminophen (a commonly used over the
Although studies are lacking, the following herbs have been used clinically
by herbal specialist to treat different types of headaches, including
An acupuncturist diagnoses headaches not as migraine, tension, or sinus, but
rather as conditions deriving from "energetic" imbalances. Headaches are
commonly seen and often successfully treated by acupuncturists.
The National Institutes of Health recommends acupuncture as a treatment for
headache. 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 to determine an appropriate treatment plan, which
(in addition to placing needles in acupuncture points) may include
lifestyle/dietary changes or herbal remedies. While results from studies have
been mixed, most researchers agree that acupuncture is safe and that headache
patients who wish to try this therapy should not be discouraged from doing
Spinal manipulation is commonly used to treat tension headaches, especially
tension headaches that originate from the neck. Evidence supporting the use of
tension headaches that originate in the neck is quite clear; however, studies
examining the effectiveness of spinal manipulation for other types of tension
headaches have been less conclusive.
In one very important study, individuals with tension headaches were randomly
assigned to receive either spinal manipulation or an antidepressant medication.
Both groups experienced significant improvement while they were being treated.
When treatment was stopped, however, the beneficial effects of spinal
manipulation lasted longer than did the effects of the antidepressant
In addition, a review article evaluating nine studies that tested spinal
manipulative therapy for tension or migraine headaches concluded that this
chiropractic technique is comparable to medications used to try to prevent
either of these two types of headaches.
Massage and Physical Therapy
Stretching exercises for the head and neck, taught by a physical therapist,
and receiving massages regularly can help reduce the frequency and duration of
tension headaches. Stretching frequently is particularly important if your work
involves typing or using a computer. Learning proper posture is another
important factor in reducing your number of headaches; a physical therapist can
Reflexology (a type of massage in which specialized thumb and finger
techniques are applied to the hands and/or feet at points that correspond to
specific organs and structures throughout the body) may be an especially
valuable technique for treating and preventing headaches.
Other techniques that some clinicians recommend include aromatherapy (the use
of essential oils from plants, often together with massage, for healing
purposes) and Reiki (an energy balancing technique) treatments.
Studies indicate that homeopathy may be no more effective than placebo in
relieving tension headaches. Interestingly, however, 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
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
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
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.
You can do many things to avoid tension headaches or relieve the
Biofeedback to control muscle tension.
Learn to meditate, breathe deeply, or try other relaxation exercises,
such as yoga or hypnotherapy.
See a Cognitive Behavioral Therapist
Other relaxation techniques that may be helpful include:
Some women who are prone to headaches will get them more often when they are
pregnant. Other women, however, experience fewer headaches during pregnancy,
especially during the second trimester.
Warnings and Precautions
It is important to use medications only as directed. Rebound headaches may
occur from overuse of medications and complications may occur from side effects
Call your health care provider if you experience a new headache, a change in
quality of a previous headache or previous headache pattern, or if you are
unable to manage your symptoms in the usual way (for example, a medication that
usually takes away the pain no longer works).
Prognosis and Complications
Serious underlying conditions due to headaches, like a tumor or a stroke, are
extremely uncommon, despite the fact that many worry about these possibilities.
Situations that may indicate a serious problem include the
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/tingling in any
one of your limbs
Headaches after a head injury, especially if you are also drowsy or
Headaches accompanied by fever, stiff neck, nausea and vomiting (may
Severe headache localized to one eye, accompanied by redness of the
eye (may indicate acute glaucoma)
The good news is that over 90% of people with tension headaches can get
significant relief from a combination of lifestyle change, relaxation, and
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Review Date: June 2003
Reviewed By: Participants in the review process include: Robert A. Anderson, MD,
President, American Board of Holistic Medicine, East Wenatchee, WA; Gary
Guebert, DC, DACBR, (Chiropractic section October 2001) Login Chiropractic
College, Maryland Heights, MO; Jacqueline A. Hart, MD, Department of Internal
Medicine, Newton-Wellesley Hospital, Boston, Ma and Senior Medical Editor
A.D.A.M., Inc.; Richard A. Lippin, MD, President, The Lippin Group, Southampton,
PA; Joseph Trainor, DC, (Chiropractic section October 2001) Integrative
Therapeutics, Inc., Natick, MA; Anne McClenon, ND, Compass Family Health Center,
Plymouth, MA; Marcellus Walker, MD, LAc, (Acupuncture section October 2001) St.
Vincent's Catholic Medical Center, New York, NY; Elizabeth Wotton, ND, private
practice, Sausalito, CA; Ira Zunin, MD, MPH, MBA, (Acupuncture section October
2001) President and Chairman, Hawaii State Consortium for Integrative Medicine,
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