What is Tension headache

Tension-type headache (previously termed tension headache or muscle contraction headache) is a common type of primary headache, characterised by mild-moderate head pain with no associated symptoms. Like other primary headaches, tension-type headaches have no apparent underlying cause. They may be episodic or chronic, in which case they are referred to as chronic daily headaches.

Statistics on Tension headache

Episodic tension-type headaches are the most common type of primary headache. The prevalence of tension-type headache has been reported as being 29–71% in different studies. This type of headache occurs most commonly in the 40–49 year age group, but it affects individuals of all ages, including children. Tension-type headache is more common amongst individuals with higher educational attainment, and women are more likely to experience tension-type headaches than men.

Risk Factors for Tension headache

Individuals with a family history of tension-type headache are thought to be predisposed to experiencing these headaches. Tension-type headaches are often associated with psychological conditions including anxiety and depression. Studies have reported associations between tension-type headaches and the following variables:

  • Self-reported levels of fatigue;
  • Time pressure at work (women);
  • Exposure to fumes (men);
  • Stress;
  • Mental tension;
  • Alcohol;
  • Weather changes;
  • Menstruation (women);
  • Exclusive sedentary behaviour (men);
  • Sleep patterns.

Progression of Tension headache

Tension-type headaches are thought to occur as a response to stress, anxiety, depression and conflict. However, the mechanisms through which tension-type headaches develop are not well understood. They appear to be of muscular origin and related to increased muscle tension while resting. While clear associations between muscle and psychological tension and tension-type headaches have been demonstrated, it is not clear whether muscle or psychological tension cause the headaches or vice versa. Nitric oxide, a chemical which functions to transmit signals through the nervous system, is thought to mediate tension-type headaches.

Symptoms of Tension headache

Many individuals with tension-type headaches do not discuss their condition with a doctor and self-medicate using over-the-counter pain killers. Often headaches become more severe and frequent with self-medication, and many people only consult a doctor when their headaches worsen. It is important to discuss tension-type headaches with a doctor as soon as possible to ensure the most appropriate medications are used to treat the headaches and that medication is not overused. Headaches which result from medication overuse are much more difficult to treat.

Clinical history; that is, asking questions about headaches symptoms and other health issues, is the key tool used by doctors to diagnose tension-type headache. A diagnosis of tension-type headache is based on the International Headache Society diagnostic criteria and will be made in an individual who reports:

  1. They have previously experienced at least 10 headaches meeting criteria B–D, on < 15 days per month. Individuals who experience more frequent headaches should receive a diagnosis of chronic daily headache;
  2. Their headaches last from 30 minutes to 7 days;
  3. Their headaches fulfil at least two of the following pain criteria:
    • Non-pulsating pain, of a pressing or tightening quality;
    • Pain of mild or moderate intensity which does not inhibit daily activity;
    • Bilateral pain (on both sides of the head);
    • Pain is not aggravated with routine physical activity;
  4. In addition, their headaches must not be associated with:
  5. Are not attributable to a secondary condition, such as an illness.


Headaches meeting these criteria may be further classified as infrequent (at least 10 previous episodes occurring on 1 or less days per month) or frequent (at least 10 previous episodes occurring on 2–15 days per month). The headaches typically persist for hours or days; however, in severe cases tension-type headaches may be continuous.

Asking questions about headache characteristics and general health is usually enough to enable the doctor to diagnose tension-type headache. The doctor is likely to enquire about the nature and frequency of headache episodes as well as how the headaches have been treated in the past. Self-medication with over-the-counter medication is typical. Chiropractic or massage therapies are also common strategies for self-treating tension-type headaches. The doctor may also enquire about your lifestyle around the time of headache onset or worsening.

The pain of a tension-type headache is typically describes as pressing or tightening pain, or a dull ache. It often extends bilaterally (on both sides) from the forehead across the side of the head and many people report pain in the neck muscles during tension-type headaches. In more severe cases pain may radiate to the shoulders, shoulder blades and between the shoulder blades. Some people who experience neck pain with tension-type headaches incorrectly believe a disorder of the neck underlies the headache. A neck disorder should not be assumed. If you experience neck pain it is important to have a doctor assess all your symptoms and diagnose your headaches accordingly.

Psychological conditions such as depression are commonly also experienced by individuals with tension-type headache. The doctor may therefore ask questions about emotional health as well as headache characteristics.


Children and adolescents

Children or adolescents presenting with tension-type headaches may also be asked about their relationships with family and friends and their performance at school.

Clinical Examination of Tension headache

The doctor may also conduct a physical examination as part of the diagnostic process. It is likely to include touching and pressing muscles of the head, neck and back to check for tenderness. Tenderness is characteristic of tension-type headaches, and is the most common abnormal finding on clinical examination.

The physical examination may also be used to rule out secondary headache causes if these are suspected. Headaches occurring secondary to severe hypertension have similar pain characteristics to those of tension-type headaches. Blood pressure may be assessed to exclude hypertension as an underlying cause. The doctor may also feel the mandibular joints (the joints of the upper and lower jaw bones) to asses for dysfunction or tenderness of these joints. Habitual teeth clenching or gum chewing suggest that another condition is causing the headache. It is important to report these behaviours to the doctor. Neurological examination may also be conducted to rule out underlying dysfunctions of the nervous system which may be causing the headaches.

How is Tension headache Diagnosed?

Tension-type headaches are diagnosed based on clinical history and examination. It is not necessary to conduct blood, urine or other special tests to diagnose this type of headache. Tests will only be conducted if it is possible that another condition (e.g. infection) is causing the headache.

Prognosis of Tension headache

Tension-type headache is not a life threatening condition. However, it may reduce productivity at work or interfere with social or family life. A considerable proportion of adults (45%) recover from tension-type headaches with appropriate treatment, which usually includes prophylactic (preventative) medicines. However, 39% continue to experience frequent headaches and 16% progress to more frequent, chronic daily headache.

How is Tension headache Treated?

Tension headache is a benign and common condition. Your doctor will only provide minimal treatment because aggressive drugs can exaccerbate the problem and lead to side-effects. The main aims of treatment are to reduce symtoms as there are generally no long-term medical consequences from the condition. Your doctor may give the following treatments:

  • Reassurance – Your doctor should explain that the headaches result from tightening of the scalp muscles often due to stress. They will also assure you the condition is not anything serious and is self-limiting.
  • Addressing contributory factors such as stress or abnormal muscles and bone structure around the face.
  • Counselling on relaxation – reduce work commitments, relaxation therapy or meditation classes and yoga, particularly if stress is a contributing factor. Regular exercise can help.
  • Medications – mild analgesics such as aspirin and paracetamol are recommended. Strong analgesics are not recommended as drug rebound headache may follow stopping of the drug. In general, drug treatment is not very successful compared to other forms of headache.
  • If treatment is not successful, your doctor may ask you to return and undergo further investigations for another possible cause. This is particularly relevant for severe headaches that wake patients from sleep.

Tension headache Prevention

Prophylactic (preventative) medication may be prescribed for individuals who experience frequent (2–15 per month) tension-type headaches. The risk of developing chronic tension-type headache rises exponentially once headache frequency reaches a weekly level. Individuals with frequent headaches may therefore be prescribed prophylactic medication with the aim of reducing their headache frequency and the risk of chronic daily headaches developing.

The most commonly prescribed medicine is called amitriptyline (e.g. Endep), an anti-depressant which reduces pain and muscle tension. Amitriptyline may be used in combination with relaxation therapy or tizanidine (a muscle-relaxing medicine). However, it is associated with weight gain in up to 25% of individuals which limits its use.

For tension-type headache prophylaxis, only a small dose is required. It is important to always take the dose prescribed by the doctor. Individuals who continue to experience headaches while taking prophylactic medication should report this to their doctor and discuss prophylactic treatment options. The doctor may gradually increase the dose or prescribe other prophylactic therapies to be taken in addition to this medicine. Due to the natural variation in headache frequency over time, at least 3 months prophylaxis should be taken before returning to the doctor to assess its effectiveness. While taking prophylactic medicine it is important to monitor your experience of headaches (e.g. frequency, duration, intensity) and the medication you use to treat the acute headache attacks in a diary. Successful prophylaxis should reduce the frequency and/or intensity of headaches and reduce the need for medication to treat acute attacks. If prophylactic medications are successful in preventing headaches they will gradually be withdrawn after 6 months but may be reinstituted if headaches return.

Headache Australia image Headache Australia is the only Australian charity that aims to support the more than 5 million Australians affected by headache and migraine. Headache Australia is an initiative of the Brain Foundation – a national charity raising funds for research from community donations.

For more information, see Headache Australia.

Tension headache References

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  5. Rasmussen BK. Migraine and tension-type headache in a general population: psychosocial factors. Int J Epi. 1992; 21(6): 1138-43. Abstract
  6. Rasmussen BK. Migraine and tension type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain. 1993; 53(1): 65-72 Abstract
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  8. International Headache Society,  The International Classification of Headache Disorders. 2nd Edition, 1st revision. 2005. [cited 8 November 2011]. Available from: URL Link
  9. Olesen J, Bousser MG, Diener HC, et al. New appendix criteria open for a broader concept of chronic migraine. Cephalgia. 2006; 26: 742-46. Full Text
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