Open Access Articles- Top Results for Tension headache

Tension headache

Tension headache
A woman experiencing a tension headache
Classification and external resources
ICD-10 G44.2
ICD-9 307.81, 339.1
DiseasesDB 12554
MedlinePlus 000797
eMedicine article/1142908
NCI Tension headache
Patient UK Tension headache
MeSH D018781

Tension headache, also known as tension-type headache, is the most common type of primary headache. The pain can radiate from the lower back of the head, the neck, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches.

Tricyclic antidepressants appear to be useful for prevention.[1] Evidence is poor for and SSRIs, propranolol and muscle relaxants.[2][3]

Tension headaches affect about 1.4 billion people (20.8% of the population) and are more common in women than men (23% to 18% respectively).[4]

Signs and symptoms

Tension-type headache pain is often described as a constant pressure, as if the head were being squeezed in a vise. The pain is frequently present on both sides of the head at the same time. Tension-type headache pain is typically mild to moderate, but may be severe.

Frequency and duration

Tension-type headaches can be episodic or chronic.[5] Episodic tension-type headaches are defined as tension-type headaches occurring fewer than 15 days a month, whereas chronic tension headaches occur 15 days or more a month for at least 6 months. Tension-type headaches can last from minutes to days, months or even years, though a typical tension headache lasts 4–6 hours.


Various precipitating factors may cause tension-type headaches in susceptible individuals:[6]

  • Stress: usually occurs in the afternoon after long stressful work hours or after an exam
  • Sleep deprivation
  • Uncomfortable stressful position and/or bad posture
  • Irregular meal time (hunger)
  • Eyestrain

One half of patients with tension-type headaches identify stress or hunger as a precipitating factor.[citation needed]

Tension-type headaches may be caused by muscle tension around the head and neck. One of the theories says that the main cause for tension-type headaches and migraine is teeth clenching which causes a chronic contraction of the temporalis muscle.[citation needed]

Another theory is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information—for example from the temporal muscle or other muscles—and interprets this signal as pain. One of the main neurotransmitters that is probably involved is serotonin. Evidence for this theory comes from the fact that chronic tension-type headaches may be successfully treated with certain antidepressants such as amitriptyline. However, the analgesic effect of amitriptyline in chronic tension-type headache is not solely due to serotonin reuptake inhibition, and likely other mechanisms are involved. Recent studies of nitric oxide (NO) mechanisms suggest that NO may play a key role in the pathophysiology of CTTH.[7] The sensitization of pain pathways may be caused by or associated with activation of nitric oxide synthase (NOS) and the generation of NO. Patients with chronic tension-type headache have increased muscle and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain thresholds. Hyperexcitability of central nociceptive neurons (in trigeminal spinal nucleus, thalamus, and cerebral cortex) is believed to be involved in the pathophysiology of chronic tension-type headache.[8] Recent evidence for generalized increased pain sensitivity or hyperalgesia in CTTH strongly suggests that pain processing in the central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type headache.[9]


Tricyclic antidepressants have been found to be more effective than SSRIs but have greater side effects.[1] Evidence is insufficient for the use of SSRIs, propranolol and muscle relaxants for prevention of tension headaches.[2][3]



Episodic tension-type headaches generally respond well to over-the-counter analgesics such as ibuprofen, paracetamol/acetaminophen, and aspirin. Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache. The first-line treatment for chronic tension type headache is amitriptyline, whereas mirtazapine and venlafaxine are second-line treatment options.[10] Other medication options include topiramate and sodium valproate (as prophylaxis).[11] Biofeedback techniques may also help.[12][13]

When all other treatment options have failed and pain is at a completely intolerable level, barbiturate medications such as fioricet and fiorinal may be prescribed as a drug of last resort. For this purpose, it is generally written as a single dose or one-two days worth of doses (once every 6 hours) until the pain stops. Although it is occasionally written in larger doses for use on a pro re nata basis this practice is discouraged due to the very high abuse potential, large range of interactions, and exceptionally high toxicity of the barbiturate class of drugs.

Botulinum toxin is a treatment trialled by some people with tension-type headache, though results are varied.[citation needed]


Acupuncture may be useful in those with frequent or chronic tension headaches.[14]

Manual therapy

People with tension-type headache often use spinal manipulation, soft tissue therapy, and myofascial trigger point treatment. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache.[15] A 2005 structured review found only weak evidence for the effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[16] A 2004 Cochrane review found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache.[17] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.[18]


Tension headaches affect about 1.4 billion people (20.8% of the population) and are more common in women than men (23% to 18% respectively).[4] Despite its benign character, tension-type headache, especially in its chronic form, can impart significant disability on patients as well as burden on society at large.[19]


Tension headaches that do not occur as a symptom of another condition may be painful, but are not harmful. It is usually possible to receive relief through treatment. Tension headaches that occur as a symptom of another condition are usually relieved when the underlying condition is treated. Frequent use of pain medications in patients with tension-type headache may lead to the development of medication overuse headache or rebound headache.


  1. ^ a b Jackson JL, Shimeall W, Sessums L et al. (2010). "Tricyclic antidepressants and headaches: systematic review and meta-analysis". BMJ 341: c5222. PMC 2958257. PMID 20961988. doi:10.1136/bmj.c5222. 
  2. ^ a b Verhagen AP, Damen L, Berger MY, Passchier J, Koes BW (April 2010). "Lack of benefit for prophylactic drugs of tension-type headache in adults: a systematic review". Fam Pract 27 (2): 151–65. PMID 20028727. doi:10.1093/fampra/cmp089. 
  3. ^ a b Banzi, R; Cusi, C; Randazzo, C; Sterzi, R; Tedesco, D; Moja, L (1 May 2015). "Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults.". The Cochrane database of systematic reviews 5: CD011681. PMID 25931277. 
  4. ^ a b Vos, T; Flaxman, A. D.; Naghavi, M; Lozano, R; Michaud, C; Ezzati, M; Shibuya, K; Salomon, J. A.; Abdalla, S; Aboyans, V; Abraham, J; Ackerman, I; Aggarwal, R; Ahn, S. Y.; Ali, M. K.; Alvarado, M; Anderson, H. R.; Anderson, L. M.; Andrews, K. G.; Atkinson, C; Baddour, L. M.; Bahalim, A. N.; Barker-Collo, S; Barrero, L. H.; Bartels, D. H.; Basáñez, M. G.; Baxter, A; Bell, M. L.; Benjamin, E. J. et al. (Dec 15, 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet 380 (9859): 2163–96. PMID 23245607. doi:10.1016/S0140-6736(12)61729-2. 
  5. ^ Headache Classification Subcommittee of the International Headache Society (2004). "The International Classification of Headache Disorders: 2nd edition". Cephalalgia 24 (Suppl 1): 9–160. PMID 14979299. doi:10.1111/j.1468-2982.2004.00653.x.  as PDF
  6. ^ Muscle Contraction Tension Headache at eMedicine
  7. ^ Ashina M, Lassen LH, Bendtsen L, Jensen R, Olesen J; Lassen; Bendtsen; Jensen; Olesen (January 1999). "Effect of inhibition of nitric oxide synthase on chronic tension-type headache: a randomised crossover trial". Lancet 353 (9149): 287–9. PMID 9929022. doi:10.1016/S0140-6736(98)01079-4. 
  8. ^ Ashina S, Bendtsen L, Ashina M; Bendtsen; Ashina (December 2005). "Pathophysiology of tension-type headache". Curr Pain Headache Rep 9 (6): 415–22. PMID 16282042. doi:10.1007/s11916-005-0021-8. 
  9. ^ Pielsticker A, Haag G, Zaudig M, Lautenbacher S; Haag; Zaudig; Lautenbacher (November 2005). "Impairment of pain inhibition in chronic tension-type headache". Pain 118 (1–2): 215–23. PMID 16202520. doi:10.1016/j.pain.2005.08.019. 
  10. ^ Bendtsen L, Jensen R; Jensen (May 2011). "Treating tension-type headache — an expert opinion". Expert Opin Pharmacother 12 (7): 1099–109. PMID 21247362. doi:10.1517/14656566.2011.548806. 
  11. ^ Yurekli VA, Akhan G, Kutluhan S, Uzar E, Koyuncuoglu HR, Gultekin F; Akhan; Kutluhan; Uzar; Koyuncuoglu; Gultekin (February 2008). "The effect of sodium valproate on chronic daily headache and its subgroups". J Headache Pain 9 (1): 37–41. PMC 3476175. PMID 18231713. doi:10.1007/s10194-008-0002-5. 
  12. ^ Nestoriuc Y, Rief W, Martin A; Rief; Martin (June 2008). "Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators". J Consult Clin Psychol 76 (3): 379–96. PMID 18540732. doi:10.1037/0022-006X.76.3.379. 
  13. ^ Rains JC (May 2008). "Change mechanisms in EMG biofeedback training: cognitive changes underlying improvements in tension headache". Headache 48 (5): 735–6; discussion 736–7. PMID 18471128. doi:10.1111/j.1526-4610.2008.01119_1.x. 
  14. ^ Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR; Allais; Brinkhaus; Manheimer; Vickers; White (2009). "Acupuncture for tension-type headache". Cochrane Database Syst Rev. 1 (1): CD007587. PMC 3099266. PMID 19160338. doi:10.1002/14651858.CD007587. 
  15. ^ Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA; Alonso-Blanco; Cuadrado; Miangolarra; Barriga; Pareja (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain 22 (3): 278–85. PMID 16514329. doi:10.1097/01.ajp.0000173017.64741.86. 
  16. ^ Biondi DM (2005). "Physical treatments for headache: a structured review". Headache 45 (6): 738–46. PMID 15953306. doi:10.1111/j.1526-4610.2005.05141.x. 
  17. ^ Bronfort G, Nilsson N, Haas M et al. (2004). Brønfort, Gert, ed. "Cochrane Database of Systematic Reviews". Cochrane Database Syst Rev (3): CD001878. PMID 15266458. doi:10.1002/14651858.CD001878.pub2.  |chapter= ignored (help)
  18. ^ Ernst E, Canter PH; Canter (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med 99 (4): 192–6. PMC 1420782. PMID 16574972. doi:10.1258/jrsm.99.4.192. 
  19. ^ Lenaerts, M. E. (2006). "Burden of tension-type headache". Current pain and headache reports 10 (6): 459–62. PMID 17087872. 

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