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Tension Headache

Headache Psychogenic

Tension headache is a common type of primary headache. It can be episodic or chronic.


Criteria for tension-type headaches includes the following [4] [8] [9] :

  • Pressing or tightening pain (non-pulsating)
  • Muscular tightness or stiffness in neck
  • Frontal-occipital location
  • Bilateral, occipitonuchal or bifrontal pain
  • Mild to moderate intensity
  • Not aggravated by physical activity
  • Duration of 30 minutes to several days
  • No nausea or vomiting (anorexia may occur) [9] 
  • Often occurs during emotional distress or intense worry
  • May be associated with insomnia
  • Often occurs upon rising or shortly thereafter
  • Difficulty concentrating
  • No prodromal or aura

The physical examination to exclude the possibility of other causes [9]:

  • Vital signs normal
  • Normal neurologic assessment
  • Tenderness in the scalp or neck
  • Acute tenderness when upper cervical muscles are palpated
  • Pain with neck flexion and stretching differentiated from nuchal rigidity associated with meningeal irritation

The differential diagnosis between tension headache and migraine is based on the clinical characteristics of the headache. Migraines are of moderate to severe intensity, have a pulsating quality are aggravated by physical activity and include photophobia and nausea. The characteristics of tension-type headache are pain of mild or moderate intensity, no photophobia, no nausea, not aggravated by physical activity, and a non-pulsating quality [7].

  • It may be triggered by or get worse with stress, fatigue, noise, or glare. There may be difficulty sleeping. Tension headaches usually do not cause nausea or vomiting.[mountsinai.org]
  • Changes in sleep patterns or insomnia, early morning or late day occurrence of headache, feelings of guilt, weight loss, dizziness, poor concentration, ongoing fatigue and nausea commonly occur.[headaches.org]
  • Among patients older than 2 years, we also detected interictal somatic disorders (20 cases) such as sleep disorders, eating difficulties, enuresis and idiopathic vomiting.[ncbi.nlm.nih.gov]
Neck Pain
  • The range of movement in all directions increased, and FPQ, VAS and the number of days with neck pain decreased significantly. There was a significant change in ENMG on the frontalis muscle whereas changes in trapezius remained insignificant.[ncbi.nlm.nih.gov]
  • Disease of any of these structures can lead to neck pain. Neck pain is medically referred to as cervicalgia.[medicinenet.com]
  • Unfortunately, a non-supportive pillow or one not suited to your neck can predispose you to neck pain or tension type headache.[physioworks.com.au]
Myofascial Trigger Point
  • Myofascial trigger points: translating molecular theory into manual therapy . J Man Manipul Therapy 2006 ; 14 : 232 –9 30 Ho , K-Y , Tan , K-H . Botulinum toxin A for myofascial trigger point injection: a qualitative systematic review .[doi.org]
  • Myofascial trigger points and sensitisation: an updated pain model for tension type headache. Cephalalgia 2007 ; 27: 383 – 393. Google Scholar SAGE Journals ISI 28. Sohn, JH, Choi, H, Lee, S.[doi.org]
  • Hubbard DR, Berkoff GM: Myofascial trigger points show spontaneous needle EMG activity. Spine 1993, 18 :1803–1807. PubMed CrossRef Google Scholar 34.[doi.org]
  • Effects of the electrical stimulation of myofascial trigger points with tension headache. Acupuncture and Electro-Therapeutics Research. 1992; 17 (4):285–90.[ncbi.nlm.nih.gov]
  • Tension headache is a common type of primary headache. It can be episodic or chronic.[symptoma.com]
  • It had various ill-defined names in the past including tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, and psychogenic headache.[emedicine.com]
Recurrent Headache
  • BACKGROUND: Tension headache and migraine are opposite ends of a benign recurrent headache spectrum. OBJECTIVE: To provide an approach to the diagnosis of benign recurrent headache.[ncbi.nlm.nih.gov]
  • Cochrane Database of Systematic Reviews Background Non‐invasive physical treatments are often used to treat common types of chronic/recurrent headache.[doi.org]
  • BACKGROUND: Non-invasive physical treatments are often used to treat common types of chronic/recurrent headache.[ncbi.nlm.nih.gov]
  • Once these tests have ruled out any other issues that could be causing recurrent headaches, your doctor can make an accurate tension headache diagnosis.[seton.net]
  • Recurrent headaches negatively affect family life, work productivity, and absenteeism, and increase emergency room visits and use of prescription and non-prescription medications.[symptoma.com]
Frontal Headache
  • Bai Zhi -Angelica root Radix Angelicae Dahuricae analgesic anti-inflammatory antipyretic antibiotic antispasmodic Bai Zhi is the go to herb for frontal headaches.[dc-acupuncture.com]
  • […] sedation and analgesia -- Monitoring the emergency patient -- Shock -- Brain resuscitation -- Adult resuscitation -- Fever in the adult patient -- Weakness -- Cyanosis -- Syncope -- Depressed consciousness and coma -- Confusion -- Seizures -- Dizziness and vertigo[worldcat.org]


The history is the most important diagnostic component for evaluation and treatment of headache. This relies on recall by the patient that is often unreliable. History should include information about the presentation, onset, and duration of symptoms, as well as social and psychological information [2].

Laboratory tests

In tension headache laboratory work will be unremarkable. Specific blood work is only useful if the history or physical examination suggests another possible diagnosis [2].

Other procedures

Head computed tomography or magnetic resonance imaging scans are required, if neurologic examination is abnormal, to rule out other diagnoses: tumor, stroke, or swelling. They may also be useful when headache pattern changed [6] [9]. A lumbar puncture and examination of cerebrospinal fluid may be needed to rule out infection or meningitis [6].


Medications can be highly effective in the treatment of chronic tension headaches, both prescription and non-prescription. Medications, however, are not always effective or well tolerated and have associated adverse effects [8]. Some medications may also cause medication dependency in some patients. Commonly used medications include [2] [4]:

Non-prescription drugs


  • Fiorinal (Butalbital, aspirin, caffeine) 
  • Fioricet (Acetaminophen, butalbital, and caffeine) 


  • Acetaminophen with codeine (Tylenol #3)
  • Acetaminophen and oxycodone (Percocet)

Ergot alkaloids and derivatives direct vasoconstrictors 

Current research advocated behavioral headache management to be effective in the management of chronic tension headache. These techniques include [4] [8]:

  • Relaxation training
  • Biofeedback
  • Stress management training
  • Cognitive behavior therapy
  • Meditation [9]

Exercise is another treatment option to be considered in the treatment of tension-type headaches. Researchers has shown an association between decreased physical activity and increased incidence of headaches[8].

Optimum treatment of tension headaches should include a variety of techniques [5] [6]:

  • Preventive measures such as avoidance of triggers and stress management.
  • Alternative therapies such as meditation, acupuncture, and biofeedback.
  • Pharmacological intervention. 

Psychological stress is the most frequent trigger of tension headache, and treatments that reduce stress and increase the ability to cope with stress are the best means of preventing and treating their occurrence [9]. Stress is thought cause tension headache by [9]:


Most tension headaches are intermittent and do not interfere with daily life to any substantial degree. However, these headaches may become chronic if life stressors are not changed [10].
One possible complication of chronic headache is an over dependence on non-prescription and prescription pain relievers [9].

The prognosis for individuals with coexisting migraine and tension-type headache has poorer long term outcomes [2].
Thirty percent of individuals who have childhood headaches develop chronic headache as adult [2].

The progression from intermittent to almost daily headaches, from episodic tension-type headache to chronic migraine occurs in many individuals over an average of 10.7 years [10].


Tension headaches are felt to be the result of muscle contraction primarily in the cervical region [2]. Chronic contraction of neck and scalp muscles may be the result of [4]:

About 2% of the adult population have a history of chronic episodic tension-type headaches [6]. The prevalence of tension-type headache in children and adolescents is increasing and is now a significant health problem [7]. Tension-type headache accounts for 42% of cases of headache once underlying neurologic or cancerous causes have been eliminated [1] [7].

Headache disorders rank among the 10 most disabling conditions, according to the World Health Organization and among the top five for women [1]. Recurrent headaches negatively affect family life, work productivity, and absenteeism, and increase emergency room visits and use of prescription and non-prescription medications [8].


The age of onset of tension headaches ranges from as young as 6 years to over 70 years with a mean of 35 years [4] [6]. In 15 percent of patients symptoms begin before age 10 [4]. They are more common in women with a female to male ratio of 2:1 in adults and children [2] [4] [6].

A family history of some form of headache occurs in 40 percent of individuals with chronic tension-type headache. However, a genetic component is not thought to be a factor [4]. The incidence of headache worldwide is estimated to be 4% of the general population, with half of these classified as tension-type headache [2] [3].

Sex distribution
Age distribution


The exact mechanism causing tension headache is not known. However, it is assumed that excessive, sustained muscle contraction of the head, neck, and jaw are at fault. The association with psychosocial factors as well as environmental factors is well documented. The triggers for headache include stress, hormonal factors (such as menstruation and pregnancy), ingested substances, bright light, florescent lights, and computers [5].

The extent of psychological factors on the development of tension-type headache is not known [3]. However, it is assumed that factors like copying skills, avoidance behaviors, anxiety and depression play a role [3]. These factors have been associated with higher levels of stress [3].

Other aggravating factors to the occurrence of tension headache are poor quality and duration of sleep, poor nutrition, and lack of exercise [9].

The high frequency of crossover between subtypes of headache suggests that the distinction between is not proven [2] [10]. This supports the theory that the various headache types are part of the same continuum with common symptoms and causes [2] [7][10].

The most significant differences between the headache types are severity and character of the pain, aggravating factors, and duration of symptoms. Tension headaches were generally characterized by the absence of photophobia and nausea and positive for bilateral presentation [7].

A diagnosis of the specific type of headache is important for appropriate treatment, but is difficult because of the overlap in the symptomatology [7].


Perhaps the most effective preventive measures for tension headaches, after stress management, are life style changes including regular exercise, balanced diet, adequate sleep, and avoidance of excessive intake of caffeine, alcohol, or nicotine [2][10].


Tension headache is a primary subgroup of the disorder chronic headache. Headaches, including tension-type headache, migraine, cluster headache and chronic daily headache syndromes, are the most common disorder of the nervous system [1]. Although classified as separate entities there is significant crossover among the subtypes and shared symptomatology. Some current theories propose that they are the connected disorders along a common continuum [2].

It is estimated that approximately 4% of the population worldwide suffer chronic headache [3]. It accounts for 10% of all emergency room visits and is the ninth most common reason for physician visits [1]. One half of all headaches fall in the category of tension-type headache [2]. They occur more frequently in women than men with a ratio of 2 to 1 [4].

Headache has a significant impact on morbidity and economics worldwide. The direct effects of headache upon the individual are related to the severity of pain, frequency of occurrence and extent of disability [5]. The economic impact includes the costs of medical care, and lost work time and productivity [2] [5]. It is estimated that headaches costs American employers over $13 billion annually [5]. Despite the cost, headache is underestimated, under-recognized, and under-treated throughout the world [1].

Patient Information

What is tension headache?

Tension headache is one of the most common forms of headache worldwide, occurring in approximately 2% of the general population. Headache can be a symptom of another, more serious diagnosis, so any chronic headache should be evaluated to exclude other diagnoses.

What are the symptoms?

The symptoms of tension headache are:

What causes tension headache?

The cause of tension headache varies from person to person, however, emotional stress seems to be the most common trigger. The exact physical component is believed to be tightening of the muscles of the neck, head, jaw and upper shoulders.

Who gets tension headache?

Anyone may get tension headache. It has been reported in individuals from 6 years old to over 70 years of age. It occurs in approximately 2 % of the population at some time in their lives.
Those experiencing stress in their lives are at higher risk.

How is it diagnosed?

Tension headache is diagnosed by the clinical symptoms of the headache. There are no specific tests for this disorder. Your healthcare provider may order some tests or procedures to exclude other, more serious diagnoses. A complete and through history, of the headache symptoms and psychosocial history is of prime importance.

How is tension headache treated?

Tension headache is treated by multiple techniques. These include:

  • Non-prescription medications like ibuprophin aspirin, acetaminophen
  • Prescription medications
  • Relaxation training
  • Biofeedback
  • Frequent regular exercise 
  • Stress management training
  • Cognitive behavior therapy
  • Meditation

How can tension headache be prevented?

Since stress appears to be the most common trigger prevention and relief of stress or anything that reduces it may be the best way to prevent the disorder.

What are the complications?

Complications of tension headache are related to how it affects daily life, absenteeism from work, interference with family relationships, and decreasing quality of life.



  1. Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton RB, Scher AI, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007; 27:193–210.
  2. Merikangas KR, Cui L, Richardson AK, Isler H, Khoromi S, Nakamura E, et al. Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study. Brit Med J. 2011;343:d5076.
  3. Wieser T, WalliserU., Womastek I, Kress HG. Dysfunctional coping in headache: Avoidance and endurance is not associated with chronic forms of headache. Eur J Pain. 2012;16:268–277.
  4. Silver N. Headache (chronic tension-type). Am Fam Physician. 2007;76(1):114-6.
  5. Friedman DI, De Ver Dye T. Migraine and the Environment. Headache. June, 2009; 947-459.
  6. Evans RW, Seifert TD. The Challenge of New Daily Persistent Headache Headache. 2011;1812: 145-154.
  7. Pacheva I, Milanov I, Ivanov I, Stefanov R. Evaluation of diagnostic and prognostic value of clinical characteristics of Migraine and Tension type headache included in the diagnostic criteria for children and adolescents in International Classification of Headache Disorders. Int J Clin Pract. 2012; 66(12): 1168–1177.
  8. Baillie LE, Gabriele JM, Penzien DB. A Systematic Review of Behavioral Headache Interventions With an Aerobic Exercise Component. Headache. 2014;54:40-53.
  9. Wells RE, Smitherman TA, Seng EK, Houle TT, Loder EW. Behavioral and Mind/Body Interventions in Headache: Unanswered Questions and Future Research Directions. Headache. June, 2014:1107-1114.
  10. Lipchik GL, Nash JM, McCool H, Holroyd KA, Stensland M. Very frequent primary headaches. Cephalalgia. 2001, 21, 465-485.

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Last updated: 2019-07-11 21:47