Tension headache

Key points about tension headache

1. Tension headaches usually begin with shoulder or neck tension and may feel like a tight band around your head, a dull ache on both sides of your head or a heavy weight on top of your head. 
2. Most people will have at least one tension headache during their lifetime. Some people have tension headaches once or twice a year, while others get them quite often, even daily.
3. Tension headache tends to develop later in the day and can last for a few hours to days.   
4. There is no single cause of tension headache but it can be made worse by overworking, not getting enough rest, poor posture and emotional or mental stress, including anxiety and depression. 
5. Most people find pain relief medicine eases the severity of a tension headache.
6. Avoiding the triggers for these headaches and making changes to your lifestyle can be helpful in preventing them.

Image: Pexels

What are the symptoms of tension headache?

Tension headache is usually described as tightness or pressure, like a tight band, around your head and often appears to start from your neck and shoulders. Other symptoms include a dull ache on both sides of your head or a heavy weight on top of your head. Some people may be sensitive to light or feel that the headache is made worse by movement, although these symptoms are less common. Read more about other types of headache and when to seek urgent medical care.

What causes tension headaches?

Tension headache is caused by tightening of the muscles around your head and neck. This often results in pain in your shoulders, neck, scalp and jaw. This is usually brought on by:

• lifestyle issues such as working too much, not getting enough sleep, missing meals, not drinking enough water (being dehydrated) or drinking alcohol excessively
• poor posture related to how you sit, stand or lie down – this can also be caused by poorly setup computer workstations or overuse of mobile devices
• emotional stress and anxiety.

What can I do to prevent tension headaches?

Self-care

It helps to learn to avoid the triggers for these headaches. Do things like:

• take regular breaks from the screen
• stretch if you are seated for long periods or lie down on your back for a while
• try using a simple pain reliever (analgesic)
• place a heat pack across your shoulders and neck to reduce pain and muscle spasm.

Making changes to your lifestyle can also be helpful, such as:

• use an appropriate head pillow so that your spine is level while sleeping
• maintain good sleep hygiene
• exercise regularly
• drink enough water and eat regularly
• use relaxation and stress management techniques, such as diaphragmatic breathing or mindfulness
• moderate caffeine intake.

Headache diary

If you get tension headaches often, it may help to keep a headache diary to help look for triggers or patterns. This can also be useful to show your doctor. Use your diary to record:

• when, where and how bad each headache
• how long each headache lasts
• anything that may have caused it, for example, hunger, eye strain, bad posture, stress, anger, etc.
• things that made it better
• things that were different on the days you were well, which may help point to what helps prevent them.

Physiotherapy

Getting advice from a physiotherapist is a good option for tension-type headaches or headaches with musculoskeletal involvement. Physiotherapists may use massage, mobilisation, manipulation and advise on home-based exercises. Exercises can also teach you about being aware of your posture such as preventing a forward head posture and rounded shoulders, by activating the transverse abdominis muscles and bracing the core muscles.

If your headaches are caused by neck problems, physiotherapy, massage or acupuncture may be helpful.

What are the treatment options for tension headache?

When you have a headache, try to rest. Sometimes applying a heat bag, or a warm or cold cloth over the aching area can help.

Medicine to relieve pain

Non-steroidal anti-inflammatories (NSAIDs) such as naproxen, ibuprofen or aspirin often provide relief for tension-type headaches. Paracetamol is less effective but may be preferred if you cannot take NSAIDs, such as if you have stomach bleeding or kidney problems. Read more about NSAIDs.

Caution – medication overuse headache

If you are taking medicines regularly, be aware of medication overuse headache. Medication overuse (rebound) headache can happen as a result of using too many pain relief medicines to treat headaches. It may feel like a tension-type headache.

These headaches often improve within 2–4 weeks of withdrawal of the overused medicine but you may feel worse before you feel better. To avoid this, take pain relief medicines like paracetamol and NSAIDs for no more than 15 days per month.

Medicine to prevent recurring tension headaches

If you get tension headaches on 15 days or more a month (also called chronic tension headaches), your doctor may prescribe medication to prevent current headaches:

• NSAIDs – daily use of NSAIDs such as naproxen (250–500 milligrams twice daily for 3 weeks) can be tried. This practice can increase the risk of medicine overuse headache but it can be helpful in breaking the cycle of recurring headaches. If the 3-week NSAID course does not break the cycle of symptoms it should not be repeated.
• Tricyclic antidepressants (TCAs) such as amitriptyline or nortriptyline can also be tried. They are usually taken 1–2 hours before bedtime. Your doctor will start you on a low dose, and increase the dose slowly if necessary. If your symptoms have improved for 3–6 months, then the TCA will be stopped slowly.

Learn more

The following links provide further information about tension headache. Be aware that websites from other countries may have information that differs from New Zealand recommendations.

Headache Ministry of Health, NZ
Tension headache PatientInfo, UK

References

1. Diagnosing and managing headache in adult in primary care BPAC, NZ, 2017
2. Headache in primary care BPAC, NZ, 2007

Reviewed by

	Dr Pyari Bose is a neurologist with special interest in headache disorders. He did headache research at King's College London, looking into the postdrome (recovery) phase of migraine using functional brain imaging.