Tension Headache

Tension headache is the most common type of headache, affecting more than three in four people at some point in their lives. This type of headache usually develops in the afternoon. The pain is mild or moderate. It may envelop your entire head or be limited to the forehead or to the back or top of your head. Many people describe the sensation as a dull tightness or pressure that occurs in a bandlike pattern (see Figure 1). The intensity of the pain may fluctuate, but it won’t be intense enough to keep you from sleeping or to awaken you.

Figure 1: Tension Headache Pain   Tension headache pain   Tension headaches often produce steady pain across the forehead or in the back of the head. Sometimes, the pain is felt throughout the head, and the sensation is often described as a dull tightness.

Unlike migraine headaches, tension headaches are rarely accompanied by other symptoms, such as nausea, vomiting, or blurred vision. In addition, researchers haven’t linked them to common migraine triggers, such as foods, genes, or hormonal changes. Tension headaches can occur infrequently, regularly, or daily (see “Chronic daily headache”). They are common at any age, but women are more susceptible to them than men are (see “Tension headaches by the numbers,” below).

Tension Headaches by the Numbers   Tension headaches by the numbers   Source: Journal of the American Medical Association

Triggers and Aggravators

Experts believe that the pain of a tension headache is caused by tightness in the muscles of the scalp and the back of the neck. A variety of emotional and physical factors can trigger this muscle tightness.

A survey published in the journal Headache reported that stress was the most common factor precipitating tension headache. Other frequent triggers included (in order of their prevalence) missed meals, lack of sleep, and fatigue. Physical problems, such as eyestrain, whiplash, or poor posture, can also act as triggers (see Figure 2).

Figure 2: Avoid the Grind   Avoid the grind -- tension headaches   Subjecting your head and neck muscles to any prolonged strain can cause them to stiffen, leading to tension headache. Maintaining good posture and avoiding repetitive motions can help avoid such problems. The following suggestions may also reduce muscle tension: Don’t rest your chin on your chest while reading. Avoid cupping the telephone between your shoulder and ear. If you use the telephone often, you may want to buy a headset. Keep your computer monitor at eye level or above to avoid neck strain. Avoid excessive gum-chewing, which can tighten jaw muscles. Try not to clench your jaw or grind your teeth.

How these factors cause the muscle tightness that leads to a headache is unknown. Not surprisingly, researchers have found that these triggers also aggravate tension headaches already in progress. Overall, the results confirm the advice doctors often give to people with tension headaches:

• Don’t skip meals.

• Get enough sleep.

• Pace yourself to avoid excessive fatigue.

Treating Tension Headache

The muscle tightness that characterizes tension headache is often difficult to reverse, and few drug options are available. OTC analgesics and even prescription pain relievers usually prove inadequate at treating tension headaches and may actually worsen the situation by turning an occasional problem into a chronic one. That’s because both OTC and prescription pain relievers target only the symptom of tension headache (pain), without addressing the underlying cause (muscle contraction). Rely too much on pain relievers, and you may find that your tension headaches gradually increase in frequency. To make matters worse, frequent use of pain relievers (taking them more than two days a week, especially those containing caffeine) may make other medications less effective at relieving your tension headaches. Thus, the best way to stop the pain of tension headache is to target its major cause: muscle contraction.

Muscle relaxants

A fast-acting but short-lived muscle relaxant such as carisoprodol (Soma, Vanadom) or metaxalone (Skelaxin) can loosen head and neck muscles (see Table 3). While these medications don’t relieve pain any more effectively than OTC analgesics, they do address the cause of the tension headache.

Despite their name, these drugs don’t directly relax tense muscles. They slow the functioning of your central nervous system, creating an overall calming effect. They work quickly, taking effect within 15–30 minutes, but the effects last only 3–4 hours. Still, such medications typically outlast the usual tension headache, which rarely continues for more than a few hours.

Unlike some muscle relaxants, carisoprodol and metaxalone generally don’t produce tolerance (the need for increasingly larger doses to obtain the same effect), but they may cause drowsiness and fatigue, which, in turn, can impair mental and physical functioning. Thus, avoid driving, operating heavy equipment, or performing other hazardous tasks while taking these medications. Muscle relaxants aren’t recommended for people with liver or kidney disease or a history of dependency.

Preventing Tension Headache

The tricyclic antidepressants amitriptyline (Elavil, Endep) and doxepin (Adapin, Sinequan) are particularly effective for preventing tension headache. One study found that three out of four people taking daily amitriptyline reported significant improvement in their head pain. Because they cause drowsiness, tricyclic antidepressants are particularly useful for those who have both tension headache and insomnia. If one tricyclic isn’t effective, another may work. Changing the dosage can also help (see “Tricyclic antidepressants”).

A long-acting muscle relaxant, such as cyclobenzaprine (Flexeril) or tizanidine (Zanaflex), can also stave off tension headache. Like their fast-acting relatives (see Table 3), these drugs slow the central nervous system, indirectly relaxing tense muscles. They also have similar side effects, including drowsiness and fatigue. Unlike carisoprodol or metaxalone, these drugs take an hour or so to work; however, their effects can last as long as a day. To reduce the likelihood that side effects will disrupt your routine, cyclobenzaprine and tizanidine should be taken only once, before bedtime.

Some people with tension headache have very sensitive areas, known as trigger points, at the back of the neck or shoulders. When touched, these tender areas sometimes prompt a headache. If your doctor identifies such trigger points during the physical exam and other treatments fail to provide relief, injecting a local anesthetic into these areas may eliminate the pain and prevent the headache from occurring again. This option has limitations, though. First, you must receive the shot at a clinic, hospital, or your doctor’s office. Second, many people are uneasy about receiving a shot in the neck or shoulders.

You can also try various types of physical and relaxation therapies to prevent tension headache, although these techniques only work if you practice them on a regular basis, preferably every day. The simplest strategy is to apply a heating pad to your neck or shoulder, to relax the muscles. Exercising these muscles also helps, by strengthening and stretching them. Your doctor may be able to provide examples of suitable exercises or a referral to a physical therapist. Other physical techniques to relieve tension headache include massage to relax muscles, traction to stretch them, and injection with a local anesthetic to enable tense muscles to relax.

Two types of relaxation therapies may also be useful. Autogenic training is a technique in which you learn to focus your attention on various parts of your body, in succession, and then imagine them becoming warm and heavy in order to relax them. Another relaxation technique is biofeedback, in which you learn to recognize when your muscles are becoming tense and learn how to relax them, based on signals from your own body. In biofeedback for tension headache, typically a therapist will attach electrodes to your skin in order to detect electrical signals from your neck and shoulder muscles. When you become tense, the biofeedback machine may beep or flash a light. You learn to recognize when you are becoming tense and then find ways to relax before the muscles contract so much you develop a tension headache.