Tension Headaches


What is a tension headache?

Tension headaches are the most common type of headache. They cause mild to moderate pain that’s described as a tight band around the head. Muscle tightness in the scalp and neck can also cause headache pain. Although the cause is unknown, stress is the most common trigger for tension headaches. They can occur at any age, but are most common in adults and older teens, slightly more common in women, and tend to run in families. Effective treatment includes the appropriate use of medications, and practicing healthy habits including stress reduction, and using non-drug treatments. Tension headaches are not linked to brain diseases, or the visual disturbances, nausea or vomiting that accompany migraine headaches.


What causes a tension headache?

The cause of tension-type headaches is unknown. Although tension headaches are often associated with tight muscles in the face, neck and scalp, that doesn’t cause them. Both genetic and environmental factors are thought to be involved. Muscle contractions in the head and neck are considered a major factor in the development of a tension headache. Muscle contractions can be a response to stress, depression, head injury, or anxiety. 

Most headache experts believe that people who have tension-type headaches have a heightened sensitivity to pain. The muscle tenderness that’s common with tension headaches is likely the result of a very sensitive pain response. 

Other headache triggers can include:

  • Holding your head in one position for a long time without moving
  • Eye strain from computer work, using a microscope, or close work requiring fine hand-eye coordination
  • Sleeping with your head or neck in an abnormal position
  • Sleeping with cold air blowing on your head and neck
  • Physical or emotional stress
  • Over-consumption of alcohol
  • Too much caffeine or withdrawal from caffeine
  • Fatigue or overexertion
  • Having a cold, flu or sinus infection
  • Teeth grinding or jaw clenching
  • Smoking too much
  • Heightened sensitivity to noise or glare
  • Having a migraine headache can also trigger a tension headache

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What are the symptoms of a tension headache?

Tension headache symptoms can include:

  • Dull, steady aching pain all over the head (not throbbing and not on just one side)
  • Pain develops slowly
  • Pain can last for 30 minutes to a week
  • Tightness or pressure across the forehead, sides and back of the head
  • Muscle tenderness in the scalp, temples, back of the neck or shoulders
  • Difficulty sleeping

Tension headaches can be episodic (happen occasionally) or chronic (happen 15 or more days a month for at least three months). Tension headaches that become more frequent can become chronic without treatment. 

Contact your doctor if you have a sudden change in the type and severity of your headaches. An abrupt, severe headache, headache after a head injury, or headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or speaking difficulties needs immediate medical attention. It could indicate a much more serious problem.


How are tension headaches diagnosed? 

If your headache causes mild to moderate pain, with no other symptoms, and responds to home treatment within a few hours, you may not need further examination or testing. However, if headaches keep you from functioning, or you need pain medication more than twice a week, see your doctor for a diagnosis and treatment plan.

Diagnosis starts with a review of your symptoms. Keeping a headache diary can be very helpful in making an accurate diagnosis. For each headache, record the date, time of day, symptoms, how long it lasted, your stress level when it developed, and what made it better or worse. If you don’t have a headache diary to share with your doctor, you’ll be asked:

  • When do your headaches occur?
  • Where do you feel the headache/its location?
  • What do the headaches feel like and how long do they last?
  • How intense is the pain, and can you function during the pain?
  • Is the pain dull, constant or pulsating, or sharp and stabbing?
  • Do you have a history of stress?
  • Have you had a head injury?
  • Have you had behavior or personality changes?
  • Do changes in position or sitting up cause headache?
  • Do you have trouble sleeping?

Your doctor will also conduct a physical exam, and may conduct other tests to rule out underlying diseases or conditions. To pinpoint the type and cause, he/she will do a neurological exam, especially if you have chronic or recurrent headaches.

If you have complicated symptoms, your doctor may order imaging tests to provide a comprehensive view of your brain. These scans – magnetic resonance imaging (MRI) and computerized tomography (CT) – can rule out a tumor or other serious causes of head pain. Other blood and lab tests may be done to check for underlying conditions. Sinus X-rays can check for congestion, infection, or other problems that may need correction.


What are the treatment options for tension headaches?

The goal of treatment is to stop the symptoms, and prevent future tension headaches by avoiding/changing your triggers. Treatment can include medications and lifestyle changes to reduce stress and anxiety. Frequent or chronic headaches that aren't relieved by over-the-counter (OTC) pain relievers may need prescription medications.

OTC pain relievers are usually the first non-prescription treatment to try. These include aspirin, ibuprofen (Advil, Motrin IB), and naproxen sodium (Aleve). They should always be taken appropriately, as your doctor prescribes them. For example, taking headache-pain medication more than three days a week can lead to rebound headaches (medication overuse headache). 

Combination medications can be more effective. They include aspirin or acetaminophen (Tylenol), or both are often combined with caffeine or a sedative drug in a single medication. Taking too much acetaminophen can damage your liver; too much ibuprofen or aspirin can irritate your stomach or damage the kidneys. Also, some medications should not be taken if you’re pregnant.

Muscle relaxers can help with head, neck and shoulder tension. 

Anticonvulsants, such as gabapentin and topiramate (Topamax, Qsymia), may also be prescribed to prevent headaches. 

Triptans and narcotics are for people who have a migraine and tension headache at the same time. Opioids, or other narcotics are rarely used because of their side effects and potential for dependency.

Antidepressants can help prevent headaches. Amitriptyline and protriptyline are the most common medications used; venlafaxine (Effexor XR) and mirtazapine (Remeron) are also used. Antidepressant side effects can include constipation, drowsiness, and dry mouth. 

Changing your triggers involves learning what your triggers are and developing ways to avoid them. A headache diary will help you identify triggers and learn what relieves the pain. 

Lifestyle and home remedies have helped many patients get relief, such as rest, ice packs, or a long, hot shower. Reduce stress by planning ahead and organizing your day. Plan time to relax and de-stress everyday. Apply heat or ice to sore tight muscles. Good posture can help keep your muscles from tensing. When standing, hold your shoulders back and your head level. Pull in your abdomen and buttocks. When sitting, make sure your thighs are parallel to the ground and your head isn't slumped forward. You may want to ask your doctor about relaxation or stress-management training, deep-breathing, massage, biofeedback, cognitive behavioral therapy, or acupuncture.

Can tension headaches be prevented?

Improving your lifestyle choices can help prevent headaches, including:

  • Get enough, but not too much, sleep. Try using a different or new pillow; change sleeping positions.
  • Don't smoke.
  • Exercise regularly.
  • Take breaks during your day to stretch your neck and shoulders
  • Eat regular, balanced meals.
  • Drink plenty of water.
  • Limit alcohol, caffeine and sugar.
  • Practice good posture.
  • Maintain a regular sleep, exercise, and meal schedule.

Other techniques that can help you reduce stress:

Biofeedback training teaches you to control certain body responses to reduce pain. 

Cognitive behavioral therapy is talk therapy that helps you learn to manage stress, and reduce the frequency and severity of your headaches. 

Any technique that relaxes you – deep breathing, yoga, meditation, prayer, progressive muscle relaxation – can help your headaches.


Mayo Clinic. (2021, Sept). Tension Headache. Retrieved 1-25-22, {https://www.mayoclinic.org/diseases-conditions/tension-headache/symptoms-causes/syc-20353977}
Mayo Clinic. (2021, Sept). Tension Headache Diagnosis and Treatment.  Retrieved 1-25-22, {https://www.mayoclinic.org/diseases-conditions/tension-headache/diagnosis-treatment/drc-20353982}
MedlinePlus. (2019, Sept.) Tension Headache. Retrieved 1-25-22, {https://medlineplus.gov/ency/article/000797.htm}
Johns Hopkins Medicine. (N.d.) Tension Headaches. Retrieved 1-25-22, {https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache/tension-headaches}


Medically reviewed by:

Dr. Desiree Levyim

Dr. Desiree Levyim is a board eligible neurologist in practice since 2020. She joins TeleMed2U in our mission to provide increased access to healthcare.

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