Tension headaches are very common, affecting as many as 40% of teenagers and adults. They tend to start at the back of your head and move forward, involving your neck, scalp, and head (for example, the temporal regions on either side of your forehead and the occiput, which is at the base of your head just above the neck). The pain, which is due to contraction (tightness) of the neck and scalp muscles, can ultimately cover your entire head. Such muscle contraction is commonly caused by stress – thus, the name "tension." Headaches originating from tightness in the neck muscles are often called cervicogenic headaches.

• Headache starts at the back of your head and spreads forward
• Dull pressure or a squeezing pain, often described as a tight band or vice around the head
• Muscles in your neck, shoulders, and jaw can feel tight and sore
• Bilateral – meaning that it affects both sides of your head equally
• May have difficulty sleeping

When you feel tense, the muscles in your shoulders, neck, scalp, and jaw tighten up, creating pain. Causes include the following:

• Stress
• Depression
• Anxiety
• Any acitivity (like using a computer, typing, fine work with your hands, or using a microcope) that causes the head to be held in one position for a long time without moving
• Sleeping in an abnormal position or in a cold room
• Eye strain
• Fatigue
• Overexertion
• Head or neck injury, even years after the injury
• Clenching your jaw or grinding your teeth, which can cause a condition known as Temporomandibular Joint (TMJ) Dysfunction, can also cause muscle contraction around the temples, neck, and shoulders, spreading to the head and resembling tension headaches
• Pain that originates from other areas, such as your sinuses, can also trigger tension headaches or a combined sinus/tension headache

• Women tend to have more headaches than men (although, prior to adolescence, boys may get more headaches than girls)
• Changes in estrogen levels such as menstruation and menopause
• Premenstrual syndrome
• Stress
• Chronic overwork
• Too much or too little sleep
• Missed or delayed meals
• Alcohol or drug use
• Certain foods or food additives may also be a trigger for some people (see Nutrition and Dietary Supplements section)

When you see your health care provider, he or she will take a detailed history in order to distinguish tension headaches from headaches of other causes, such as migraines. Your health care provider will ask questions about when your headaches occur, how long they last, how frequently they come on, the location of the pain, and any symptoms that accompany the headaches. Sometimes it helps to keep a diary about your headaches prior to seeing the doctor; this way, you'll have an accurate recording of how often they happen and you won't forget the details related to your headaches.

When you do see your physician, the physical exam will include assessing your head, neck, eyes, and sinuses as well as performance of a neurologic examination. Don't be surprised if the doctor asks you some questions to test your short term memory. On exam, the physician is likely to find musculoskeletal tenderness around your neck and scalp.

Tests that your doctor may order, depending on your symptoms and exam, include:

• CT scan or MRI to look for a mass or other brain disorder or to check for sinusitis
• Xray of the neck to look for arthritis or spinal problems; xray of the sinuses to look for sinusitis
• Electroencephalogram (EEG) – a brain wave study , looking for any seizure activity
• Lumbar puncture – a "spinal tap" done for different reasons, including to rule out any infection like meningitis

Unfortunately, as many as 60% of people with tension headaches do not seek the advice of their physician and simply resort to taking over the counter medications for the pain. This is too bad because a comprehensive treatment plan including relaxation (see Mind/Body Medicine), exercise and other lifestyle changes, and occasional medication can be very effective in significantly reducing the frequency and intensity of tension headaches.

Many of the medications used to prevent or treat tension headaches, however, have risks and side effects. Therefore, using methods that do not include medications are preferred if you are able to achieve successful pain control and reduce the frequency of your headaches. Biofeedback, yoga, and relaxation techniques, for example, can be quite effective for both acute relief and decreased headache frequency. Regular exercise can also reduce how often you get a tension headache.

Keeping a headache diary, particularly when you first begin to experience headaches, can help identify the source of your tension headaches and how to modify your environment and habits to avoid headaches. When a headache occurs, write down the date and time the headache began. Note what you ate for the preceding 24 hours, how long you slept the night before, what you were experiencing just before the headache, any unusual stress in your life, how long the headache lasted, and what you did to make it stop.

Good health habits, as listed below, are important for helping to lessen stress and tension headaches:

• Adequate sleep
• Eating a healthy diet 
• Exercising regularly
• Quitting smoking
• Choose from a variety of relaxation techniques (see Mind/Body Medicine section)

Medications are used both to treat the pain from a headache at the time that you have it (acute therapy) and to prevent the headaches from coming if you are a person who gets them frequently (chronic therapy).

Acute pain control:

Over-the-counter (OTC) pain relievers are usually effective temporary remedies. Talk to your doctor about which of these is best for you.

• Acetaminophen
• Aspirin
• Ibuprofen
• Naproxen

If over the counter medications are not adequate for pain control, a physician may prescribe a more potent version of non-steroidal anti-inflammatory drug (NSAID) such as naproxen, ibuprofen, diclofenac, tolmetin, or ketoprofen. Another medication that your doctor might consider is called isometheptene. Rarely, if your headaches are very severe and nothing else relieves the pain, your physician may consider prescribing opiods like codeine or hydrocodone.

Prevention of chronic, recurrent tension headaches:

• Tricyclic antidepressants, such as amitriptyline, imipramine, desipramine, and nortriptyline, may be used; generally, relaxation techniques and cognitive behavioral therapy (see Mind/Body Medicine) are encouraged first, before this class of medication is considered as an adjunct to these techniques, especially in children.
• Other antidepressants may be considered by your doctor as well, including monoamine oxidase inhibitors (MAOIs such as phenelzine and tranylcypromine), selective serotonin-reuptake inhibitors (SSRIs like fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram), bupropion, nefazodone, or venlafaxine.
• Anti-anxiety agents, like alprazolam or clonazepam, might be prescribed for a short period of time to decrease muscle tension or to treat anxiety symptoms during periods of extreme stress.

If an injury or problem in the cervical spine is contributing to tension headaches, a nerve block, using a steroid to reduce inflammation and muscle contraction, may be considered to lessen the head pain.

Diet

Certain foods can trigger tension headaches; these include:

• Chocolate
• Cheese
• Monosodium glutamate (MSG), a flavor enhancer

On the other hand, following a diet that is rich in fruits and vegetables, whole grains, and uses fish and soy for protein instead of red meat may help lessen the frequency and intensity of your headaches.

Magnesium

Magnesium levels tend to be lower in those with headaches, both migraines and tension types. In the case of tension headaches, this may be due to the fact that low levels of magnesium may trigger muscle tightness and pain. Therefore, if you suffer from frequent tension headaches, consider, together with your physician, taking magnesium supplements and carefully keeping track of whether your headaches happen less often or are less severe.

Vitamin B Complex

Vitamin B complex is considered to be an anti-stress agent and, therefore, potentially helpful to take if you experience tension headaches.

5-hydroxytryptophan (5-HTP)

5-hydroxytryptophan (5-HTP) is an amino acid. The body makes 5-HTP from tryptophan (another amino acid that is obtained from the diet) and converts it to an important brain chemical known as serotonin. 5-HTP dietary supplements help raise serotonin levels in the brain, which may have a positive effect on sleep, mood, anxiety, aggression, appetite, temperature, sexual behavior, and pain sensation. Some studies suggest that 5-HTP supplements may be effective in children and adults with various types of headaches including tension, but more research is needed before knowing its safety and effectiveness.

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field of herbal medicine.

Cayenne (Capsicum frutescens/Capsicum spp.)

Capsaicin, a substance found in cayenne pepper, has powerful pain-relieving properties when applied topically. To relieve chronic, recurrent headaches, including tension and cluster headaches (a severe one-sided headache that tends to occur in clusters, happening repeatedly every day at the same time for possibly several weeks), capsaicin is placed inside the nose.

Peppermint (Mentha x piperita)
When applied topically to the forehead and temples, peppermint has the ability to relieve tension headaches and may be comparable to acetaminophen (a commonly used over the counter medication).

Others

Although studies are lacking, the following herbs have been used clinically by herbal specialist to treat different types of headaches, including tension:

• Dong quai (Angelica sinensis)
• Devil's claw (Harpagophytum procumbens)
• Ginkgo biloba (Ginkgo biloba)
• Jamaica dogwood (Piscidia erythrina/Piscidia piscipula)
• Lavender (Lavandula angustifolia)
• Linden (Tilia cordata/platypus ) flowers
• Skullcap (Scutellaria lateriflora)
• Willow bark (Salix spp.)

An acupuncturist diagnoses headaches not as migraine, tension, or sinus, but rather as conditions deriving from "energetic" imbalances. Headaches are commonly seen and often successfully treated by acupuncturists.

The National Institutes of Health recommends acupuncture as a treatment for headache. Acupuncturists diagnose tension headaches by paying careful attention to the kidney and its associated meridians (energy pathways in the body), as well as liver and gallbladder meridians. The physical location of the headache also helps the acupuncturist to determine an appropriate treatment plan, which (in addition to placing needles in acupuncture points) may include lifestyle/dietary changes or herbal remedies. While results from studies have been mixed, most researchers agree that acupuncture is safe and that headache patients who wish to try this therapy should not be discouraged from doing so.

Spinal manipulation is commonly used to treat tension headaches, especially tension headaches that originate from the neck. Evidence supporting the use of tension headaches that originate in the neck is quite clear; however, studies examining the effectiveness of spinal manipulation for other types of tension headaches have been less conclusive.

In one very important study, individuals with tension headaches were randomly assigned to receive either spinal manipulation or an antidepressant medication. Both groups experienced significant improvement while they were being treated. When treatment was stopped, however, the beneficial effects of spinal manipulation lasted longer than did the effects of the antidepressant medication.

In addition, a review article evaluating nine studies that tested spinal manipulative therapy for tension or migraine headaches concluded that this chiropractic technique is comparable to medications used to try to prevent either of these two types of headaches.

Stretching exercises for the head and neck, taught by a physical therapist, and receiving massages regularly can help reduce the frequency and duration of tension headaches. Stretching frequently is particularly important if your work involves typing or using a computer. Learning proper posture is another important factor in reducing your number of headaches; a physical therapist can teach you.

Reflexology (a type of massage in which specialized thumb and finger techniques are applied to the hands and/or feet at points that correspond to specific organs and structures throughout the body) may be an especially valuable technique for treating and preventing headaches.

Other techniques that some clinicians recommend include aromatherapy (the use of essential oils from plants, often together with massage, for healing purposes) and Reiki (an energy balancing technique) treatments.

Studies indicate that homeopathy may be no more effective than placebo in relieving tension headaches. Interestingly, however, one of the most common reasons people seek homeopathic care is to relieve the pain associated with chronic headaches. Many homeopaths report that homeopathy helps treat and prevent recurrent tension headaches. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

The following remedies are commonly prescribed for tension headaches:

• Belladonna— for throbbing headaches that come on suddenly; symptoms tend to worsen with motion and light, but are partially relieved by pressure, standing, sitting, or leaning backwards.
• Bryonia— for headaches with a steady, sharp pain that occurs most often in the forehead but may radiate to the back of the head; symptoms tend to worsen with movement and light touch, but firm pressure alleviates the pain; the person for whom this remedy is most appropriate is usually irritable and may experience nausea, vomiting, and constipation.
• Gelsemium— for pain that extends around the head and feels like a tight band of constriction; pain usually originates in the back of the head and may be relieved following urination; this remedy is most appropriate for individuals who feel extremely weak and have difficulty keeping their eyes open.
• Ignatia— for pain that may be described as a feeling of something being driven into the skull; these types of headaches tend to be triggered by emotion, including grief or anxiety, and the treatment is appropriate for both children and adults
• Iris versicolor— for throbbing headaches that occur on one side of the head, especially after eating sweets; visual disturbances may also occur; these headaches are worse in the early morning, during spring and fall, and symptoms tend to worsen with vomiting.
• Lachesis— for headaches that tend to occur on the left side of the head; symptoms are typically worse in the mornings, before menstruation, and with exposure to warmth and sunlight; symptoms tend to improve with open air and firm pressure.
• Nux vomica— for headaches associated with hangovers, overindulgence in foods or alcohol, and overwork; these types of headaches are often accompanied by nausea and/or dizziness; this remedy is most appropriate for individuals who tend to be constipated and irritable.
• Pulsatilla— for headaches triggered by eating rich, fatty foods, particularly ice cream; pain tends to move but may be concentrated in the forehead or on one side of the head and may be accompanied by digestive problems or occur around the time of menstruation; children for whom this remedy is appropriate often develop these symptoms while at school.
• Sanguinaria— for right-sided headaches that begin in the neck and move upwards, recur in a predictable pattern (such as every seven days); pain is aggravated by motion, light, or sun exposure, odors, and noise; this remedy is appropriate for children who may have a craving for spicy or acidic foods, despite having a general aversion to eating due to the headache.
• Spigelia— for stinging, burning, or throbbing sinus pain that often occurs on the left side of the head; symptoms tend to worsen with cold weather and motion but may be temporarily relieved by cold compresses and lying on the right side with the head propped up.

You can do many things to avoid tension headaches or relieve the pain:

• Biofeedback to control muscle tension.
• Learn to meditate, breathe deeply, or try other relaxation exercises, such as yoga or hypnotherapy.
• See a Cognitive Behavioral Therapist

Other relaxation techniques that may be helpful include:

• Guided imagery
• Hypnosis

Some women who are prone to headaches will get them more often when they are pregnant. Other women, however, experience fewer headaches during pregnancy, especially during the second trimester.

It is important to use medications only as directed. Rebound headaches may occur from overuse of medications and complications may occur from side effects of medications.

Call your health care provider if you experience a new headache, a change in quality of a previous headache or previous headache pattern, or if you are unable to manage your symptoms in the usual way (for example, a medication that usually takes away the pain no longer works).

Serious underlying conditions due to headaches, like a tumor or a stroke, are extremely uncommon, despite the fact that many worry about these possibilities. Situations that may indicate a serious problem include the following:

• Sudden and severe headache that persists or increases in intensity over 24 hours
• A sudden, severe headache that you describe as "your worst ever," even if you are prone to headaches
• Chronic or severe headaches that begin after age 50
• Headaches accompanied by memory loss, confusion, loss of balance, change in speech or vision, or loss of strength in or numbness/tingling in any one of your limbs
• Headaches after a head injury, especially if you are also drowsy or feel nauseated
• Headaches accompanied by fever, stiff neck, nausea and vomiting (may indicate meningitis)
• Severe headache localized to one eye, accompanied by redness of the eye (may indicate acute glaucoma)

The good news is that over 90% of people with tension headaches can get significant relief from a combination of lifestyle change, relaxation, and medication.

Altura BM, Altura BT. Tension headaches and muscle tension: is there a role for magnesium? Med Hypotheses. 2001;57(6):705-713.

Annequin D, Tourniaire B, Massiou H. Migraine and headache in childhood and adolescence. Pediatr Clin North Am. 2000;47(3):617-631.

Astin JA., Ernst E. The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. Cephalagia. 2002;22(8):617-623

Baghdikian B, Lanhers M, Fleurentin J, et al. An analytical study, anti-inflammatory and analgesic effects of Harpagophytum procumbens and Harpagophytum zeyheri. Planta Med. 1997;63:171–176.

Barrows KA, Jacobs BP. Mind-body medicine: an introduction and review of the literature. Med Clin North Am. 2002;86(1):11-31.

Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Alt Med Review. 1998;3(4):271-280.

Blumenthal M. The Complete German Commission E Monographs. Austin, Tex: American Botanical Council. Boston: Integrative Medicine Communications; 1998.

Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther. 1995;18(3):148-154.

Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280(18): 1576-1579.

Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001;24(7):457-466.

Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines. 3rd ed. New York, NY: Penguin Putnam; 1997: 217-220.

Dagenais S. Haldeman S. Chiropractic. Prim Care. 2002;29(2):419-437.

Fusco BM, Giacovazzo M. Peppers and pain. The promise of capsaicin. Drugs. 1997;53(6):909-914.

Fusco BM, Marabini S, Maggi CA, Fiore G, Geppetti P. Preventative effect of repeated nasal applications of capsaicin in cluster headache. Pain. 1994;59(3):321-325.

Gobel H, Schmidt G, Soyka D. Effect of peppermint and eucalyptus oil preparations on neurophysiological and experimental algesimetric headache parameters. Cephalalgia. 1994;14(3):228-234.

Hammill JM, Cook TM, Rosecrance JC. Effectiveness of a physical therapy regimen in the treatment of tension-type headache. Headache. 1996;36(3):149-153.

Holroyd KA, O'Donnell FJ, Stensland M, Lipchik GL, Cordingley GE, Carlson BW. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. JAMA. 2001;285(17):2208-2215.

Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine. 1996;21(15):1746-1759.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 238-239.

Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 27(17):1835-1843; discussion 1843.

Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Ann Intern Med. 2002;136(5):374-383.

Karst M, Reinhard M, Thum P, Wiese B, Rollnik J, Fink M. Needle acupuncture in tension-type headache: a randomized, placebo-controlled study. Cephalagia. 2001;21(6):637-642.

Launso L, Brendstrup E, Arnberg S. An exploratory study of reflexological treatment for headache. Altern Ther Health Med. 1999;5(3):57-65.

Linde K, Melchart D, Fisher P et al. Acupuncture for idiopathic headache (Cochrane Review). In: The Cochrane Library, Issue 3, 2001. Oxford: Update Software.

Lipchik GL, Nash JM. Cognitive-behavioral issues in the treatment and management of chronic daily headache. Curr Pain Headache Rep. 2002;6(6):473-479.

Long L, Huntley A, Ernst E. Which complementary and alternative therapies benefit which conditions? A survey of the opinions of 223 professional organizations. Complement Ther Med. 2001;9(3):178-185.

Lundeberg T. Acupuncture in headache. Cephalagia. 1999;19 Suppl 25:65-68.

Manias P, Tagaris G, Karageorgiou K. Acupuncture in headache: a critical review. Clin J Pain. 2000;16(4):334-339.

Marcus DA. Estrogen and tension-type headache. Curr Pain Headache Rep. 2001;5(5):449-453.

Mauskop A. Alternative therapies in headache. Is there a role? [Review] Med Clin North Am. 2001;85(4):1077-1084.

McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence report: behavioral and physical treatments for tension-type and cervicogenic headache. Des Moines (IA): Foundation for Chiropractic Education and Research; 2001. Product No. 2085.

McGrady AV, Bush EG, Grubbs BP. Outcome of biofeedback-assisted relaxation for neurocardiogenic syncope and headache: a clinical replication series. Appl Psychophysiol Biofeedback. 1997;22(1):63-72.

Melchart D, Linde K, Fischer P, et al. Acupuncture for idiopathic headache. Cochrane Database Syst Rev. 2001;(1):CD001218.

Melchart D, Linde K, Fischer P, et al. Acupuncture for recurrent headaches: a systematic review of randomized controlled trials. Cephalalgia. 1999;19(9):779-786;discussion 765.

Mueller L. Tension-type, the forgotten headache. How to recognize this common but undertreated condition. Postgrad Med. 2002;111(4):25-26, 31-32, 37-38.

Newall C, Anderson L, Phillipson J. Herbal Medicines: A Guide for Health-care Professionals. London, England: Pharmaceutical Press; 1996: 174-175, 278-280.

NIH Consensus Statement: Acupuncture. National Institutes of Health, Office of the Director. 1997;15(5):1-34. Accessed at http://odp.od.nih.gov/consensus/cons/107/107_statement.htm on June 30, 2003.

Nilsson N, Christensen HW, Harvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther. 1997;20(5):326-330.

Penzien DB, Rains JC, Andrasik F. Behavioral management of recurrent headache: three decades of experience and empiricism. Appl Psychophysiol Biofeedback. 2002;27(20:163-181.

Powers SW, Mitchell MJ, Byars KC, Bentti AL, LeCates SL, Hershey AD. A pilot study of one-session biofeedback training in pediatric headache. Neurology. 2001;56(1):133.

Quinn C, Chandler C, Moraska A. massage therapy and frequency of chronic tension headaches. Am J Public Health. 2002;92(10):1657-1661.

Savi L, Rainero I, Valfre W, Gentile S, Lo Giudice R, Pinessi L. A comparison of patients with migraine and tension-type headache. Panminerva Med. 2002;44(1):27-31.

Silberstein SD, Rosenberg J. Multispecialty consensus on diagnosis and treatment of headache. Neurology. 2000;54(8):1553.

Solomon GD. Chronic tension-type headache: advice for the viselike-headache patient. Cleve Clin J Med. 2002;69(2):167-172.

Solomon S. Posttraumatic headache. Med Clin North Am. 2001;85(4):987-996.

Tavola T, Gala C, Conte G, Invernizzi G. Traditional Chinese acupuncture in tension-type headache: a controlled study. Pain. 1992;48:325-329.

Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Penguin Putnam; 1992: 89-94.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995: 236-239.

Vernon H, McDermaid CS, Hagino C. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. Complement Ther Med. 1999;7:142-155.

Vithoulkas G. Homeopathic treatment of chronic headache: a critique. Homeopathy. 2002;91(1):32-34.

Walach H, Haeusler W, Lowes T et al. Classical homeopathic treatment of chronic headaches. Cephalalgia. 1997;17:119-126.

Walach H, Lowes T, Mussbach D et al. The long-term effects of homeopathic treatment of chronic headaches: 1 year follow up. Cephalalgia. 2000;20:835-837.

Walach H, Lowes T, Mussbach D et al. The long-term effects of homeopathic treatment of chronic headaches: one year follow-up and single case time series analysis. Br Homeopath J. 2001;90(2):63-72.

White AR, Resch K-L, Chan JCK et al. Acupuncture for episodic tension-type headache: a multicentre randomized controlled trial. Cephalalgia. 2000;20:632-637.

Yucal B, Kora K, Ozyalcin S, Alcalar N, Ozdemir O, Yucel A. Depression, automatic thoughts, alexithymia, and assertiveness in patients with tension-type headache. Headache. 2002;69(2):167-172.