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Tension Headache

Definition:
A tension headache is the most common headache, and yet it's not well understood. A tension headache generally produces a diffuse, usually mild to moderate pain over your head. Many people liken the feeling to having a tight band around their head. A tension headache may also cause pain in the back of your neck at the base of your skull.

Although headache pain sometimes can be severe, in most cases it's not the result of an underlying disease. The vast majority of headaches are so-called primary headaches. Besides tension headaches, these include migraines and cluster headaches.

In many cases, there's no clear cause for a tension headache. Fortunately, effective treatments for tension headaches are available. Managing a tension headache is often a balance between fostering healthy habits, finding effective nondrug treatments and using medications appropriately. In addition, a number of preventive, self-care and alternative treatments may help you deal with headache pain.

Causes:
Experts continue to debate the causes and even the name of tension headaches. Over the years, as different theories emerged about the origins of this type of headache, it was known by names such as muscle contraction headache, psychogenic headache, depressive headache, essential headache and ordinary headache.

The exact cause or causes of tension headache are unknown. Until a few years ago, many researchers believed that the pain of tension headache stemmed from muscle contraction in the face, neck and scalp, perhaps as a result of heightened emotions, tension or stress. But many researchers have questioned this idea.

More recent research discredits this theory. Studies using a test called an electromyogram, which records the electric currents generated by muscle activity, haven't detected increased muscle tension in people diagnosed with tension headache. In addition, people with migraine have as much muscle tension as do people with a tension headache, if not more.

As a result, The International Headache Society uses the term "tension-type headache" instead of "tension headache," calling attention to the fact that muscle tension may not be the main cause of this kind of head pain.

Chemical changes
Researchers now believe that tension headache may result from changes among certain brain chemicals — serotonin, endorphins and numerous other chemicals — that help nerves communicate. These are similar to biochemical changes associated with migraine. Although it's not clear why the chemical levels fluctuate, the process is thought to activate pain pathways to the brain and to interfere with the brain's ability to suppress the pain. On one hand, tight muscles in the neck and scalp may contribute to a headache in someone with altered chemical levels. On the other hand, the tight muscles may be a result of these chemical changes.

Because both tension headache and migraine involve similar changes in brain chemicals, some researchers believe that the two types of headache are related. Some experts speculate that migraine may develop from the regular occurrence of tension headache. The distinctive migraine features form as the pain becomes more severe. Other research suggests that mild migraine is in reality a type of tension headache.

Two classifications
Tension headache is classified into two forms: episodic and chronic. These forms distinguish between occasional headaches separated by varying lengths of time between attacks and frequent headaches that occur, in many cases, almost daily.
  • Episodic. Episodic tension headaches occur on fewer than 15 days a month. These headaches are usually brief, lasting a few minutes to a few hours. Episodic tension headaches may cause scalp and neck muscle tenderness in addition to head pain. People with increasingly frequent attacks of the episodic form may be at higher risk of developing the chronic form of the headache over a period of years.
  • Chronic. Chronic tension headaches occur on 15 days a month or more for at least three months. Compared with the episodic form, chronic tension headache is less common, but twice as many women as men have the chronic form. The duration and the severity of episodic and chronic tension headaches are similar, although for many people with the chronic form, pain is daily and almost continuous. Like the episodic form, chronic tension headache can be with or without scalp tenderness.

In some cases, depression and anxiety may cause chronic tension headaches. If you do have a mood disorder, it's critical to treat this condition as well as your headache to achieve the best possible outcome. For example, if you have both depression and tension headache, treatment for your headaches may be less effective if the depression goes undiagnosed and untreated.

Controversy surrounds the issue of whether chronic tension headache is really a separate entity from chronic migraine. Doctors often have trouble distinguishing between the two types of headache. Both disorders are thought to stem from episodic headaches after pain pathways become sensitized, and both involve similar biochemical changes in the brain.

Triggers and aggravators
There are many possible triggers of tension headache. You may have no identifiable or consistent trigger, or have several obvious ones. Potential triggers include:

  • Stress
  • Depression and anxiety
  • Lack of sleep or changes in sleep routine
  • Skipping meals
  • Poor posture
  • Working in awkward positions or holding one position for a long time
  • Lack of physical activity
  • Occasionally, hormonal changes related to menstruation, pregnancy, menopause or hormone use
  • Medications used for other conditions, such as depression or high blood pressure
  • Overuse of headache medication
Half the people with tension headache report that they felt stressed or hungry before their headache began.

Tension headache may be made worse by jaw pain from clenching or grinding teeth (bruxism) or by head trauma, such as a blow to the head or whiplash injury. People with stiff joints and muscles due to arthritis of the neck or inflammation of the shoulder joints may develop tension headache.

Headaches in children
Chronic tension headaches in children are similar to headaches in adults and are often caused by stress, anxiety or depression. Although adults may not always realize it, children can experience tremendous stress — ranging from peer pressure and unreasonable parental expectations to difficulty in school and physical or sexual abuse. And all children, even very young ones, can experience depression.

Risk Factor:
Tension headache probably accounts for a majority of all primary headaches. And it's more common in women than in men. Almost 90 percent of women and about 70 percent of men experience tension headaches during their lifetimes. Tension headache is most prevalent in people between the ages of 20 and 50. The majority of people who get migraines also get tension-type pain.

When to seek medical advice:
Pain is often one of your body's ways of signaling illness. But headache pain, even when it's severe, usually isn't the result of an underlying disease. Occasionally, however, headaches may indicate a serious medical condition, such as a brain tumor or rupture of a weakened blood vessel (aneurysm). Always be sure to tell your doctor about any headache that concerns you. Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

If tension headache disrupts your life, don't hesitate to talk to your doctor. The condition is a biological disorder for which there's effective treatment. Many people can manage their headaches by working with their doctors to develop a comprehensive, individualized treatment plan that involves lifestyle changes, medication and complementary therapies.

In addition, see your doctor or go to the emergency room immediately if you have any of these warning signs and Symptoms:
  • Abrupt, severe headache, often like a thunderclap
  • Headache with a fever, stiff neck, rash, mental confusion, seizures, double vision, weakness, numbness or speaking difficulties
  • Headache after a head injury, especially if it gets worse
  • Chronic, progressive headache that is precipitated by coughing, exertion, straining or a sudden movement
  • Onset of new headache pain after age 50
Call your doctor if your child has head pain that's severe or that causes him or her to miss school or other activities. A child who's too young to tell you what's wrong may cry and hold his or her head to indicate severe pain.

Symptoms:
A tension headache can last from 30 minutes to an entire week. You may experience these headaches occasionally, or nearly all the time. If your headaches occur 15 or more days a month for several months, they're considered chronic. Unfortunately, chronic tension headaches sometimes persist for years.
A tension headache may cause you to experience a dull, achy pain or sensation of tightness in your forehead or at the sides and back of your head. Many people liken the feeling to having a tight band of pressure encircling their heads. In its most extensive form, the pain feels like a hooded cape that drapes down over the shoulders. The headache is usually described as mild to moderately intense. The severity of the pain varies from one person to another, and from one headache to another in the same person. Many people report that the pain starts first thing in the morning or late in the day when work stress or conflict at home is anticipated.

Some people with tension headache experience neck or jaw discomfort. There may also be:
  • Tenderness on your scalp, neck and shoulder muscles
  • Difficulty sleeping (insomnia)
  • Fatigue
  • Irritability
  • Loss of appetite
  • Difficulty concentrating
Unlike some forms of migraine, tension headache usually isn't associated with visual disturbances (blind spots or flashing lights), nausea, vomiting, abdominal pain, weakness or numbness on one side of the body, or slurred speech. While physical activity typically aggravates migraine pain, it doesn't make tension headache pain any worse. A few people with tension headache experience an increased sensitivity to light or sound, but this isn't a common symptom.

Dignosis:

If you have chronic or recurrent headaches, your doctor may try to pinpoint the type and cause of your headaches using these approaches:
  • Getting a description of your pain. Your doctor can learn a lot about your headaches from your description of the type of pain, including its severity, location, frequency and duration, and other signs and symptoms you may have.
  • Conducting tests. If you have unusual or complicated headaches, your doctor may order tests to rule out serious causes of head pain, such as a tumor or an aneurysm. Two common tests used to image your brain are computerized tomography (CT) and magnetic resonance imaging (MRI) scans. A CT scan is a diagnostic imaging procedure that uses a series of computer-directed X-rays to provide a comprehensive view of your brain. An MRI doesn't use X-rays. Instead, it combines a magnetic field, radio waves and computer technology to produce clear images.
  • Asking you to keep a headache calendar. One of the most helpful things you can do is keep a headache calendar for at least two months. Each time you get a headache, jot down a description of the pain, including how severe it is, where it's located and how long it lasts. Also note any medications you take. A headache calendar can offer valuable clues that may help your doctor diagnose your particular kind of headache and discover possible headache triggers.
Complications:
Because tension headache is so common, its impact on job productivity and overall quality of life is considerable. When your head is "gripped in a vise," as the pain is often described, you may feel unable to attend family and social activities. You might need to stay home from work, or if you do go to your job, you work at only a fraction of your normal efficiency.

Treatment:
Few people with episodic tension headache seek medical attention. One reason is that tension headache usually is easy to treat with over-the-counter medications. Other reasons may be a fear of not being taken seriously by the doctor or the misperception that tension headache is purely psychological in nature, that admitting you have one means you're weak or neurotic.

While much remains unknown and even controversial about tension headache, the condition is widely recognized as a biological disorder. And fortunately, while doctors may disagree about what causes this type of headache, they do know how to help you.

Medications
A variety of medications, both over-the-counter (OTC) and prescription, are available for treating tension headache. You may find fast, effective relief by taking pain relievers such as aspirin, ibuprofen (Advil, Motrin, others) or acetaminophen (Tylenol, others). These medications are inexpensive and readily available and don't require a prescription from your doctor. People with severe or chronic tension headaches may require stronger painkillers or preventive medications to reduce the frequency and severity of head pain. Which drug works best varies from one person to another.

Whether you have episodic or chronic headaches, don't overuse OTC medications. Limit your use of painkillers to two days a week. Try to take the medications only when necessary, and use the smallest dose needed to relieve your pain. Overusing pain medications can cause rebound headaches or the development of chronic daily headaches, triggering the very symptoms you're trying to stop. In addition, all medications used to treat headache have side effects, some of which may be serious. For prescription medications, of course, follow the recommended dosage and do not exceed it.

Acute therapy
Acute therapy aims to stop or reduce the pain of an existing headache attack. Many different medications are used for the acute treatment of tension headache:
  • Analgesics. Analgesics are pain relievers. Acetaminophen (Tylenol, others) and a class of drugs known as nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in reducing headache pain. Side effects of acetaminophen are rare, but if you take the drug in large doses for long periods of time, it can cause serious liver damage. NSAIDs include the OTC drugs aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Prescription NSAIDs include naproxen (Naprelan, Naprosyn), indomethacin (Indocin) and ketorolac tromethamine (Toradol). Side effects include nausea, diarrhea or constipation, stomach or abdominal pain, stomach bleeding, and ulcers. You can reduce or eliminate these symptoms by taking NSAIDs after meals or with milk.
  • Combination medications. Aspirin or acetaminophen (or both of these analgesics) are often combined with caffeine or a sedative drug in a single medication. For example, Excedrin combines aspirin, acetaminophen and caffeine. Combination drugs such as this may be more effective than are pure analgesics for pain relief. Although many combination drugs are available over-the-counter, analgesic-sedative combinations can be obtained only by prescription because they may be addictive and can lead to chronic daily headache. Don't use these drugs more than two days a week, and use them only with careful monitoring by your doctor.
  • Other medications. For people who experience both migraine and episodic tension headaches, a triptan can effectively relieve the pain of both headaches. Opiates, or narcotics, are rarely used because of their side effects and potential for dependency. These include codeine combined with acetaminophen (Tylenol With Codeine No. 3).
Medications don't cure headaches, and over time painkillers and other medications may lose their effectiveness. In addition, all medications have side effects. If you take medications regularly, including products you buy over-the-counter, discuss the risks and benefits with your doctor. Also, remember that pain medications aren't a substitute for recognizing and dealing with the stressors that may be causing your headaches.

Prevention:
Although medications can provide temporary relief, lifestyle changes are ultimately the best way to combat tension headaches. Make sure you're following a regular sleep schedule and eating balanced meals. In addition, the following tips may help:
  • Exercise regularly. Regular aerobic exercise, such as walking, swimming or biking, can help reduce the frequency and intensity of headaches. Exercise relieves stress, relaxes your muscles and increases the levels of one of your body's natural stress relievers, beta-endorphin. Yoga, massage, stretching and posture classes also can help prevent tension headaches. If you already have a headache, exercise can help relieve the pain. In some cases, however, exercise may bring on a headache, so check with your doctor before starting any exercise program. Your doctor may recommend that you work with a physical therapist to learn exercise techniques that may specifically benefit people with chronic tension headaches.
  • Manage stress. In addition to regular exercise, techniques such as biofeedback training and relaxation therapy can help reduce stress. Biofeedback teaches you to control certain body responses that help reduce pain. During a biofeedback session, you're connected to devices that monitor and give you feedback on body functions such as muscle tension, heart rate and blood pressure. You then learn how to reduce muscle tension and slow your heart rate and breathing yourself. The goal of biofeedback is to help you enter a relaxed state so that you can better cope with your pain. Ask your doctor whether such a program might help you.

    Cognitive behavior therapy also may help you learn to manage stress and reduce the frequency and severity of your headaches. During this type of talk therapy, a counselor helps you learn ways to view and cope with life events more positively.

    Other relaxation techniques include deep breathing, yoga, meditation and progressive muscle relaxation, which is accomplished by tensing one muscle at a time, and then completely releasing the tension, until every muscle in your body is relaxed. You can learn relaxation techniques in special classes or at home using books or tapes. Many of them may also be helpful for children.

Preventive medications
Certain medications taken at regular intervals may reduce the frequency and severity of attacks. Your doctor may prescribe these if you have more than two headaches a week or have tension headaches that aren't relieved by acute medication and nondrug therapy. Your doctor also may recommend preventive medication if your headache lasts longer than three to four hours, if severe pain becomes disabling or causes you to overuse acute medication, or if you can't take acute medication because of other medical conditions.

Doctors often prescribe antidepressants to prevent tension headache, especially the chronic form. These drugs aren't painkillers. Rather, they work to stabilize the levels of brain chemicals such as serotonin, which may be involved in the development of a headache. You don't have to have depression in order to use these drugs.

Preventive medications may include:
  • Tricyclic antidepressants. Tricyclic antidepressants, including amitriptyline and nortriptyline (Pamelor), are the most commonly used medications to prevent tension headache. They're effective against both the episodic and chronic forms. Side effects of these medications may include weight gain, drowsiness, dry mouth, blurred vision and constipation. Older adults also may experience confusion or faintness when taking tricyclic antidepressants.
  • Selective serotonin reuptake inhibitors (SSRIs). Antidepressants such as paroxetine (Paxil), venlafaxine (Effexor) and fluoxetine (Prozac, Sarafem) produce fewer side effects than do the tricyclic antidepressants but generally are less reliable in preventing headaches. Further studies are needed to demonstrate their effectiveness.
  • NSAIDs. Chronic tension headache may be effectively managed with NSAIDs such as ibuprofen (Advil, Motrin IB, others) and ketoprofen (Orudis). In these circumstances, you take the medication daily.
  • Other medications. Other medications that may prevent tension headache include anticonvulsants such as divalproex (Depakote) and muscle relaxants such as tizanidine (Zanaflex). If you experience migraine-like symptoms, your doctor may prescribe a medication commonly used to treat migraines, such as beta blockers or calcium channel blockers.
Preventive medications may require several weeks to build up in your nervous system before they take effect. So don't get frustrated if you haven't seen improvements shortly after you begin taking the drug — it may take a couple of months or longer. You may need a combination of different medications for maximum effectiveness. Also be aware that overusing caffeine or painkillers for acute relief may reduce the effect of a preventive drug.

To obtain the greatest benefit from preventive medication, keep your use of acute pain relievers to a minimum. Your doctor will monitor your treatment to see how the preventive medication is working. If your headaches are under control, your dose of medication may be reduced gradually over time.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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