Chronic Tension Headache | Causes and Treatment (2023)

Chronic tension headache is a condition where you have a tension headache on at least 15 days every month for at least three months. The cause of chronic tension headache is often not clear. A medicine called amitriptyline may help to prevent the headaches from occurring.

What is chronic tension headache and who is affected by it?

Chronic tension headache is a condition where you have a tension headache on at least 15 days every month for at least three months.This can be tiring and depressing. Tension headache (also called tension-type headache) is the common type of headache that most people have at some time.

It's not known exactly how common chronic tension headache is, as few studies have looked at this clearly. Some studies have estimated that around 1 in 30 of all adults have chronic tension headaches - which means they have a headache on more than half of all days for three months or more. However, it is possible that a proportion of these patients actually have developed medication-overuse headaches (medication-induced headaches) as a result of their tension headaches. Therefore, it can be difficult to be certain which is their main problem.

Chronic means persistent; it does not mean severe. The severity of the headaches can vary from mild to severe. Because of the persistent nature of the headaches, however, this condition is often quite disabling and distressing, and most patients take preventative medication.

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What causes chronic tension headache?

This condition tends to develop in people who start off with having tension headaches with increasing frequency, until they occur on most days. However, the cause of the tension headaches is not always clear, and may be more than one thing. They may be due to tension in the muscles at the back of the head and neck, but it is now clear that this is not always the cause. Other causes reported by patients include stress, tiredness, hunger and eye strain. Many chronic tension headaches develop for no apparent reason. Working long hours bent over a computer may trigger them.

Some people get tension headaches if they drink too much caffeine or alcohol, if they don't drink enough water or if they go for a long time between meals and become tired and hungry. Occasionally, tension headaches can be caused by poor vision, particularly if reading in low light for long periods. Some may be triggered by environmental discomforts such as heat, cold, brightness or wind.

Some research suggests that your genetic make-up may be a factor. This means that some people may inherit a tendency to be more prone to develop tension headaches than others when stressed or anxious.

By definition, tension headaches are not caused by other conditions. So, if you have chronic tension headache, a doctor's examination will be normal apart from the muscles around the head perhaps being fairly tender when a doctor presses on them. Any tests that may be done will be normal.

Note: medication-overuse headache can be similar to chronic tension headache.

Medication-overuse headache is caused by taking painkillers (or triptan medicines) too often for tension headaches or migraine attacks. See the separate leaflet called Medication-overuse Headache (Medication-induced Headache).

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What are the symptoms of each tension headache?

  • Tension headaches are usually felt as a band or across the forehead. They can be uncomfortable and tiring, but they do not usually disturb sleep. Some people feel a squeezing or pressure on their head.
  • It usually occurs on both sides, and often spreads down your neck, or seems to come from your neck. Sometimes it is just on one side.
  • The pain is usually moderate or mild. Tension headaches can interrupt concentration but are usually not bad enough to send you to bed. Most people can work through a tension headache if they really need to.
  • A tension headache can last from 30 minutes to seven days. Most last a few hours.
  • Tension headaches tend to become worse as the day goes on and are often mildest in the morning. They are not usually made worse by physical activity.
  • An exception to this would be a headache caused by sleeping in an awkward position, causing a sore neck, or an ache in the face and jaw due to tooth grinding.
  • There are usually no other symptoms.

Sometimes migraines are mistaken for chronic tension headaches. Some people don't like bright lights or loud noises, and don't feel like eating much when they have a tension headache. However, marked dislike of light or loud noise, and visual disturbances, like zigzag lines, are more suggestive of migraine. A mild feeling of sickness (nausea) can occur, especially if you are using a lot of painkillers. However, marked nausea is, again, more a feature of migraine.

The headaches you have with chronic tension headache occur frequently. In some cases, the headache can seem to be permanent, and hardly ever goes, or only eases off but never goes completely.

Many people with chronic tension headache put up with their headaches without seeing a doctor. In one study, two thirds of people diagnosed with chronic tension headache had had daily or near daily headache for an average of seven years before consulting a doctor. Most continued to function at work or school, but their performance was often not as good as it could be. Almost half had anxiety or depression, possibly as a result of coping with their frequent headaches.

If you think you have chronic tension headache, it is best to see a doctor, as treatment can often help.

How can I be sure it is not a more serious type of headache?

With tension headaches, you are normally well between headaches, and have no other ongoing symptoms. A doctor diagnoses tension headaches by their description. In addition, there is nothing abnormal to find if a doctor examines you (apart from some tenderness of muscles around the head when a headache is present). Tests are not needed unless you have unusual symptoms, or something other than chronic tension headache is suspected. Of particular note, medication-overuse headache (medication-induced headache) should be ruled out (described earlier) as this can often be mistaken for chronic tension headache.

Compared to migraine, a tension headache is usually less severe, and is constant rather than throbbing. Also, migraine attacks usually cause a one-sided headache, and many people with a migraine attack feel sick (nausea) or are sick (vomit). Some people have both migraine attacks and tension headaches at different times. In addition, some people find that one of the types of headaches is followed by another, perhaps because the pain and tiredness due to the first headache cause the second.

What are the treatments for chronic tension headache?

Painkillers

You may well be used to taking painkillers such as paracetamol, aspirin, ibuprofen, etc. Importantly though, you should not take painkillers for headache for more than a couple of days at a time. Also, on average, do not take them for more than two days in any week for headaches. If you take them more often, you may develop medication-overuse headache (medication-induced headache). Do not take painkillers to prevent headaches. Take each day as it comes. Perhaps reserve painkillers for days which are particularly bad.

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Opiate painkillers such as codeine, dihydrocodeine and morphine are not normally recommended for tension headaches. This includes combination tablets that contain paracetamol and codeine, such as co-codamol. The reason is because opiate painkillers can make you drowsy. They are also the most likely type of painkiller to cause medication-overuse headache if used regularly.

Treating the cause: diary

It may help to keep a diary if you have frequent headaches. Note when, where, and how bad each headache is, and how long each headache lasts. Also note anything that may have caused it. A pattern may emerge and you may find a trigger to avoid. For example, hunger, eye strain, bad posture, stress, anger, etc.

Some doctors suggest reviewing your diet. The list of foods which can be triggers in some people includes caffeinated drinks, chocolate, cheese and alcohol. Other doctors suggest focusing on a healthy balanced diet, with a good mixture of slow-release energy foods (taken in small regularly spaced meals) and a low intake of refined sugars.

Stress and depression

Stress is a trigger for some people who develop tension headaches. Avoid stressful situations whenever possible. Sometimes a stressful job or situation cannot be avoided. Learning to cope with stress and to relax may help. Breathing and relaxation exercises, or coping strategies, may ease anxiety in stressful situations and prevent a possible headache. There are books and apps which can teach you how to relax. Sometimes a referral to a counsellor or psychologist may be advised.

Regular exercise

Many people with frequent headaches say that they have fewer headaches if they exercise regularly. If you do not do much exercise, it may be worth trying some regular activities like brisk walking, jogging, cycling, swimming, etc. (This will have other health benefits too.) It is not clear how exercise may help. It may be that exercise helps to ease stress and tension, which can have a knock-on effect of reducing tension headaches. It also may be that it strengthens your core and upper back muscles and improves posture. This means you are less likely to 'droop' when you sit and increase tension in the upper back and neck. It could also be an effect of getting the heart rate, breathing and blood flow increasing around the upper body, improving the supply of oxygen to muscles generally.

Physiotherapy

Physiotherapy may help chronic tension headaches through teaching relaxation techniques and breathing exercises. It may also help through detecting and changing physical habits which may be contributing to the headaches. This might include poor posture. Patients must take an active part in this kind of therapy, and do their exercises regularly, in order to see an improvement.

Acupuncture

There is some evidence that acupuncture, particularly when combined with medical therapy, can be helpful in the treatment of chronic daily headaches.

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Cognitive behavioural therapy (CBT)

CBT can be a helpful add-on in the treatment of chronic daily headache. Behavioural therapies work towards reducing or eliminating the stress which may contribute to the development of chronic tension headaches. Some patients dislike the idea of talking therapies, as they feel this suggests that the doctor thinks their headache is actually depression. However, there is good evidence that these therapies do help. This might be because chronic pain is in itself stressful and CBT and other talking therapies help to break the stress-headache-stress cycle.

Preventative medication

Amitriptyline is the medicine most commonly used to treat chronic tension headaches. This medicine is not a painkiller and so does not take away a headache if a headache develops. It is an antidepressant medicine and you have to take it every day with the aim of preventing headaches. (One effect of some antidepressants is to ease pain and prevent headaches even in people who are not depressed. So, although amitriptyline is classed as an antidepressant, it is not used here to treat depression.)

A low dose is started at first and may need to be increased over time. It is slow to take effect - the low starting dose is to allow you to tolerate the medicine more easily. If higher doses are started immediately they can make you tired and sleepy. It can therefore take a couple of months of gradual dose increases before the medicine really works.

Once the headaches have been reduced for 4-6 months, the amitriptyline can be stopped. Treatment can be resumed if headaches return (recur). Other medicines are sometimes tried if amitriptyline is not suitable or does not help. These include topiramate (more often used to prevent migraine), gabapentin (more usually treatment for pain due to inflamed nerves) and tizanidine (more often used as treatment for muscle spasm). Modern selective serotonin reuptake inhibitor (SSRI) antidepressants such as fluoxetine (Prozac®) are not generally felt to be as helpful in treating chronic tension headaches.

The aims of preventative treatment are to reduce the number of headaches, or reduce their severity, or both. So, with treatment, the headaches may not go completely, but they will often develop less often and be less severe. Any headache that does occur whilst taking preventative medication may also be eased better than previously by a painkiller.

It is often difficult in retrospect to say how well a preventative treatment has worked. Therefore, it is best to keep a headache diary for a couple of weeks or so before starting preventative medication. This is to record when and how severe each headache was, and also how well it was eased by a painkiller. Then, keep the diary going as you take the preventative medicine to see how well things improve. The headaches are unlikely to go completely, but the diary may show a marked improvement.

FAQs

What is the best treatment for chronic tension headaches? ›

Rest, ice packs or a long, hot shower may be all you need to relieve a tension-type headache. A variety of strategies can help you reduce the severity and frequency of chronic tension-type headaches without using medicine. Try some of the following: Manage your stress level.

Why do I constantly have tension headaches? ›

Tension headaches occur when neck and scalp muscles become tense or contract. The muscle contractions can be a response to stress, depression, head injury, or anxiety. They may occur at any age, but are most common in adults and older teens. It is slightly more common in women and tends to run in families.

How do you get rid of a massive tension headache? ›

Apply heat to relieve tense neck and shoulder muscles. Use a heating pad set on low, a hot water bottle, a hot shower or bath, a warm compress, or a hot towel. Or apply ice or a cool washcloth to the forehead. Massage also can relieve muscle tension — and sometimes headache pain.

What can a neurologist do for tension headaches? ›

A headache neurologist can help differentiate a tension-type headache from a migraine, and from all the other types of head pain that will not respond to the types of headache medications frequently used by non-headache specialists in a one-size-fits-all fashion to treat headache.

Are tension headaches everyday normal? ›

No, it's NOT normal to get headaches everyday

Most people have headaches from time to time. But if you have a headache more days than not, you might have chronic daily headaches, which come in many forms – most of them pretty disabling.

Can tension headaches last for years? ›

HOW LONG WILL IT LAST? Tension headaches may last a few hours, several days, weeks, or even months.

What happens if tension headaches won't go away? ›

Sometimes tension-type headaches may be a sign of an underlying disorder such as thyroid disease or an underlying tumor or a primary headache disorder, such as chronic migraine or new daily persistent headache. Anyone over age 50 with a new onset headache should see their doctor for an evaluation .

What is the best muscle relaxer for tension headache? ›

Muscle relaxants – These help relax muscle irritability. Tizanidine has been the main medication studied for daily use in tension headache.

What happens to the brain during a tension headache? ›

Newer theories suggest tension headaches are caused by changes in brain chemicals called neurotransmitters (including serotonin), similar to what happens with a migraine. Scientists don't know why the levels of neurotransmitters go up and down, but they think it activates pain pathways in the brain.

Which nerve is associated with tension headaches? ›

Greater Occipital Nerve (GON)

While it is true that tension of the muscles and tissue in the back of the head and neck is often the major contributing factor to tension headaches, it is actually the nerves in these regions that are the main culprits.

Is tension headache a neurological disorder? ›

Tension-type headache is a neurological disorder characterised by a predisposition to attacks of mild to moderate headache with few associated symptoms. The diagnosis is based on the history and examination.

When should I be worried about tension headaches? ›

Your headache pain may be serious if you have: sudden, very intense headache pain (thunderclap headache) severe or sharp headache pain for the first time. a stiff neck and fever.

What's the longest a tension headache can last? ›

Tension headaches last at least 30 minutes but they can last much longer, sometimes for several days.

Which medication can typically be used to treat a tension headache? ›

Drugs prescribed to treat the pain of tension headaches include: Nonprescription Pain Relievers These are usually adequate to relieve mild to moderate pain. They include aspirin, acetaminophen, ibuprofen and naproxen.

What can make tension headache worse? ›

It may be triggered by or get worse with stress, fatigue, noise, or glare. You may have difficulty sleeping. Tension headaches usually do not cause nausea or vomiting. People with tension headaches try to relieve pain by massaging their scalp, temples, or the bottom of the neck.

Which symptom is most indicative of a tension headache? ›

Signs and symptoms of a tension-type headache include: Dull, aching head pain. Sensation of tightness or pressure across the forehead or on the sides and back of the head. Tenderness in the scalp, neck and shoulder muscles.

Where are tension headaches located? ›

Tension headaches are the most common type of headache. Tension headaches typically do not cause nausea, vomiting, or sensitivity to light. Tension headaches affect both sides of the head, come on slowly, and are described as a tight band or vice around the head.

Can tension headaches be psychological? ›

It's not a coincidence — headaches are more likely to occur when you're stressed. Stress is a common trigger of tension-type headaches and migraine. It can also trigger other types of headaches or make them worse. Stress is a particularly common headache trigger in children and young adults.

What can mimic tension headaches? ›

Stress, sleep disturbances, neck or jaw pain, or eye strain may trigger these headaches. Headaches may occur several or many days each month. Doctors base the diagnosis on symptoms and results of a physical examination and sometimes do imaging tests to rule out other disorders.

What does a severe tension headache feel like? ›

Tension headaches are the most common type of headache. Stress and muscle tension are often factors in these headaches. Tension headaches typically don't cause nausea, vomiting, or sensitivity to light. They do cause a steady ache, rather than a throbbing one, and tend to affect both sides of the head.

What makes a tension headache worse? ›

It may be triggered by or get worse with stress, fatigue, noise, or glare. You may have difficulty sleeping. Tension headaches usually do not cause nausea or vomiting. People with tension headaches try to relieve pain by massaging their scalp, temples, or the bottom of the neck.

Should I go to the ER for tension headaches? ›

Seek emergency care if:

The headache is accompanied by high fever, confusion, stiff neck, prolonged vomiting, slurred speech or numbness or weakness, especially on one side of the body. Headache medication does not relieve chronic or excruciating pain.

Why does my head feel tight every day? ›

The most common causes of pressure and pain in the head are tension headaches and migraines. Both of these conditions respond well to treatments. In rare cases, pressure in the head is a sign of a more serious condition. If the issue persists, you should see a doctor.

Can a brain tumor feel like a tension headache? ›

Brain tumor headaches cause intense pain that people may confuse with migraine or tension-type headaches. However, brain tumors cause other symptoms in addition to headaches, including: fatigue. weakness.

Can tension headaches be severe? ›

Tension headaches

In most cases, they are mild to moderate in severity and occur infrequently. But a few people get severe tension headaches, and some are troubled by them for three or four times a week.

How long is too long to have a headache? ›

By definition, chronic daily headaches occur 15 days or more a month, for longer than three months. True (primary) chronic daily headaches aren't caused by another condition. There are short-lasting and long-lasting chronic daily headaches. Long-lasting headaches last more than four hours.

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