What are tension-type headaches?

Tension-type headaches are the most common type of headache in adolescents. They are commonly referred to as muscle contraction headaches, stress headaches, daily headaches, or chronic non-progressive headaches. When a patient has both tension-type headaches and migraine, the headache is often referred to as chronic migraine or transformed migraine.

A tension-type headache might occur periodically (episodic, less than 15 days per month) or chronically (daily or > 15 days per month). The headache is described as a mild to moderate constant band-like pain or pressure that lasts from 30 minutes to all day in duration. Tension headaches usually begin gradually, and often occur in the middle of the day.

The "severity" of a tension headache may increase significantly with its frequency. Severe tension-type headaches occur daily or almost daily and the pain is usually described as a throbbing pain affecting the front, top, or sides of the head. Although the intensity of the pain may vary throughout the day, the pain is almost always present. It is important to realize that although tension headaches come and go over a prolonged period of time and might impair your day-to-day function, they do not cause neurological damage, or affect vision, balance, or strength.

What causes tension-type headaches?

There is no single cause for tension-type headaches. This type of headache syndrome may be an inherited trait that runs in families. In some people, tension-type headaches are thought to be associated with or result in tightened muscles in the back of the neck and scalp. This muscle tension may be caused by (1) inadequate rest, (2) poor posture, or (3) emotional or mental stress, including depression. This stress may be known (overt) or unknown (covert) to the patient and his or her parents. The most common sources of stress in children and adolescents include school, family, and friends or peers. Examples of stressors (not in any particular order) include:

  • Not getting enough sleep
  • Being on the honor role or a straight-A student
  • Having problems at home/difficult family life
  • Going to a new school
  • Having overly permissive or overly strict parents
  • Having a substitute or strict teacher
  • Having a new brother or sister
  • Being a "teacher’s pet"
  • Having no close friends or having bad friends
  • Being bullied
  • Preparing for school tests or exams
  • Learning to drive
  • Joining too many extra-curricular activities
  • Starting a new part-time job
  • Going on a field trip or vacation
  • Being overweight
  • Having other children make fun of you
  • Competing in sports or other activities
  • Learning difficulties
  • Recent move
  • Divorce
  • Death of a family member

Having the adolescent seen by a headache specialist might be helpful, particularly when the cause of tension-type headaches is difficult to identify. Once the evaluation is completed, it is important to reassure the patient that the headache pain they are experiencing is NOT due to a brain tumor.

What are the symptoms of tension-type headaches?

Patients with tension-type headaches commonly report these symptoms:

  • Constant or episodic, mild-to-moderate head pain
  • Headache upon awakening
  • General muscle aches
  • Difficulty falling asleep and staying asleep
  • Chronic fatigue
  • Irritability
  • Disturbed concentration
  • Mild sensitivity to light or noise
  • Occasional dizziness
  • Occasional nausea

The presence of an aura (physical warning sign), significant sensitivity to light or noise, nausea and vomiting are not symptoms associated with this type of headache syndrome (they are more frequently seen in migraine). Often, the pain associated with a tension headache is difficult for the patient to describe. There are no associated neurological symptoms (for example, balance or visual disturbances) in patients with tension-type headaches.

How common are tension-type headaches?

Tension-type headaches affect 15 to 20% of adolescents and a lower percentage in younger children. The percent of adults who suffer with occasional tension headaches ranges from 30% to about 80%. Women are twice as likely to suffer from tension-type headaches as men. Tension-type headaches are more common in patients with a history of migraine -- the resulting dual headache condition is called mixed headache or chronic migraine or transformed migraine.

Most people with episodic tension headaches have them no more than once or twice a month, but the headaches can occur more frequently. Nearly 60 percent of people with tension headaches report that their daily activities are impaired because of the headaches.

Chronic tension headaches tend to be more common in females and in students who are "high achievers," (eg, straight As or overly involved in extracurricular activities). Many patients with chronic tension headaches have already had the headaches for more than 60 to 90 days when evaluated. Many have missed an excessive amount of school and more patients with this type of headache overuse their pain medications, causing even more headache problems.

How are tension-type headaches diagnosed?

The correct headache diagnosis is needed to develop an effective treatment plan. The most important aspect of the headache evaluation is the headache history, which should be obtained from both the teen and his or her parents.

The history includes asking patients to describe how they feel with the headache, what happens when a headache occurs, the frequency and duration of the headaches, and any associated symptoms experienced. A description of previous and current medications taken to treat the headaches is also an important part of the headache evaluation. The results of any previously conducted studies or tests should be brought with you to the headache evaluation.

After completing the medical history part of the evaluation, your doctor will perform physical and neurological examinations. Usually, the results of these examinations are normal for people with tension-type headaches.

An interview with a psychologist is commonly a part of the headache evaluation. The psychologist usually meets with the child and the parents together, and then with them separately for structured interviews. The parents may be asked to complete computerized questionnaires in order to provide more in-depth information. Usually, no severe problems are discovered, but stress factors are often identified.

After evaluating the results of the headache history, physical examination, neurological and psychological examination, your doctor should be able to determine what type of headache you have, whether or not a serious problem is present and if additional tests are needed. Often, no additional blood tests or scans are needed.

How are tension-type headaches treated?

Tension-type headaches are treated using several drug and non-drug strategies. Among the non-drug strategies are lifestyle changes (sleep, dietary changes), physical therapy, stress management/relaxation training, and counseling.

Stress Management, Relaxation Training, Counseling. Both episodic and chronic tension headaches can be improved using stress management and relaxation training. This is an essential part of managing these types of headaches.

Recognizing and treating the underlying stress and tension that is causing the headaches is very helpful. Often, however, patients forget what stressful events initiated their headaches. Counseling helps patients identify their headache triggers and learn useful coping methods.

Relaxation techniques include deep breathing exercises, progressive muscle relaxation, mental imagery relaxation or relaxation to music. Ask your doctor for more information about these techniques.

Biofeedback is another method of learning how to manage stress. During biofeedback, a series of sensors are connected to your body. The sensors detect changes in physical functions, such as muscle tension, blood pressure, heart rate or skin temperature, and provide immediate feedback through a tone or display on a computer screen. Biofeedback helps you recognize that your body is tense, identify the things that make it tense, and learn ways to reduce the tension. Biofeedback usually requires several sessions with a skilled biofeedback therapist.

If you miss more than 5 days of school per term, your counselor will need to work with you and your parents to develop a plan so that you can make up missed school work and ensure a smooth transition back to school. Continued excessive school absence is a significant impediment to recovery.

Medications. For occasional symptomatic relief of infrequent tension headaches, over-the-counter (nonprescription) medications are recommended. Ask the advice of your doctor or pharmacist about the use of acetaminophen (Tylenol®), ibuprofen (Advil® or Motrin®) or naproxen sodium (Aleve®). The use of aspirin in children under age 14 is not recommended. Also, avoid compounds that contain caffeine. Do not use these products more than 2 days a week.

For relief of chronic tension headaches, daily preventive medications may be prescribed. These medications -- which are aimed at reducing both the frequency and severity of the headaches -- may include antidepressants, such as amitriptyline hydrochloride (Elavil®); topiramate (Topamax®), and cyproheptadine (Periactin®). These medications are not habit-forming.

Benzodiazepines, butalbital combinations and narcotics (Codeine) should be avoided because these medications could become habit-forming or addictive.

Be sure to take medications only as prescribed by your doctor. Also, inform your doctor of any over-the-counter medications you may be taking. Read the ingredient label of all nonprescription drugs to make sure they do not contain the same ingredients as other over-the-counter or prescription drugs you are taking. For example, Excedrin® contains acetaminophen, aspirin, and caffeine -- ingredients often found in other headache-relieving products. Overuse of these medications or the daily use of pain-relieving medications can cause analgesic rebound headaches -- a condition described below.

Medication Overuse can Increase Headaches. An extremely important factor contributing to the development of chronic daily headaches is the overuse of pain medications. Medication overuse can occur in any type of headache patient.

Medications associated with analgesic rebound headaches include acetaminophen, ibuprofen, NSAIDs, triptans, ergotamine preparations, butalbital combination analgesics, opiates and caffeine-containing combination analgesics. Effective treatment of headaches associated with medication overuse requires withdrawal from the medications causing the rebound headaches. Rebound headaches might not go away for weeks after the medications are discontinued.

Treating Tension Headaches without Medications. Although medications are helpful, it is important to learn other headache treatment methods. Here are some relaxation strategies:

  • Apply an ice pack to the painful area of your head. Firmly position it on your forehead, temples, or the back of your neck (for example, first place a thin cloth on your forehead, followed by the ice pack, then finally secure it in place with a headband).
  • Take a warm bath or shower; take a nap; or take a walk.
  • Ask someone to rub your neck and back, or treat yourself to a massage.
  • Apply gentle, steady rotating pressure to the painful area of your head with your index finger and/or thumb. Maintain pressure for 7 to 15 seconds, then release. Repeat as needed.
  • Rest, sit or lie quietly in a cool, low-lit room. Close your eyes and try to release the tension in your back, neck and shoulders.
  • For patients who have excessive muscle contractions in the neck, physical therapy exercises performed daily are often helpful.

If your headaches are not lessening/improving, contact your doctor.

How can I help reduce or prevent headaches?

  • Follow your treatment plan. Avoid taking medications that have not been ordered by your physician. Do not overuse over-the-counter medications.
  • Reduce emotional stress. Take time to relax and take time away from stressful situations. Learn relaxation skills, such as deep breathing and progressive muscle relaxation.
  • Reduce physical stress. Proper rest and sleep will allow you to deeply relax so you can face the stressors of the new day. When sitting for prolonged periods, get up and stretch periodically. Relax your jaw, neck, and shoulders.
  • Exercise regularly. Get at least 30 minutes of exercise three times a week.
  • Talk to a friend, family member, religious professional or health care professional if your problems are getting to you.

What types of headache management programs are available to patients?

There are several, including:

Clinical Trials. Some children and adolescents with migraines don’t experience headache relief despite trying many of the currently available medications. If this is the case for your child, ask your doctor about possible participation in a clinical trial. Clinical trials provide access to drugs not yet approved by the FDA. Such drugs are not available through "regular" doctors’ offices; they are only available through doctors and health care organizations that have agreed to participate in the clinical trials. Your doctor will help determine if your child is an appropriate candidate for this type of research study.

Rehabilitation Program. Some hospitals and/or other health care facilities offer inpatient program for children and adolescents; ask your doctor if their facility offers such programs. Patients typically accepted into these programs are those who are missing school, overusing medications, and whose headache pain is controlling their lives.

Infusion Suite. When headaches last longer than 24 hours and other medications have been unsuccessful in managing the attacks, medication administered in an "infusion suite" can be considered. An infusion suite is a designated set of rooms at a hospital or clinic that are monitored by a nurse and where intravenous drugs are administered. The intravenous drugs are usually able to end the migraine attack. Patients’ length of stay at the infusion suite can range from a several hours to all day.

Headache ‘Checklist’ of Management Suggestions

1) Educate yourself and your family. Read about your type of headache and its treatment.

2) Maintain a headache diary.

3) Ask your doctor for written instructions about what to do when you have a headache.

4) Limit your use of over-the-counter (nonprescription) medications to no more than two days per week. Excessive use can actually increase headaches.

5) Follow a regular schedule:

  • Don’t skip meals, especially breakfast
  • Get 8 hours of sleep nightly
  • Exercise 30 minutes/day
  • Drink 6 to 8 glasses of water/day
  • Learn to identify and avoid headache "triggers." Common triggers include caffeinated foods and beverages (chocolate, teas, colas, coffee), nitrates (luncheon meats, sausage/hot dogs, pepperoni), tyramine (aged cheeses, pizza), Doritos®, Ramen® noodles, other "junk" foods, and Oriental foods containing MSG
  • Minimize stress and other headache triggers

6) Daily school attendance IS A MUST!

7) Initiate non-drug measures at the earliest onset of your headache:

  • Seek rest in a cool, dark, quiet, comfortable location
  • Use relaxation strategies and other methods to reduce stress
  • Apply a cold compress

8) Don’t wait!! Take the maximum allowable dosage of recommended medication(s) at the first sign of a severe headache.

9) Take prescribed medication regularly, as directed, and maintain regular follow-up visits.

10) Call your doctor when problems arise.

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 8/1/2009...#11203