Tension headache, as the name suggests, is a headache caused by stress or strain or tension that can be physical or mental. This type of headache is also referred to as a stress headache.
It may be caused by the tightening of the muscles around the head, scalp or neck. However, some experts no longer attribute this to be the cause.
In medical circles, it is referred to as tension-type headache, as classified by the International Headache Society in 1988.The symptoms are typical with mild to moderate pain being felt usually on both sides of the head.
Diagnosis is confirmed by the symptoms and some imagery tests to rule other causes of headache.
Treatment consists of several drug options given alone or in combination to get relief from the symptoms.

Types: Episodic and Chronic Tension Headaches

Tension headaches can be episodic or chronic. They are classified as chronic when they occur 15 times a month or more, for six months while episodic headaches occur less than 15 times a month.
Episodic tension-type headache is the most common type of headache. It is triggered by an isolated stressful condition while chronic tension headaches are due to everyday stress.
The International Headache Society has defined three categories based upon the frequency of the headaches and how persistent they are.
• Infrequent episodes of tension-type headache occur less than 12 times a year with each episode lasting from 30 minutes to 7 days.
• Frequent episodes of tension-type headache occur between 1 to 14 episodes per month on average with each episode lasting from 30 minutes to 7 days
• Chronic (persistent) tension-type headache occurs on an average of 15 times a month with the headache lasting continuously for hours.

Statistics

• Tension headaches are the most common types of primary headaches accounting for more than 90% of the headaches.
• They are twice more common in women.
• Chronic tension-type pain is seen in 3% of the population.
• These headaches can occur at any age but are more commonly seen in adults between the age of 20 to 50 years.
• About 70% of the men and 88% of the women develop this headache sometime during their lives.
• They are seen more in the highly educated class.

Causes and Trigger Factors

The exact cause of tension headache is not yet well understood. As mentioned above, it is believed to be caused by the tenseness of the scalp and neck muscles. Tension headaches can also coexist with migraine headaches. There is no hereditary cause as is seen with migraine.
Potential trigger factors include:
• Mental depression
• Stress
• Anxiety
• Sleep deprivation
• Head injury
• Bad posture
• Jaw clenching or teeth grinding, which causes a continuous contraction of the temporalis muscle (present over the temples)
• Alcohol
• Too much smoking
• Too much caffeine or its withdrawal
• Eyestrain
• Fatigue
• Hunger
Of these trigger factors, stress and hunger are the most common triggering factors accounting for half the cases.

Symptoms

The pain of tension headache is constant and generally diffuse and is not located at a particular part of the head. It is a dull type of pain of mild to moderate intensity and feels like a tight band (Pressing sensation) around the head.
It may last for a short time of 30 minutes or a few days. A typical tension headache lasts for 4 to 6 hours.
It is worst at the temples and back of the head and can spread to the shoulders. It usually occurs in the afternoon. Though the headache pain is always there, its severity can vary during the course of the day. Tenderness is present on your scalp, neck and shoulder muscles.
During the headache, there may be difficulty in falling asleep. There may be a loss of appetite. Usually, vomiting and nausea are not present, which are often seen with migraine. This headache usually may not make you stay absent from work or school like migraine does.

Diagnosis

Tension headache is diagnosed with the type of headache pain. It is diffuse, constant, of dull nature and mild to moderate in intensity.
Certain tests like CT scan or MRI may be necessary to rule out any secondary causes of headache. They are the same as described in tests and diagnosis of migraine.

Treatment of Tension Headache

When we think of treating a headache, we think of painkillers to stop the headache. But, pain killers may stop your headache temporarily and if you keep taking these headache pills often, you could land up with some other side effects of these drugs.
It is important to know that overuse or frequent use of such medicines can result in medication overuse headaches, which are more frequent and more severe. These are rebound headaches that keep coming back.
To avoid this problem do not use headache medication for more than nine days a month. It is necessary, therefore, to follow a pattern to deal with and can get rid of these headaches.
Medication is best when taken at the onset of the pain when the symptoms are just beginning to appear and not so severe.

Self-help for tension headache

• Learn to deal with stress. Meditation is ideal and will help you raise your stress threshold. Learn the proper art of meditation and do it every day throughout life.
• Avoid the trigger factors mentioned above.
• Maintain a headache diary, which will help your doctor diagnose your tension headache and will also help to identify the trigger factor/s, which set off your headache.

Pain relievers

There are several types of pain relievers, which your doctor may prescribe for your headache.
• Over the counter analgesics like aspirin and ibuprofen
• Acetaminophen or paracetamol (Tynelol) are not so effective and the resulting excessive use may lead to medication overuse headaches.
• Prescription drugs include indomethacin (Indocin), naproxen (Naprosyn) and ketorolac.

Drug combinations

There are combinations of analgesics with caffeine or sedatives and you should use them on medical advice only as they are habit-forming and can lead to medication overuse headaches.
Examples include
• Excedrin contains aspirin, acetaminophen and caffeine
• Analgesic and antihistamine combinations like Syndol and Percogesic
• Analgesic and barbiturate combinations like Fiorinal

Triptans

Triptans are effective in relieving the pain of both tension and migraine headaches. They are available as orals, injectables and nasal sprays. A more detailed note on triptans is available at this post, which describes the treatment of migraine.

Muscle relaxants

Muscle relaxants such as Tizanidine relieves the increased muscle tone and spasm, which causes the tension headache.

Narcotics

Narcotic pain relievers are rarely used due to their side effects and addiction problems.

Medication to Prevent Tension Headaches

Preventive medication is given
• To reduce the frequency and severity in case of chronic cases
• When pain relievers do not give relief or you cannot take them for some reason.
• Stress management does not work
• When the headache pain is disabling
• In case of medication overuse to reduce the pain.

Tricyclic antidepressants

Besides depression, antidepressants have other uses. They prevent headaches by stabilizing the levels of brain chemicals like serotonin, which gives relief from headaches.
Amitriptyline, nortriptyline (Pamelor) and doxepin are the most commonly used antidepressants to prevent tension headaches – both the episodic form and the chronic form. Side effects include dry mouth, weight gain, and drowsiness.
SSRIs produce fewer side effects but are not so effective.

Antiseizure drugs and muscle relaxants

Muscle relaxants such as tizanidine and anticonvulsant (antiseizure) drugs such as topiramate (Topamax) and gabapentin (Neurontin) are quite effective to help prevent tension headaches or at least reduce the frequency and severity.
To obtain better results from preventive medication try to keep the use of curative medication to the minimum. In addition, avoid using medication, which contains caffeine as this reduces the effect of preventive medicines.
It may take weeks or a couple of months for preventive therapy to show results. Be patient and persistent and stay in touch with your doctor.

Treatment with Alternative Medicine

Alternative medicine aims at reducing and managing stress.
• Gentle massaging of the head, neck, shoulder, and back helps to relieve the tension in the muscles of these areas and can give some relief from the headache pain.
• Acupuncture can give some temporary relief from a chronic tension headache.
• Slow deep breathing helps to relieve stress and helps to give relief.
• Biofeedback is a technique that provides information about the muscle tension, brain waves, skin temperature and such other signs with the help of small electrodes, which are attached to the skin.
• In cases where there is associated depression or anxiety, behavior therapy helps in relieving the mental state and headache pain.

Natural and Home Remedies

Natural and home remedies should be the first line of treatment for headaches because medicines though promptly effective do have their side effects, particularly of medication overuse headaches.
• Learn to manage stress effectively.
• Applying heat or ice packs to the site of pain will reduce the soreness of the tense muscles and give relief. Some may benefit from heat packs while some find relief from using cold packs.
• Bad posture is one of the reasons why you may get headache pain as it tenses up the head, neck and back muscles. Adopt the right posture while walking, standing, sitting and sleeping.
• Sleep well.
• Exercise regularly, particularly the neck and back if you are prone to a tension headache.

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