Tension-type headaches are the most common type of headache, accounting for about half of all headaches. The pain is usually mild-to-moderate in intensity, with a steady pressing or tightening quality (like a vise being squeezed around the head). The headache is not accompanied by nausea or vomiting, and the pain is not increased by routine physical activity such as walking or climbing stairs. A tension-type headache attack can last anywhere from 30 minutes to an entire week.
Who Gets Tension-Type Headaches?
Women are more likely to get tension-type headaches than men. Nearly everyone will have at least one tension-type headache at some point in their lives. Many people who have migraine headaches also have tension-type headaches.
What Is The Difference Between Tension-Type Headaches and Migraine Headaches?
Migraines and tension headaches have some similar characteristics, but also some important differences:
Migraine pain is usually throbbing and while tension-type headache pain is usually a steady ache
Migraine pain may affect only one side of the head while tension-type headache pain typically affects both sides of the head
Migraine pain, but not tension-type pain, worsens with head movement
Migraine headaches, but not tension-type headaches, may be accompanied by nausea or vomiting, sensitivity to both light and sound, or aura
Treatment
Treatment of tension-type headache focuses on relieving pain when attacks occur, and preventing recurrence of attacks. Most tension-type headache attacks respond to simple over-the-counter pain relievers such as aspirin, ibuprofen (Advil), or naproxen (Aleve).
Patients who have two or more tension-type headache attacks each month should talk to their doctors about preventive therapy. This may include a tricyclic antidepressant, such as amitriptyline (Elavil), combined with behavioral therapies. Behavioral treatment approaches include relaxation therapy, biofeedback, stress management, and cognitive-behavioral therapy.
Introduction
Most people are familiar with headaches, the all too common affliction marked by throbbing, piercing, or vise-like pain around much or a part of the head. There are many different kinds of headaches, and they range from being an infrequent annoyance to a persistent, severe, and disabling medical condition.
The brain itself is insensitive to pain, so that is not what hurts when a headache arises. The pain, instead, occurs in the following locations:
The tissues covering the brain
The attaching structures at the base of the brain
Muscles and blood vessels around the scalp, face, and neck
Doctors categorize headaches as either primary or secondary, which helps to distinguish the many different kinds of headaches and to determine appropriate treatments for each.
Primary Headaches. A headache is considered primary when a disease or other medical condition does not cause it. Most primary headaches fall into three main types: Tension-type, migraine, and cluster headaches.
Tension headache is the most common primary headache.
Neurovascular headaches are the second most frequently occurring primary headaches and include migraines (the more common) and cluster headaches. Such headaches are caused by an interaction between blood vessel and nerve abnormalities.
Tension-Type Headaches
General Description. Tension-type headaches, also called muscle contraction headaches or simply tension headaches, are the most common of all headaches. Tension-type headaches tend to have the following characteristics:
General Description. Tension-type headaches, also called muscle contraction headaches or simply tension headaches, are the most common of all headaches. Tension-type headaches tend to have the following characteristics:
The pain is commonly described as a tight feeling, as if the head were in a vise. It usually occurs on both sides of the head and is often experienced in the forehead, in the back of the head and neck, or in both regions. Soreness in the shoulders or neck is common.
The pain is of mild-to-moderate intensity and is steady, not throbbing or pulsating
The headache is not accompanied by nausea or vomiting
The pain is not worsened by routine physical activity (climbing stairs, walking)
Some patients may have either sensitivity to light or sensitivity to noise, but not both
Types of Tension Headache. In 2004, the International Headache Society updated its original 1988 classification criteria. Tension-type headaches are now divided into the following four classifications:
Frequent episodic tension-type headache. Headaches occur at least once but not more than 15 days per month for at least 3 months (a minimum of 12 days but not more than 180 days per year). Headaches last from at least 30 minutes to 7 days.
Infrequent episodic tension-type headache. At least 10 episodes of headache that occur less than 1 day per month (12 days per year). Because these headaches occur infrequently, they do not impact a patient's quality of life as severely as frequent episodic headaches and may not require attention from a medical professional.
Chronic tension-type headache. Headaches occur at least 15 days per month for at least 3 months (180 days per year). The headache persists for hours at a time and may be continuous.
Probable tension-type headache. Probable tension headaches may be classified as probable frequent episodic, probable infrequent episodic, or probable chronic. They have most, but not all, of the symptoms of tension-type headaches and are not attributed to migraine without aura or other neurological disorders. Probable chronic tension-type headache may be related to medication overuse.
Prognosis
Both episodic tension-type headache and chronic daily headache affect quality of life. Tension-type headache episodes are rarely disabling, however, and rarely require emergency treatment. If they do, usually there is a migraine component occurring with the tension-type headache.
Nevertheless, although they are not medically dangerous and occur relatively rarely, chronic tension headaches have a negative impact on quality of life, families, and work productivity. Several studies have reported lower quality of life with any chronic daily headache compared to those no headaches or only episodic ones. Many people with chronic tension-type headaches also suffer from anxiety and depression.
Tension-type headaches can, in most cases, be treated and prevented. Episodes of these headaches can also resolve over time. In one study, nearly half of patients with frequent or chronic tension-type headache were not experiencing headaches when examined 3 years later. Patients who have both tension-type and migraine headaches may face steeper challenges in recovery.
Causes
The causes of tension-type headache are still uncertain. Although tension-type headaches were once thought to be primarily due to muscle contractions, this theory has largely been discounted. Instead, researchers think that tension-type headaches occur due to an interaction of different factors that involve pain sensitivity and perception, as well as the role of brain chemicals (neurotransmitters). Genetic factors are likely be involved in chronic tension-type headache, whereas environmental factors (physical and psychological stress) may play a role in the physiologic processes involved with episodic tension-type headache.
Pain Sensitivity and Perception
Research indicates that patients rceptiowith tension-type headache may have abnormalities in the central nervous system, (which includes the nerves in the brain and spine), that increase their sensitivity to pain.
Tension-type headaches may also be linked to myofascial trigger points in the neck and shoulder muscles. Myofascial pain involves the fascia (connective tissue) and muscles. Trigger points are knots in the muscle tissue that can cause tightness, weakness, and intense pain in various areas of the body. (For example, a trigger point in the shoulder may result in headache.) Because fibromyalgia is also characterized by myofascial pain, researchers are exploring whether there may be an association between this condition and tension-type headache.
Tension-type headaches may also be linked to myofascial trigger points in the neck and shoulder muscles. Myofascial pain involves the fascia (connective tissue) and muscles. Trigger points are knots in the muscle tissue that can cause tightness, weakness, and intense pain in various areas of the body. (For example, a trigger point in the shoulder may result in headache.) Because fibromyalgia is also characterized by myofascial pain, researchers are exploring whether there may be an association between this condition and tension-type headache.
Triggers for Tension-Type Headache
In addition to stress, many different factors can trigger or aggravate tension-type headaches:
Medication and Substance Overuse. About a third of persistent headaches -- whether chronic migraine or tension-type -- are medication-overuse headaches. These are the result of a rebound effect caused by the regular overuse of headache medications. Nearly any headache medication can produce this effect. Headaches can also occur after withdrawing from caffeine, nicotine, or alcohol.
Poor Posture and Work Conditions. Working or sleeping in an awkward position can contribute to posture problems (especially those that affect muscles in neck and shoulders) that trigger headaches. Eyestrain caused by overwork can also play a role.
Fatigue. Lack of sleep and tiredness from overwork are also headache triggers.
Foods and Beverages. Rapid consumption of ice cream or other very cold foods or beverages is the most common trigger of sudden headache pain, which may be prevented by warming the food or drink for a few seconds in the front of the mouth before swallowing. Not eating on time is also a trigger for headache.
Physical Activity. Intense physical exertion (including athletics or sexual activity) as well as lack of physical activity can trigger headaches. However, tension-type headache pain is not worsened by routine physical activity.
Dental Problems. Jaw clenching or teeth grinding, especially during sleep, are signs of temporomandibular joint dysfunction (TMJ, also known as TMD). TMJ pain can occur in the ear, cheek, temples, neck, or shoulders. This condition often coexists with chronic tension headache. Some patients with TMJ may see improvement in tension-type headaches from procedures or exercises therapies that specifically address the dental condition.
In addition to stress, many different factors can trigger or aggravate tension-type headaches:
Medication and Substance Overuse. About a third of persistent headaches -- whether chronic migraine or tension-type -- are medication-overuse headaches. These are the result of a rebound effect caused by the regular overuse of headache medications. Nearly any headache medication can produce this effect. Headaches can also occur after withdrawing from caffeine, nicotine, or alcohol.
Poor Posture and Work Conditions. Working or sleeping in an awkward position can contribute to posture problems (especially those that affect muscles in neck and shoulders) that trigger headaches. Eyestrain caused by overwork can also play a role.
Fatigue. Lack of sleep and tiredness from overwork are also headache triggers.
Foods and Beverages. Rapid consumption of ice cream or other very cold foods or beverages is the most common trigger of sudden headache pain, which may be prevented by warming the food or drink for a few seconds in the front of the mouth before swallowing. Not eating on time is also a trigger for headache.
Physical Activity. Intense physical exertion (including athletics or sexual activity) as well as lack of physical activity can trigger headaches. However, tension-type headache pain is not worsened by routine physical activity.
Dental Problems. Jaw clenching or teeth grinding, especially during sleep, are signs of temporomandibular joint dysfunction (TMJ, also known as TMD). TMJ pain can occur in the ear, cheek, temples, neck, or shoulders. This condition often coexists with chronic tension headache. Some patients with TMJ may see improvement in tension-type headaches from procedures or exercises therapies that specifically address the dental condition.
Causes of Secondary Headaches
About 90% of people seeking help for headaches have a primary headache. The rest are secondary headaches, caused by an underlying disorder that produces headache as a symptom. More than 300 conditions can cause headaches. These can range from sinus conditions to brain tumor. While fear of brain tumor is common among people with headaches, headache is almost never the first or only sign of a tumor. Changes in personality and mental functioning, vomiting, seizures, and other symptoms are more likely to appear first.
About 90% of people seeking help for headaches have a primary headache. The rest are secondary headaches, caused by an underlying disorder that produces headache as a symptom. More than 300 conditions can cause headaches. These can range from sinus conditions to brain tumor. While fear of brain tumor is common among people with headaches, headache is almost never the first or only sign of a tumor. Changes in personality and mental functioning, vomiting, seizures, and other symptoms are more likely to appear first.
Risk Factors
Tension-type headaches are the most common headaches, accounting for nearly half of all headaches. According to one study, nearly 40% of Americans have at least one episode of tension headache during the course of a year. Tension-type headaches are more common among women than men. Some reports estimate that over 85% of women and about 63% of men will have a tension-type headache at some point during a year. Nearly everyone has at least one tension-type headache during their lifetime.
Episodic tension-type headaches are more common than chronic tension-type headaches. Surveys indicate that about 3% of the general population has chronic tension-type headache.
Tension-type headaches are most likely to occur among people in their 40s. The prevalence of tension-type headaches declines as people become older.
Headaches in Children
Headaches are rare before age 4 but increase in prevalence throughout childhood, reaching a peak around age 13. In one large study, about 7% of 7-year olds and 15% of 11-year olds had headaches. Ten percent of these childhood headaches were recurrent. In many of these patients, chronic headaches persist into adulthood. In addition, as adults these patients have a tendency to develop multiple physical or psychiatric complaints, such as back pain, muscle aches, digestive complaints, and depression.
Studies have found that only a minority of chronic childhood headaches are due to physical conditions, such as head injuries or medical problems. Many children with tension-type headache episodes also suffer from some form of emotional disorder.
Psychosocial factors associated with childhood tension-type headaches include:
Sleep problems. Many children who experience chronic daily headaches suffer from sleep disturbances, especially difficulty falling asleep.
Moderate or severe depression.
Emotional rigidity in a child and more repressed anger than their peers.
Family stress. This includes maternal illness or separation, family bereavement, relationship problems, mental illness in a family member, and other stressful family events.
Problems at school. According to a National Headache Foundation survey, nearly 30% of children miss school because of headaches. For many children, the start of the school season can be a particularly stressful time.
The National Headache Foundation recommends these tips for parents:
Keep a diary of childs headaches noting time of onset, length and intensity of attack, location of pain, and food triggers.
Make sure child gets plenty of sleep at regular times.
Avoid changes in childs eating routing (hunger and eating at irregular times can trigger headaches).
Discuss any headache concerns with childs doctor.
Diagnosis
Diagnosing the cause of persistent daily headache is difficult, even for expert doctors. Studies report that people who visit the emergency room with disabling headache are often misdiagnosed as tension-type headaches instead of migraines. It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.
Extensive testing may be advised for anyone with a chronic, daily headache. Tracking times of medications, withdrawal, and headache, using the headache diary, is usually very helpful in diagnosis.
According to the International Headache Society, a diagnosis of tension-type headache is suggested by the following symptoms:
Pressing or tightening (but non-pulsating) feeling
Mild-to-moderate pain on both sides of the head
Not aggravated by routine physical activity (walking, climbing stairs, etc.)
In episodic tension-type headaches:
No nausea or vomiting
Photophobia (intolerance of light) or phonophobia (intolerance of sound) may be absent or one of these symptoms (but not both) may be present
In chronic tension-type headaches:
No vomiting
No moderate or severe nausea
No more than one of the following symptoms: Mild nausea, photophobia, or phonophobia
Some types of chronic tension headache may include tenderness upon manual palpitation of the head (pericranial tenderness).
Headaches are rare before age 4 but increase in prevalence throughout childhood, reaching a peak around age 13. In one large study, about 7% of 7-year olds and 15% of 11-year olds had headaches. Ten percent of these childhood headaches were recurrent. In many of these patients, chronic headaches persist into adulthood. In addition, as adults these patients have a tendency to develop multiple physical or psychiatric complaints, such as back pain, muscle aches, digestive complaints, and depression.
Studies have found that only a minority of chronic childhood headaches are due to physical conditions, such as head injuries or medical problems. Many children with tension-type headache episodes also suffer from some form of emotional disorder.
Psychosocial factors associated with childhood tension-type headaches include:
Sleep problems. Many children who experience chronic daily headaches suffer from sleep disturbances, especially difficulty falling asleep.
Moderate or severe depression.
Emotional rigidity in a child and more repressed anger than their peers.
Family stress. This includes maternal illness or separation, family bereavement, relationship problems, mental illness in a family member, and other stressful family events.
Problems at school. According to a National Headache Foundation survey, nearly 30% of children miss school because of headaches. For many children, the start of the school season can be a particularly stressful time.
The National Headache Foundation recommends these tips for parents:
Keep a diary of childs headaches noting time of onset, length and intensity of attack, location of pain, and food triggers.
Make sure child gets plenty of sleep at regular times.
Avoid changes in childs eating routing (hunger and eating at irregular times can trigger headaches).
Discuss any headache concerns with childs doctor.
Diagnosis
Diagnosing the cause of persistent daily headache is difficult, even for expert doctors. Studies report that people who visit the emergency room with disabling headache are often misdiagnosed as tension-type headaches instead of migraines. It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.
Extensive testing may be advised for anyone with a chronic, daily headache. Tracking times of medications, withdrawal, and headache, using the headache diary, is usually very helpful in diagnosis.
According to the International Headache Society, a diagnosis of tension-type headache is suggested by the following symptoms:
Pressing or tightening (but non-pulsating) feeling
Mild-to-moderate pain on both sides of the head
Not aggravated by routine physical activity (walking, climbing stairs, etc.)
In episodic tension-type headaches:
No nausea or vomiting
Photophobia (intolerance of light) or phonophobia (intolerance of sound) may be absent or one of these symptoms (but not both) may be present
In chronic tension-type headaches:
No vomiting
No moderate or severe nausea
No more than one of the following symptoms: Mild nausea, photophobia, or phonophobia
Some types of chronic tension headache may include tenderness upon manual palpitation of the head (pericranial tenderness).
Differentiating Medication-Overuse (Rebound) Headache from Tension-Type Headache.
About a third of persistent headaches are the result of the rebound effect caused by the overuse of headache medications (formerly called rebound headaches).
Usually in such cases, medications have been taken on an ongoing basis for more than 3 days each week. If patients stop taking these drugs, the headaches come back. The patient then starts taking the drugs again. Eventually the headache simply persists and medications are no longer effective. Even after successful medication withdrawal, relapse is common, particularly with drugs that contain caffeine, so doctors should check for this type of headache even in patients who have previously been treated.
Medications implicated in medication-overuse headache include barbiturates, sedatives, narcotics, and migraine medications, particularly those that also contain caffeine. (Heavy caffeine use can also cause this condition.) Simple painkillers, such as aspirin or ibuprofen, are less likely causes of medication-overuse headaches.
About a third of persistent headaches are the result of the rebound effect caused by the overuse of headache medications (formerly called rebound headaches).
Usually in such cases, medications have been taken on an ongoing basis for more than 3 days each week. If patients stop taking these drugs, the headaches come back. The patient then starts taking the drugs again. Eventually the headache simply persists and medications are no longer effective. Even after successful medication withdrawal, relapse is common, particularly with drugs that contain caffeine, so doctors should check for this type of headache even in patients who have previously been treated.
Medications implicated in medication-overuse headache include barbiturates, sedatives, narcotics, and migraine medications, particularly those that also contain caffeine. (Heavy caffeine use can also cause this condition.) Simple painkillers, such as aspirin or ibuprofen, are less likely causes of medication-overuse headaches.
Differentiating Tension Headaches from Chronic Migraines
Migraines and tension headaches have some similar characteristics, but also some important differences:
Migraine pain is usually throbbing, while tension-type headache pain is usually a steady ache
Migraine pain may affect only one side of the head, while tension-type headache pain typically affects both sides of the head
Migraine pain, but not tension-type pain, worsens with head movement
Migraine headaches, but not tension-type headaches, may be accompanied by nausea or vomiting, sensitivity to light and sound, or aura
Treatment
Management of tension-type headaches focuses in the short term on treating acute attacks, and in the long term on preventing recurrent episodes of headache. In general, short-term treatment of tension-type headache involves drugs (mainly pain relievers) while long-term preventive measures include both drug and non-drug approaches. With medications, relaxation training, lifestyle changes, and other therapies, nearly all patients can be helped.
Treatment for Acute Attacks of Tension-Type Headaches
Fortunately, most acute tension-type headaches get better without any treatment, and simple over-the-counter pain relievers such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) can treat mild symptoms. Aspirin or ibuprofen (Motrin) are usually the first choices, followed by naproxen (Aleve). Some patients may also find helpful medications that combine a pain reliever with caffeine.
Massage therapy may also be useful for treating acute episodes of tension-type headache.
Treatment and Prevention of Frequent and Chronic Tension-Type Headaches
Daily preventive treatment is recommended for patients who experience at least two headache attacks a month. Preventive treatments do not work as well when patients are overusing pain-relief medication, so doctors may recommend stopping and withdrawing from analgesics before beginning preventive approaches.
The goals of preventive treatment are to reduce the frequency and severity of headache attacks, and to improve the response to pain medication.
Preventive treatment for tension-type headache includes:
Drug treatment with an antidepressant, usually the tricyclic antidepressant amitriptyline
Relaxation training and biofeedback
Stress management through cognitive-behavioral therapy
Studies indicate that best results are achieved when drug treatment is combined with relaxation or stress-management training.
Withdrawing from Medications After Medication-Overuse Headaches
If headaches develop because of medication overuse, the patient cannot recover without stopping the drugs. (If caffeine is the culprit, a person may only need to reduce coffee or tea drinking to a reasonable level, not necessarily stop drinking it altogether.) The patient usually has the option of stopping abruptly or gradually and should expect the following course:
Most headache drugs can be stopped abruptly, but the patient should be sure to check with the doctor before withdrawal. Certain non-headache medications, such as anti-anxiety drugs or beta-blockers, require gradual withdrawal under medical supervision.
If the patient chooses to taper off standard headache medications, withdrawal should be completed within 3 days or less. Otherwise the patient may become discouraged.
No matter which approach is used for stopping medication, the patient must expect a period of worsening headache for a few days afterward. Alternative pain relievers may be administered during the first days to help withdrawal.
Most people feel better within 2 weeks, although headache symptoms can persist up to 16 weeks (and in rare cases even longer).
Medications
The standard treatments for tension-type headaches are non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, and tricyclic antidepressants, usually amitriptyline (Elavil).
Due to the risks of overuse and dependence, opoids, opoid-like drugs, and sedative hypnotics are not recommended for treatment of tension-type headaches.
Pain Relievers
Several pain relievers are helpful for mild-to-moderate headaches. They should not be used to prevent headaches, however.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). NSAIDs are common pain relievers that block prostaglandins, substances that dilate blood vessels and cause inflammation and pain. NSAIDs are usually the first drugs tried for almost any kind of headache. There are dozens of NSAIDs. Common NSAIDs include:
Over-the-counter NSAIDs. Aspirin, ibuprofen (Motrin), naproxen (Aleve), ketoprofen (Actron, Orudis KT)
Prescription NSAIDs. Diclofenac (Voltaren, Cataflam, Solaraze), tolmetin (Tolectin), indomethacin (Indocin)
Patients should be aware that long-term use of high-dose NSAIDs may increase the risk for stomach bleeding and heart problems, including heart attack and stroke.
Acetaminophen. Acetaminophen (Tylenol) is a good alternative to NSAIDs when stomach distress, ulcers, or allergic reactions prohibit their use. A high dose (1,000 mg), however, is needed for this drug to be effective for headaches. Midrin (a combination of a drug that narrows blood vessels, a mild sedative, and acetaminophen) may be very helpful for tension-type headaches.
Acetaminophen does have some adverse effects, however, and the daily dose should not exceed 4 grams (4,000 mg). Patients who take high doses of this drug for long periods are at risk for liver damage, particularly if they drink alcohol and do not eat regularly. Acetaminophen may cause serious kidney problems in people who already have kidney disease. It also may interact with certain medications, including the blood thinner warfarin.
Tricyclics and Other Antidepressants
Antidepressants known as tricyclics are most often used for prevention of severe chronic tension-type headaches. Newer selective serotonin-reuptake inhibitors (SSRIs) antidepressants are also sometimes used in milder cases.
Tricyclic Antidepressants. Tricyclics are not only useful for depression but also appear to help relieve muscle pain and improve sleep. They are sometimes classified in one of two categories: tertiary or secondary amines:
Tertiary amines include amitriptyline (Elavil) and imipramine (Tofranil). Amitriptyline is the tricyclic most commonly used for tension-type headache. These drugs tend to cause more drowsiness than secondary amines, which may be helpful for patients with sleep problems.)
Secondary amines include desipramine (Norpramin) and nortriptyline (Pamelor, Aventyl). Secondary amines may have fewer side effects than tertiary amines, but they are just as toxic in high amounts.
A tricyclic antidepressant is usually started at a lower dose and then slowly increased. A headache diary can help the patient and the doctor assess the effectiveness of the treatment. In general, patients should remain on preventive drug treatment for at least 6 months. After that time, the doctor will slowly reduce the dose while continuing to monitor the frequency of headache attacks.
Side effects are fairly common with these medications. Drowsiness is the most common, but may vary by specific drug. In addition, side effects most often reported include dry mouth, constipation, blurred vision, sexual dysfunction, weight gain, trouble urinating, heart rhythm problems, and dizziness. Blood pressure may also drop suddenly when sitting up or standing.
Tricyclics can have serious, although rare, side effects, including heart rhythm problems, which can be dangerous for some patients with certain heart diseases. These drugs can be fatal with overdose.
Other Antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) work by increasing levels of serotonin in the brain. SSRIs used for tension-type headache preventive treatment include paroxetine (Paxil) and citalopram (Celexa). Other antidepressants used for tension-type headache are mirtazapine (Remeron) and venlafaxine (Effexor), which target both serotonin and norepinephrine.
Although these antidepressants have fewer side effects than tricyclics, they do not appear to be as effective for preventive treatment of tension-type headaches.
Investigational Drugs
Tizanidine. Tizanidine (Zanaflex) is a muscle relaxant that is being studied as a possible preventive drug for chronic tension-type headaches. In one study, the combination of tazanidine and amitriptyline provided faster headache relief than amitriptyline alone. It is still not clear how useful this drug is for most patients.
Topiramate. In one study, the anticonvulsant medication topiramate (Topamax), which is used for migraine prevention, was also effective for patients with chronic tension-type headache. Large randomized controlled trials are needed to confirm this result. Other anti-seizure medications are also under investigation.
Botulinum Toxin. Botulinum toxin A (Botox) injections are now widely used to relax muscles and reduce skin wrinkles. Botox is also becoming popular as a treatment for chronic daily headaches, which include tension-type headache. However, at present there is little scientific evidence to support its use. Botox is not approved for headache treatment.
Nitric Oxide Synthase Inhibitors. Nitric oxide synthase inhibitors block nitric oxide, which may play a role in increasing nerve activity that leads to headache. Drugs are currently being investigated in clinical trials for migraine treatment, and may also be studied for tension-type headache.
Lifestyle Changes
Psychological and behavioral techniques, and lifestyle changes, can have a beneficial effect on tension-type headaches. These therapies can also enhance the effects of drug treatments. To date, relaxation training and biofeedback have the strongest evidence for improvement in tension-type headache outcomes.
Relaxation Training and Biofeedback
Relaxation training uses breathing exercises, guided imagery, and other techniques to help relax muscles and relieve stress. Biofeedback uses a device to record a patients bodily responses (heart rate, surface skin temperature, muscle tension). This information is then fed back to the patient through a sound or visual image. Through this feedback, patients learns to control their physical responses. In clinical studies, relaxation training and biofeedback, both alone and in combination, have led to improvements in tension-type headache.
Stress Management and Behavioral Training
Cognitive-behavioral therapy (CBT) teaches patients how to recognize and cope with stressors in their life. It can help patients understand how their thoughts and behavior patterns may affect their symptoms, and how to change the way the body responds to anticipated pain. CBT is often included in stress management techniques. Research indicates that CBT and stress management is most effective when combined with relaxation training or biofeedback.
Massage, Spinal Manipulation, and Physical Therapy
Massage can help relax tense muscles, and may be helpful during acute headache attacks, although there is little evidence for long-term benefits. Although some small studies have suggested that spinal manipulation by chiropractors or osteopaths may have some benefits for preventing tension-type headaches, there is insufficient evidence overall to confirm their effectiveness for tension-type headache pain reduction.
Evidence is stronger on the benefits of spinal manipulation for patients with headaches originating from nerve or muscular problems in the neck. Some researchers believe that tension-type headaches relieved by spinal manipulation are probably really caused by neck problems.
There has been little research evaluating the benefits of physical therapy for tension-type headache. Still, a physical therapist may be helpful in teaching specific exercises for strengthening and stretching muscles or improving posture. A physical therapist may also be able to advise on ergonomic changes to the patients workplace environment.
Acupuncture
An analysis of 26 trials of acupuncture suggested that it may have some benefit for tension headache, but the evidence to date is not completely convincing. Some studies comparing short-term acupuncture to sham (dummy) procedures report no benefits. A recent study suggested that acupuncture may help tension-type headache, but needling at non-acupuncture points worked just as well. This suggests a placebo effect may account for the headache relief experienced by acupuncture patients.
