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Tension headaches: therapy, causes

by Josephine Andrews
Published: Last Updated on 301 views

Tension headache is the most common type of headache. More than every second adult in Germany suffers from it at least once a year Usually it is a dull, bilateral headache, accompanied by muscular tension in the neck area. Normal painkillers are suitable for treatment. If tension headaches occur several times a month, preventive therapy may be helpful. Here you can read everything you need to know about the disease.

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.


quick overview

  • Symptoms: bilateral, pressing and cramping pain in the head, pain does not worsen with physical activity, sometimes slight sensitivity to light and noise
  • Treatment: Over-the-counter painkillers for a short period of time, including flupirtine for children, rubbing diluted peppermint oil on the temples and neck, home remedies for mild symptoms (eg willow tea preparations)
  • Prevention: Endurance training such as jogging or training the shoulder and neck muscles, relaxation techniques, biofeedback, in the case of chronic headaches, for example the antidepressant amitriptyline, possibly the epilepsy drug topiramate or the muscle-relaxing drug tizanidine, combined with stress management therapy
  • Causes and risk factors: Possibly particularly pain-sensitive trigger points in the head, neck and shoulder muscles , possibly altered blood and nerve water, disturbed outflow of venous blood, triggered by stress, feverish infection, incorrect muscular strain, in the case of chronic suffering possibly genetic factors
  • Diagnosis: Recording of the medical history by the doctor, checking of special diagnostic criteria (duration, symptoms, exclusion of other diseases), neurological examination, blood pressure measurement, possibly blood or cerebrospinal fluid analysis, less often imaging procedures, recording of the brain waves (EEG)
  • Course and prognosis: Basically a good prognosis, since the disease often disappears by itself, in the minority of those affected it becomes chronic, but healing is also possible in the chronic form, and in women during pregnancy the symptoms often decrease

What is a tension headache?

Tension headache is a “primary” headache. This means that it is not due to a specific cause. A tension headache is therefore not caused by another illness such as a head injury, a metabolic disease or chronic medication. This pain has a specific cause and is therefore counted among the “secondary” headaches.

Sufferers describe the tension headache as a dull, oppressive pain (“vice feeling”). According to the German Society for Neurology, more than half of adults and about one fifth of children and adolescents suffer from tension headaches at least once a year. As a rule, it occurs for the first time between the ages of 20 and 40.

Episodic or chronic tension headache?

The International Headache Society (IHS) differentiates between episodic (occasional) and chronic tension-type headaches.

The episodic tension headacheis defined as the occurrence of tension headache within three months on at least one and a maximum of 14 days per month.

Episodic tension headaches are more common in women. The onset of the disease is often between the ages of 20 and 30, but children and older people are also affected.

Chronic tension headache pain

  • occur 15 days or more per month in a three month period or
  • more than 180 days per year on and on
  • they last for hours or never stop.

Transitions between both forms are possible, especially from episodic to chronic tension headaches. About 80 percent of patients with chronic symptoms previously suffered from an episodic tension headache. Chronic tension headaches are particularly common between the ages of 20 and 24 and after the age of 64. Women and men are affected about equally often.

What are the symptoms?

Tension headache duration varies from person to person and from pain attack to pain attack. The pain usually lasts for hours to several days. Typically, tension headaches, in contrast to migraines , occur on both sides and are felt by those affected to be oppressive and constricting, but not pulsating. Overall, these are mild to moderate headaches that are not aggravated by routine physical activity . Everyday tasks may be more difficult, but are usually feasible. Unlike migraines, nausea, vomiting and blurred vision are not typical symptoms of tension headaches. Affected people are sometimes more sensitive to light and noise. Neck or shoulder muscles are often tense with tension headaches.

Distinguishing between tension headaches and migraines at a glance

tension headache migraine
localization Both sides, affecting the whole head, as if clamped in a vise Usually on one side, often on the forehead, temples or behind the eyes
pain characteristic Boring, oppressive Pulsating, pounding
Phenomena during headache None, possibly moderate sensitivity to light and noise Aura: visual disturbances, speech disturbances, nausea and vomiting
Pain aggravated by physical activity no yes

How is tension headache treated?

Those affected take painkillers from the group of so-called non-steroidal anti-inflammatory drugs against tension headaches. These drugs prevent certain pain-causing substances from forming in the body. Active substances such as

Tension headaches can also be treated with combinations of ASA, paracetamol and caffeine . Studies have shown this combination to be more effective than the individual substances and than the combination of paracetamol and ASA without caffeine.

However, the drugs sometimes have undesirable side effects such as blood-thinning effects or stomach problems and sometimes even lead to headaches (pain-induced headaches) if used too frequently. For this reason, the recommendation is to take them as infrequently as possible and in the lowest dose that is still effective. This means that you can take it no more than three consecutive days and no more than ten days a month. In children, the pain-relieving drug flupirtine is also effective against tension headaches.

Therapy options also include preventive measures and diluted peppermint oil, which the person concerned applies to the temples and neck. The pain-relieving effect of peppermint oil in acute tension headaches has been proven in studies.

Preparations with willow tea or meadowsweet are sometimes used to relieve symptoms associated with milder tension headaches . These home remedies contain salicylates, which are converted into salicylic acid after absorption in the body . Salicylic acid has a mechanism of action similar to that of the synthetic drug acetylsalicylic acid.

Home remedies have their limits. If the symptoms persist, do not improve or even worsen, you should always consult a doctor.

Are there preventive measures?

Since the clinical picture recurs in many sufferers or even takes a chronic course in some cases, long-term preventive measures are essential for tension headaches. Those affected are recommended to regularly (two to three times a week) do endurance training such as jogging, swimming or cycling to combat recurring episodes and to train their shoulder and neck muscles in a targeted manner. There are other things you can do to prevent tension headaches.

Prevention through non-drug measures

Relaxation techniques and stress management training have a positive effect. Most of the time, these changes improve the tension-type headache, but a long-term cure is unlikely. Whether acupuncture treatment helps patients is controversial.

In addition to the options mentioned, so-called biofeedback is intended to reduce tension headaches. You learn to consciously influence your bodily functions. It is therefore particularly suitable for people who suffer from muscle tension in tension headaches. You learn to solve them yourself. The method has been shown to be very effective in some studies. Some health insurance companies therefore cover the costs of this treatment.

With biofeedback, a device measures certain physical parameters such as pulse, blood pressure, skin resistance, body temperature, heart rate and respiratory rate. The patient sees the results on a screen. He recognizes whether they deviate from the norm and through which thoughts, feelings or moods he influences them positively. The more often he trains, the better he perceives and controls his body.

Eventually, this succeeds even without direct feedback from the measuring device. In this way, people with tension headaches learn to reduce symptoms and, in the long term, the frequency of pain episodes.

Prevention with medication

Especially in the case of a chronic course of tension headaches, medication that is taken regularly sometimes improves the clinical picture. The antidepressant amitriptyline, which also works against pain, is mainly used. Alternatively, there are other active ingredients such as doxepin , imipramine or clomipramine. Since undesirable side effects sometimes occur with these preparations, the dosage is slowly increased. The effectiveness becomes apparent after four to eight weeks at the earliest.

According to a study, about half of patients with tension headaches benefit from this drug therapy. However, its effectiveness is disputed among experts.

If this therapy is not sufficiently effective, the doctor prescribes other groups of active ingredients, such as the epilepsy drug topiramate used to treat migraines, or the muscle-relaxing drug tizanidine. It also seems sensitive to combine the medication with stress management therapy.

What are the causes and risk factors?

Although tension headaches are the most common type of headache, the exact causes have not yet been fully elucidated. Doctors used to think that tension headaches were caused by tightening of the neck, neck and shoulder muscles. Hence the name “tension” headache. Although this tension is probably actually involved in the development of tension headaches, the exact mechanisms are still unclear.

Some researchers believe that certain trigger points in the muscles of the head, neck, and shoulders are particularly sensitive to pain in tension headache sufferers. Other scientists point out that in the case of tension headaches, blood and cerebrospinal fluid are altered or blood flow disorders in the veins may cause the disease.

The imaging methods of magnetic resonance imaging (MRI) showed that certain brain regions involved in pain processing are altered in tension headaches.

Although the exact processes that lead to the development of tension headaches are still unclear, there are some known risk factors : stress, feverish infections and improper muscular strain are common triggers. While genetic factors do not appear to be very relevant in episodic tension-type headaches, they do play a role in chronic tension-type headaches. If a family member suffers from the chronic form, the risk is about three times as high of also developing it.

In addition, women, people after a separation situation, overweight, diabetics and patients with joint wear and tear (arthrosis) have a higher risk of developing tension headaches.

What is striking about chronic tension headaches is the connection to psychological complaints: it occurs more frequently in patients with panic disorders, anxiety disorders, depressive symptoms or sleep disorders.

How is tension headache examined and diagnosed?

The right person to contact if you suspect a tension headache is a specialist in neurology. In the case of headaches, the conversation between the patient and the doctor to record the medical history (anamnesis) is particularly important. Based on the anamnesis, the doctor assesses which of the numerous causes are most likely to exist in your case. The doctor will first ask you to give him precise information about the tension headache. Possible questions are:

  • How severe is the headache (minor, tolerable, almost unbearable)?
  • Where exactly do you feel the headache (unilateral, bilateral, temples, back of the head, etc.)?
  • How does the headache feel (dull, nagging, aching or throbbing, pounding)?
  • Do other disorders occur before or during the headache, such as visual disturbances, speech disturbances, photophobia, nausea and vomiting?
  • Do the symptoms get worse with physical exertion?
  • Do the headaches come after a certain situation, or have you identified triggers for the headache yourself?

Since forms other than tension headaches are also caused by diseases or medication, the doctor tries to rule out these other causes. For example, he asks you the following questions:

  • Do you take any medicine? If yes, which?
  • how much do you sleep having trouble sleeping?
  • Have you hit or hurt your head lately?
  • Do you suffer from seizures?
  • Are you regularly sick (eg with morning sickness)?
  • Have you recently become very sensitive to light or do you have visual disturbances?

Diagnostic criteria for tension headache

According to the definition of the International Headache Society (IHS), tension-type headache is diagnosed when at least ten headaches have occurred that meet the following criteria:

  • Duration between 30 minutes and seven days
  • No nausea, no vomiting
  • Little or no concomitant sensitivity to light or noise
  • At least two of the following characteristics are present: occurs on both sides, aching/confusing/non-pulsating pain, mild to moderate pain intensity, not aggravated by routine physical activities
  • Not due to another disease

According to the IHS, dizziness is not a typical feature of tension headaches.

After the anamnesis, a detailed neurological examination is carried out. The doctor uses various tests to briefly check the function of the brain and spinal cord. If necessary, he will also test various reflexes, such as the pupillary reflex or the Achilles tendon reflex.

In addition to the neurological examination, the doctor feels the muscles in the head, neck and shoulders with his hands. If the muscles in these parts of the body are obviously tense, this may be an indication of a tension headache. The doctor also measures blood pressure, since high blood pressure can also be a cause of headaches. It may be useful to take a blood sample in order to discover general abnormalities (eg increased inflammation values).

If the doctor is not sure whether the symptoms are caused by a tension headache or a secondary headache, further examinations are necessary. These include, above all, methods with which the brain is represented visually. In addition, special examinations such as recording the brain waves (EEG) and analyzing the cerebrospinal fluid ( liquor ) are sometimes necessary.

Imaging methods: CT and MRI

If there is a suspicion that instead of a tension headache, a pathologically dilated blood vessel in the brain (aneurysm) or a brain tumor is responsible for the symptoms, an imaging procedure such as computed tomography (CT) or magnetic resonance imaging (MRI) is usually used. In order to show blood vessels better, the affected person is first injected with a certain contrast medium into a vein before his head is moved into the examination tube on a movable bed (CT angiography).

Electroencephalogram (EEG)

An electroencephalogram (EEG) is done to differentiate tension headaches from an undiagnosed seizure disorder, brain tumor, or other structural change in the brain. To do this, small metal electrodes are attached to the scalp, which are connected to a special measuring device with cables. The doctor uses it to measure the brain waves at rest, during sleep or under light stimuli. This procedure is neither painful nor harmful and is therefore particularly popular for examining children.

Cerebral fluid examination (liquor puncture)

In order to exclude a changed cerebral water pressure (CSF pressure) or meningitis, a cerebrospinal fluid puncture is sometimes necessary. The patient with the supposed tension headache usually takes a sedative or light sleeping medication. Children are usually given general anesthesia. Then the doctor first disinfects the lumbar region on the back and covers it with sterile towels. A local anesthetic is injected under the skin so that the patient does not feel any pain during the puncture.

The doctor then inserts a hollow needle into a liquor reservoir in the spinal canal, determines the liquor pressure and removes cerebrospinal fluid for a laboratory test. The spinal cord ends above the puncture site, which is why it is not injured during this examination. Most people find the examination uncomfortable but tolerable, especially since the cerebrospinal fluid puncture usually only takes a few minutes.

Course of the disease and prognosis

In general, the prognosis for tension headaches is good. It often goes away on its own.

In about three to twelve percent of those affected, however, the headache becomes chronic. This is often very stressful for those affected. Competent support in dealing with psychological problems may also be helpful here. However, this form also heals on its own in some patients. Symptoms often improve in women when they are pregnant. Only eight percent of those affected suffer from a chronic form of tension headache from the start.

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