RELATED STORIES • Common headache types • Headaches and hormones: What's the connection? • Headaches: Self-care measures for headache relief • Headaches: Reduce stress to prevent the pain PAIN MANAGEMENT Headache • Migraine headache • Tension headache • Cluster headache • Rebound headaches • Primary cough headaches • Ice cream headaches • Exercise headaches • External compression headaches • Spinal headaches • Thunderclap headaches • Sex headaches • Chronic daily headaches • Sinus headaches

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Although headache pain sometimes can be severe, in most cases it's not the result of an underlying disease. The vast majority of headaches are so-called primary headaches. These include migraine, cluster headache and tension headache.

A tension headache is the most common headache, and yet it's not well understood. A tension headache generally produces a diffuse, usually mild to moderate pain over your head. Many people liken the feeling to having a tight band around their head. A tension headache may also cause pain in the back of your neck at the base of your skull.

In many cases, there's no clear cause for a tension headache. Fortunately, effective treatments for tension headaches are available. Managing a tension headache is often a balance between fostering healthy habits, finding effective nondrug treatments and using medications appropriately. In addition, a number of preventive, self-care and alternative treatments may help you deal with headache pain.

A tension headache can last from 30 minutes to an entire week. You may experience them occasionally, or nearly all the time. If your headaches occur 15 or more days a month for several months, they're considered chronic. Unfortunately, chronic tension headaches may sometimes persist for years.

A tension headache may cause you to experience a dull, achy pain or sensation of tightness in your forehead or at the sides and back of your head. Many people liken the feeling to having a tight band of pressure encircling their heads. In its most extensive form, the pain feels like a hooded cape that drapes down over the shoulders. The headache is usually described as mild to moderately intense. The severity of the pain varies from one person to another, and from one headache to another in the same person. Most people report that the pain starts soon after waking in the morning or early in the day.

Some people with tension headache experience neck or jaw discomfort or a clicking sound when opening the jaw. There may also be:

• Tenderness on the scalp, neck and shoulder muscles
• Difficulty sleeping (insomnia)
• Fatigue
• Irritability
• Loss of appetite
• Difficulty concentrating

Unlike some forms of migraine, tension headache usually isn't associated with visual disturbances (blind spots or flashing lights), nausea, vomiting, abdominal pain, weakness or numbness on one side of the body, or slurred speech. While physical activity typically aggravates migraine pain, it doesn't make tension headache pain any worse. A few people with tension headache experience an increased sensitivity to light or sound, but this isn't a common symptom.

Experts continue to debate the causes and even the name of tension headaches. Over the years, as different theories emerged about the origins of this type of headache, it was known by names such as muscle contraction headache, psychogenic headache, depressive headache, essential headache and ordinary headache.

The exact cause or causes of tension headache are unknown. Until a few years ago, many researchers believed that the pain of tension headache stemmed from muscle contraction in the face, neck and scalp, perhaps as a result of heightened emotions, tension or stress. But many researchers have questioned this idea.

More recent research discredits this theory. Studies using a test called an electromyogram, which records the electric currents generated by muscle activity, haven't detected increased muscle tension in people diagnosed with tension headache. In addition, people with a migraine headache have as much if not more muscle tension than that of people with a tension headache.

As a result, The International Headache Society uses the term tension-type headache instead of tension headache, calling attention to the fact that muscle tension may not be the main cause of this kind of head pain.

Chemical changes
Researchers now believe that tension headache may result from changes among certain brain chemicals — serotonin, endorphins and numerous other chemicals — that help nerves communicate. These are similar to biochemical changes associated with migraine. Although it's not clear why the chemical levels fluctuate, the process is thought to activate pain pathways to the brain and to interfere with the brain's ability to suppress the pain. On one hand, tight muscles in the neck and scalp may contribute to a headache in someone with altered chemical levels. On the other hand, the tight muscles may be a result of these chemical changes.

Another chemical in the body that may play a role in tension headache is nitric oxide, which is involved in the transmission of nerve impulses. Overproduction of nitric oxide has been linked to chronic tension headache and migraine. And substances that block the production of nitric oxide have been shown to reduce the muscle tightness associated with tension headache.

Because both tension headache and migraine involve similar changes in brain chemicals, some researchers believe that the two types of headache are related. A majority of people diagnosed as having migraine also get an occasional tension headache, and a quarter of people diagnosed with tension headache get occasional migraine. Some experts speculate that migraine may develop from the regular occurrence of tension headache. The distinctive migraine features form as the pain becomes more severe. Other research suggests that mild migraine is in reality a type of tension headache.

Two classifications
Tension headache is classified into two forms: episodic and chronic. These forms distinguish between occasional headaches separated by varying lengths of time between attacks and frequent headaches that occur, in many cases, almost daily.

• Episodic. Episodic tension headache occurs on fewer than 15 days a month. These headaches are usually brief, lasting a few minutes to a few hours. In one survey of people with episodic tension headache, over 60 percent had scalp and neck muscle tenderness in addition to head pain. People with increasingly frequent attacks of the episodic form may be at higher risk of developing the chronic form of the headache over a period of years.
• Chronic. Chronic tension headache occurs on 15 days a month or more for at least three months. Compared with the episodic form, chronic tension headache is less common, but twice as many women as men have the chronic form. The duration and the severity of episodic and chronic tension headaches are similar, although for many people with the chronic form, pain is daily and almost continuous. Like the episodic form, chronic tension headache can be with or without scalp tenderness.

People whose parents, siblings or children have chronic tension headache are more likely to develop the chronic form. Although this suggests a genetic predisposition, it's unlikely that a single gene is responsible. More likely, multiple factors, including an inherited susceptibility, play a role.

People with chronic tension headache are more likely to experience anxiety or depression, compared with people who don't have headaches. Whether these mood disorders contribute to tension headaches or vice versa is uncertain. Many people who have tension headache say the pain often occurs during or after times of heightened stress and anxiety. If you do have a mood disorder, it's critical to treat this condition as well as your headache to achieve the best possible outcome. For example, if you have both depression and tension headache, treatment for your headaches may be less effective if the depression goes undiagnosed and untreated.

Controversy surrounds the issue of whether chronic tension headache is really a separate entity from chronic migraine. Doctors often have trouble distinguishing between the two types of headache. Both disorders are thought to stem from episodic headaches after pain pathways become sensitized, and both involve similar biochemical changes in the brain.

Triggers and aggravators
There are many possible triggers of tension headache. You may have no identifiable or consistent trigger, or have several obvious ones. Potential triggers include:

• Stress
• Depression and anxiety
• Lack of sleep or changes in sleep routine
• Skipping meals
• Poor posture
• Working in awkward positions or holding one position for a long time
• Lack of physical activity
• Occasionally, hormonal changes related to menstruation, pregnancy, menopause or hormone use
• Medications used for other conditions, such as depression or high blood pressure
• Overuse of headache medication

Stress is the most common trigger reported for tension headache. Among groups of people who may share similar kinds of stressful life events, the people with tension headache are more likely to perceive such events negatively and have less effective coping strategies.

Tension headache may be made worse by jaw pain from clenching or grinding teeth (bruxism) or by head trauma, such as a blow to the head or whiplash injury. People with stiff joints and muscles due to arthritis of the neck or inflammation of the shoulder joints may develop tension headache.

Headaches in children
Chronic tension headaches in children are similar to headaches in adults and are often caused by stress, anxiety or depression. Although adults may not always realize it, children can experience tremendous stress — ranging from peer pressure and unreasonable parental expectations to difficulty in school and physical or sexual abuse. And all children, even very young ones, can suffer from depression.

Tension headache probably accounts for a majority of all primary headaches. And it's more common in women than in men. Almost 90 percent of women and about 70 percent of men experience tension headaches during their lifetimes. Tension headache is most prevalent in people between the ages of 30 and 39. After age 39, prevalence declines. The majority of people who get migraine also get tension-type pain.

Pain is often one of your body's ways of signaling illness. But headache pain, even when it's severe, usually isn't the result of an underlying disease. Occasionally, however, headaches may indicate a serious medical condition, such as a brain tumor or rupture of a weakened blood vessel (aneurysm). Always be sure to tell your doctor about any headache that concerns you. Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

If tension headache disrupts your life, don't hesitate to talk to your doctor. The condition is a biological disorder that can be treated effectively. A comprehensive approach, involving both nonmedication and medication therapies, is successful for most people with tension headache who seek assistance.

In addition, see your doctor or go to the emergency room immediately if you have any of these warning signs and symptoms:

• Abrupt, severe headache, often like a thunderclap
• Headache with a fever, stiff neck, rash, mental confusion, seizures, double vision, weakness, numbness or speaking difficulties
• Headache after a head injury, especially if it gets worse
• Chronic, progressive headache that worsens after coughing, exertion, straining or a sudden movement
• Onset of new headache pain after age 40

Call your doctor if your child has head pain that's severe or that causes him or her to miss school or other activities. A child who's too young to tell you what's wrong may cry and hold his or her head to indicate severe pain.

If you're like most people, you probably don't go to your doctor with a headache. In many cases a couple of pain relievers, a few moments to relax and a good night's sleep are enough to give you relief.

But even when the pain is severe or disabling, you may hesitate to admit you're bothered by headaches. After all, the old notion that headaches are purely psychological is a difficult one to put to rest.

But headaches are now widely recognized as biological disorders. If you suffer from headaches, don't hesitate to seek help, especially if you're concerned about what's causing them.

If you have chronic or recurrent headaches, your doctor may try to pinpoint the type and cause of your headache using these approaches:

• Getting a description of your pain. Your doctor can learn a lot about your headaches from your description of the type of pain, including its severity, location, frequency and duration, and other symptoms you may have.
• Conducting tests. If you have unusual or complicated headaches, your doctor may order tests to rule out serious causes of head pain, such as a tumor or an aneurysm. Two common tests used to image your brain are computerized tomography (CT) and magnetic resonance imaging (MRI) scans. A CT scan is a diagnostic imaging procedure that uses a series of computer-directed X-rays to provide a comprehensive view of your brain. An MRI doesn't use X-rays. Instead, it combines magnetism, radio waves and computer technology to produce clear images of your brain.
• Asking you to keep a headache calendar. One of the most helpful things you can do is keep a headache calendar for at least two months. Each time you get a headache, jot down a description of the pain, including how severe it is, where it's located and how long it lasts. Also note any medications you take. A headache calendar can offer valuable clues that may help your doctor diagnose your particular kind of headache and discover possible headache triggers.

Because tension headache is so common, its impact on job productivity and overall quality of life is considerable. When your head is "gripped in a vise," as the pain is often described, you may feel unable to attend family and social activities. You might need to stay home from work, or if you do go to your job, you work at only a fraction of your normal efficiency.

Few people with tension headache seek medical attention. One reason is that tension headache usually is easy to treat with over-the-counter medications. Other reasons may be a fear of not being taken seriously by the doctor or the misperception that tension headache is purely psychological in nature, that admitting you have one means you're weak or neurotic.

While much remains unknown and even controversial about tension headache, the condition is widely recognized as a biologic disorder. And fortunately, while doctors may disagree about what causes this type of headache, they do know how to help you.

Medications
A variety of medications, both over-the-counter (OTC) and prescription, are available for treating tension headache. You may find fast, effective relief by taking pain relievers such as aspirin, ibuprofen (Advil, Motrin, others) or acetaminophen (Tylenol, others). These medications are inexpensive and readily available and don't require a prescription from your doctor. People with severe or chronic tension headache may require stronger painkillers or preventive medications to reduce the frequency and severity of head pain. Which drug works best varies from one person to another.

Whether you have episodic or chronic headaches, don't overuse OTC medications. Limit your use of painkillers to two days a week. Try to take the medications only when necessary, and use the smallest dose needed to relieve your pain. Overusing pain medications can cause rebound headaches or the development of chronic daily headache, triggering the very symptoms you're trying to stop. In addition, all medications used to treat headache have side effects, some of which may be serious. For prescription medications, of course, follow the recommended dosage and do not exceed it.

Acute therapy
Acute therapy aims to stop or reduce the pain of an existing headache attack. Many different medications are used for the acute treatment of tension headache:

• Analgesics. Analgesics are pain relievers. Acetaminophen (Tylenol, others) and a class of drugs known as nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in reducing headache pain. Side effects of acetaminophen are rare but if the drug is taken in large doses for long periods of time, it can cause serious liver damage. NSAIDs include the OTC drugs aspirin, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and ketoprofen (Orudis KT). Prescription NSAIDs include naproxen (Naprelan, Naprosyn), indomethacin (Indocin) and ketorolac tromethamine (Toradol). Side effects include nausea, diarrhea or constipation, stomach or abdominal pain, stomach bleeding, and ulcers. You can reduce or eliminate these symptoms by taking NSAIDs after meals or with milk.
• Combination medications. Aspirin or acetaminophen (or both of these analgesics) are often combined with caffeine or a sedative drug, such as butalbital, in a single medication. For example, Excedrin combines aspirin, acetaminophen and caffeine. Combination drugs such as this may be more effective than are pure analgesics for pain relief. Also, brand name drugs such as Amidrine, Midrin and Migrex are combinations that sometimes are used to treat tension headache. Although many combination drugs are available over the counter, analgesic-sedative combinations can be obtained only by prescription because they may be addictive and can lead to chronic daily headache. Don't use these drugs more than one day a week, and use them only with careful monitoring by your doctor.

• Other medications. For people who experience both migraine and episodic tension headache, a triptan can effectively relieve the pain of both headaches. Opiates, or narcotics, are rarely used because of their side effects and potential for dependency. These include codeine combined with acetaminophen (Tylenol With Codeine No. 3) and oxycodone (OxyContin, Roxicodone).

Medications don't cure headaches, and over time painkillers and other medications may lose their effectiveness. In addition, all medications have side effects. If you take medications regularly, including products you buy over-the-counter, discuss the risks and benefits with your doctor. Also, remember that pain medications aren't a substitute for recognizing and dealing with the stressors that may be causing your headaches.

Although medications can provide temporary relief, lifestyle changes are ultimately the best way to combat tension headaches. The following tips may help:

• Exercise regularly. Regular aerobic exercise, such as walking, swimming or biking, can help reduce the frequency and intensity of headaches. Exercise relieves stress, relaxes your muscles and increases the levels of one of your body's natural stress relievers, beta-Endorphin. Yoga, massage, stretching and posture classes also can help prevent tension headaches. If you already have a headache, exercise can help relieve the pain. In some cases, however, exercise may bring on a headache, so check with your doctor before starting any exercise program.
• Manage stress. In addition to regular exercise, techniques such as biofeedback training and relaxation therapy can help reduce stress. Biofeedback teaches you to control certain body responses that help reduce pain. During a biofeedback session, you're connected to devices that monitor and give you feedback on body functions such as muscle tension, heart rate and blood pressure. You then learn how to reduce muscle tension and slow your heart rate and breathing yourself. The goal of biofeedback is to help you enter a relaxed state so that you can better cope with your pain. Ask your doctor whether such a program might help you.

  Other relaxation techniques include deep breathing, yoga, meditation and progressive muscle relaxation, which is accomplished by tensing one muscle at a time, and then completely releasing the tension, until every muscle in your body is relaxed. You can learn relaxation techniques in special classes or at home using books or tapes. Many of them may also be helpful for children.

Preventive medications
Certain medications taken at regular intervals may reduce the frequency and severity of attacks. These may be prescribed if you have more than two headaches a week or have tension headaches that aren't relieved by acute medication and nondrug therapy. Your doctor also may recommend preventive medication if your headache lasts longer than three to four hours, if severe pain becomes disabling or causes you to overuse acute medication, or if you can't take acute medication because of other medical conditions.

Doctors often prescribe antidepressants to prevent tension headache, especially the chronic form. These drugs aren't painkillers. Rather, they work to stabilize the levels of brain chemicals such as serotonin, which may be involved in the development of a headache. You don't have to have depression in order to use these drugs.

Preventive medications may include:

• Tricyclic antidepressants. This group of antidepressants, including amitriptyline and nortriptyline (Aventyl, Pamelor), are the most commonly used medications to prevent tension headache. They're effective against both the episodic and chronic forms. Side effects of these medications may include weight gain, drowsiness, dry mouth, blurred vision and constipation. Older adults also may experience confusion or faintness when taking tricyclic antidepressants.
• Selective serotonin reuptake inhibitors (SSRIs). Antidepressants such as paroxetine (Paxil), venlafaxine (Effexor) and fluoxetine (Prozac, Sarafem) produce fewer side effects than do the tricyclic antidepressants but generally are less reliable in preventing headache. Further studies are needed to demonstrate their effectiveness.
• NSAIDs. Chronic tension headache may be effectively managed with NSAIDs such as ibuprofen (Advil, Motrin IB, others) and ketoprofen (Orudis KT). In these circumstances, the medication is taken daily.
• Other medications. Other medications that may prevent tension headache include divalproex (Depakote) and gabapentin (Neurontin). Both drugs were developed to treat seizure disorders, but sometimes can prevent headache. Muscle relaxants such as tizanidine (Zanaflex) also have been effective. Migraine medications sometimes are used to prevent tension headache, although few studies indicate how effective they are. Studies on an experimental drug that blocks the production of nitric oxide in the brain show it to be effective in reducing headache pain.

Preventive medications usually require several weeks to build up in the nervous system before they take effect. So don't get frustrated if you haven't seen improvements shortly after you begin taking the drug — it may take a couple of months or longer. You may need a combination of different medications for maximum effectiveness. Also be aware that overusing caffeine or painkillers for acute relief may reduce the effect of a preventive drug.

Preventive medication is considered successful if it results in a 50 percent reduction in the intensity of tension-type head pain or in the frequency and duration of attacks. To obtain the greatest benefit from preventive medication, limit your use of acute pain relievers to a minimum. Your doctor will monitor your treatment to see how the preventive medication is working. If your headaches are under control, your dose of medication may be reduced gradually over time.

Rest, ice packs or a long, hot shower may be all you need to relieve a tension headache. A variety of nonmedication strategies can help reduce the severity and frequency of chronic headache. This approach can be a vital part of any treatment plan for headache.Try some of the following suggestions to see which work best for you:

Healthy lifestyle. Behaviors that promote general good health also may help prevent headache. These lifestyle measures include following regular eating and sleeping schedules and avoiding excess caffeine. It's also important to stay physically active. Regular aerobic exercise, such as walking, swimming or biking, can help reduce the frequency of tension headache. If you already have a headache, exercise may help relieve the pain. But be sure to talk to your doctor before starting any exercise program.

Stress management. Stress is a commonly reported trigger for tension headache. One way to help reduce stress is by planning ahead and organizing your day. Another way is to allow more time to relax. And if you're caught in a stressful situation, consider stepping back and allowing emotions to settle. A variety of relaxation techniques are useful in coping with tension headache, including deep breathing and biofeedback. If anxiety or depression is an issue, behavior therapy may be helpful for dealing with stress and pain.

Muscle relaxation. Muscle tension is associated with tension headache. Applying heat or ice to sore muscles may ease the tension. Which treatment to apply is a matter of personal preference. Some people find heat more effective, while others prefer cold. If heat is your choice, you may use a heating pad set on low, a hot-water bottle, a warm compress or a hot towel. A hot bath or shower also may help. If cold is your choice, wrap the ice pack in a cloth before use to protect your skin.

Massage is a wonderful way to relieve muscle tension. For some people, it also may provide relief from headache pain. Gently massage the muscles of your head, neck and shoulders with your fingertips. Or have someone else do the massage for you.

Perfecting your posture. Good posture can help keep your muscles from tensing up. It places minimal strain on your muscles, ligaments, tendons and bones. Good posture supports and protects all parts of your body and allows you to move efficiently. When standing, hold your shoulders back and your head high. Pull in your abdomen and buttocks and tuck in your chin. When sitting, make sure your thighs are parallel to the ground and your head isn't slumped forward.

Try to avoid sitting, standing or working in one position for long periods of time. Wearing poorly fitting shoes or high heels also can cause posture problems. Do regular stretching and strengthening exercises for your neck and shoulders. Here are other tips for improving your posture:

• Stand with your weight on both feet.
• When standing in one place, put one foot up on a stool or chair rung and switch to the other foot periodically.
• Don't carry a shoulder bag that weighs more than 2 pounds.
• Sit in a straight-back chair with your back supported.
• When sitting for long periods, occasionally elevate your legs by placing your feet on a footstool. If possible, get up and move around every half-hour or so.

Living with chronic pain can be extremely difficult. In addition to the physical symptoms, chronic pain can make you anxious or depressed. Ultimately, it may affect your relationships with friends and family, your productivity at work and the overall quality of your life.

You may find that talking to a counselor or therapist can help you cope with the effects of chronic pain. Or you may find encouragement and understanding in a headache support group. Although support groups aren't for everyone, they can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences. If you're interested, your doctor may be able to recommend a group in your area.

The following nontraditional therapies may help if you suffer from chronic headache pain:

• Acupuncture. Acupuncture may provide relief from chronic headache pain, among other benefits, according to researchers at the National Institutes of Health. Acupuncture practitioners treat you using extremely thin, disposable needles that generally cause little pain or discomfort. The American Academy of Medical Acupuncture Web site provides referrals to medical doctors who use acupuncture in their practices.
• Massage. Massage is a wonderful way to reduce stress and relieve tension. It's especially effective for relieving tight, tender muscles in the back of your head, neck and shoulders. For some people, it may also provide relief from headache pain.
• Essential oils. Some studies have shown that a salve made from ginger, peppermint and wintergreen oils may help relieve tension headaches. You may get relief simply by smelling the salve, or you may want to rub it on the nape of your neck and your temples.