Tension headache

Tension headache
Tension headache
Classification and external resources
ICD-10 G44.2
ICD-9 307.81, 339.1
DiseasesDB 12554
MedlinePlus 000797
MeSH D018781

A tension headache (renamed a tension-type headache by the International Headache Society in 1988) is the most common type of primary headache. The pain can radiate from the neck, back, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches.[1]


Signs and symptoms

Tension-type headache pain is often described as a constant pressure, as if the head were being squeezed in a vise. The pain is frequently bilateral which means it is present on both sides of the head at once. Tension-type headache pain is typically mild to moderate, but may be severe.

Frequency and duration

Tension-type headaches can be episodic or chronic.[2] Episodic tension-type headaches are defined as tension-type headaches occurring fewer than 15 days a month, whereas chronic tension headaches occur 15 days or more a month for at least 6 months. Tension-type headaches can last from minutes to days, months or even years, though a typical tension headache lasts 4–6 hours.


Various precipitating factors may cause TTH in susceptible individuals:[3]

  • Stress: usually occurs in the afternoon after long stressful work hours or after an exam
  • Sleep deprivation
  • Uncomfortable stressful position and/or bad posture
  • Irregular meal time (hunger)
  • Eyestrain
  • Caffeine withdrawal
  • Dehydration

One half of patients with TTH identify stress or hunger as a precipitating factor.[citation needed]

Tension headaches may be caused by muscle tension around the head and neck. One of the theories says that the main cause for tension type headaches and migraine is teeth clenching which causes a chronic contraction of the temporalis muscle.[citation needed]

Another theory is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information, for example from the temporal muscle or other muscles, and interprets this signal as pain. One of the main neurotransmitters which is probably involved is serotonin. Evidence for this theory comes from the fact that chronic tension-type headaches may be successfully treated with certain antidepressants such as amitriptyline. However, the analgesic effect of amitriptyline in chronic tension-type headache is not solely due to serotonin reuptake inhibition, and likely other mechanisms are involved. Recent studies of nitric oxide (NO) mechanisms suggest that NO may play a key role in the pathophysiology of CTTH.[4] The sensitization of pain pathways may be caused by or associated with activation of nitric oxide synthase (NOS) and the generation of NO. Patients with chronic tension-type headache have increased muscle and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain thresholds. Hyperexcitability of central nociceptive neurons (in trigeminal spinal nucleus, thalamus, and cerebral cortex) is believed to be involved in the pathophysiology of chronic tension-type headache.[5] Recent evidence for generalized increased pain sensitivity or hyperalgesia in CTTH strongly suggests that pain processing in the central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type headache.[6]


Tricyclics have been found to be more effective than SSRIs but have greater side effects.[7] Evidence is insufficient for the use of propranolol and muscle relaxants for prevention of tension headaches.[8]


Episodic tension-type headaches generally respond well to over-the-counter analgesics such as ibuprofen, paracetamol/acetaminophen, and aspirin. Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache. Other medications for chronic tension-type headaches include amitriptyline[9] mirtazapine,[10] topiramate, and sodium valproate (as prophylaxis).[11] Biofeedback techniques may also help.[12][13]

Botulinum toxin is a treatment trialled by some people with tension-type headache, though results are varied.

Manual therapy

People with tension-type headache often use manual therapy, such as spinal manipulation, soft tissue therapy, and myofascial trigger point treatment. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache.[14] A 2005 structured review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[15] A 2004 Cochrane review found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache.[16] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.[17]


Tension-type headaches respond very well to treatment with intra-oral appliances such as bite splints to prevent grinding. Good results have also been reported with a device designed by Elliot Shevel, a South African Maxillo-Facial and Oral Surgeon, called a Posture Modifying Appliance (PMA).[18][19][20]


Tension headaches that do not occur as a symptom of another condition may be painful, but are not harmful. It is usually possible to receive relief through treatment. Tension headaches that occur as a symptom of another condition are usually relieved when the underlying condition is treated. Frequent use of pain medications in patients with tension-type headache may lead to the development of medication overuse headache or rebound headache.[citation needed]

See also


  1. ^ Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population--a prevalence study. J Clin Epidemiol. 1991;44(11):1147-57.
  2. ^ The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004, 24 Suppl 1:9-160.
  3. ^ "Muscle Contraction Tension Headache: eMedicine Neurology". Emedicine.com. 2008-09-18. http://www.emedicine.com/neuro/topic231.htm. Retrieved 2010-03-22. 
  4. ^ Ashina M, Lassen LH, Bendtsen L, Jensen R, Olesen J. Effect of inhibition of nitric oxide synthase on chronic tension-type headache: a randomized crossover trial. Lancet. 1999 Jan 23;353:287-9
  5. ^ Ashina S, Bendtsen L, Ashina M. Pathophysiology of tension-type headache. Curr Pain Headache Rep, 2005 Dec; 9:415-22.
  6. ^ Pielsticker A, Haag G, Zaudig M, Lautenbacher S. Impairment of pain inhibition in chronic tension-type headache. Pain. 2005 Nov;118:215-23.
  7. ^ Jackson JL, Shimeall W, Sessums L, et al. (2010). "Tricyclic antidepressants and headaches: systematic review and meta-analysis". BMJ 341: c5222. doi:10.1136/bmj.c5222. PMC 2958257. PMID 20961988. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2958257. 
  8. ^ Verhagen AP, Damen L, Berger MY, Passchier J, Koes BW (April 2010). "Lack of benefit for prophylactic drugs of tension-type headache in adults: a systematic review". Fam Pract 27 (2): 151–65. doi:10.1093/fampra/cmp089. PMID 20028727. 
  9. ^ Holroyd KA, O'Donnell FJ, Stensland M, Lipchik GL, Cordingley GE, Carlson BW (May 2001). "Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial". JAMA 285 (17): 2208–15. doi:10.1001/jama.285.17.2208. PMC 2128735. PMID 11325322. http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11325322. 
  10. ^ de Ru JA, Buwalda J (June 2008). "Botulinum toxin A injection into corrugator muscle for frontally localised chronic daily headache or chronic tension-type headache". J Laryngol Otol 123 (4): 1–6. doi:10.1017/S0022215108003198. PMID 18588738. 
  11. ^ Yurekli VA, Akhan G, Kutluhan S, Uzar E, Koyuncuoglu HR, Gultekin F (February 2008). "The effect of sodium valproate on chronic daily headache and its subgroups". J Headache Pain 9 (1): 37–41. doi:10.1007/s10194-008-0002-5. PMID 18231713. 
  12. ^ Nestoriuc Y, Rief W, Martin A (June 2008). "Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators". J Consult Clin Psychol 76 (3): 379–96. doi:10.1037/0022-006X.76.3.379. PMID 18540732. 
  13. ^ Rains JC (May 2008). "Change mechanisms in EMG biofeedback training: cognitive changes underlying improvements in tension headache". Headache 48 (5): 735–6; discussion 736–7. doi:10.1111/j.1526-4610.2008.01119_1.x. PMID 18471128. 
  14. ^ Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain 22 (3): 278–85. doi:10.1097/01.ajp.0000173017.64741.86. PMID 16514329. 
  15. ^ Biondi DM (2005). "Physical treatments for headache: a structured review". Headache 45 (6): 738–46. doi:10.1111/j.1526-4610.2005.05141.x. PMID 15953306. 
  16. ^ Bronfort G, Nilsson N, Haas M et al. (2004). Non-invasive physical treatments for chronic/recurrent headache. In Brønfort, Gert. "Cochrane Database of Systematic Reviews". Cochrane Database Syst Rev (3): CD001878. doi:10.1002/14651858.CD001878.pub2. PMID 15266458. 
  17. ^ Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMC 1420782. PMID 16574972. http://www.jrsm.org/cgi/content/full/99/4/192. 
  18. ^ de Tommaso M, Shevel E, Pecoraro C, Sardaro M, Divenere D, Di Fruscolo O, Lamberti P, Livrea P. (2006). "Intra-oral orthosis vs amitriptyline in chronic tension-type headache: a clinical and laser evoked potentials study". Head Face Med 2: 15–24. doi:10.1186/1746-160X-2-15. PMC 1484471. PMID 16725028. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1484471. 
  19. ^ Shevel E. (2005). "Craniomandibular muscles, intraoral orthoses and migraine". Expert Rev Neurother 5 (3): 371–7. doi:10.1586/14737175.5.3.371. PMID 15938670. 
  20. ^ de Tommaso M, Shevel E, Libro G, Guido M, Di Venere D, Genco S, Monetti C, Serpino C, Barile G, Lamberti P, Livrea P. (2005). "Effects of amitriptyline and intra-oral device appliance on clinical and laser-evoked potentials features in chronic tension-type headache". Neurol Sci. 26: 152–4. doi:10.1007/s10072-005-0432-7. PMID 15926017. 

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