Headaches - tension
An in-depth report on the causes, diagnosis, treatment, and prevention of common headaches.
What Are Tension-Type Headaches?
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 while tension-type headache pain is usually a steady ache.
Migraine pain often affects only one side of the head while tension-type headache pain typically affects both sides of the head.
- Migraine headaches, but not tension-type headaches, may be accompanied by nausea or vomiting, sensitivity to both light and sound, or aura.
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 (OTC) pain relievers such as aspirin, ibuprofen (Advil, Motrin, generic), or naproxen (Aleve, generic). However, OTC medications, especially those that contain caffeine, should not be used more than twice a week because they can cause medication overuse (rebound) headaches.
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, generic), combined with behavioral therapies. Behavioral treatment approaches include relaxation therapy, biofeedback, stress management, and cognitive-behavioral therapy.
Most people have had headaches. There are many different kinds of headaches, and they range from being an infrequent annoyance to a persistent, severe, and disabling medical condition. Tension-type headaches are among the most common of all headaches. The pain of a tension-type headache can range from mild to severe and last anywhere from a few minutes to several days.
Brain tissue itself does not generate sensations of pain, so the brain is not what hurts when you have a headache. Rather, the pain occurs in some of 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
Primary and Secondary Headaches
Primary Headaches. A headache is considered primary when it is not caused by another medical condition or disease. Most primary headaches fall into three main types: tension-type, migraine, and cluster headaches.
- Tension-type headache is the most common primary headache and accounts for 90% of all headaches.
- Migraine headache is the second most common primary headaches. Migraine is referred to as a neurovascular headache because it is most likely caused by an a combination of blood vessel and nerve abnormalities.
- Cluster headache is a less common type of primary headache that is sometimes also referred to as a neurovascular headache.
Secondary Headaches. Secondary headaches are caused by other medical conditions, such as sinus infections, neck injuries, and strokes. About 2% of headaches are secondary to abnormalities or infections in the nasal or sinus passages, and they are commonly referred to as sinus headaches.
Episodic and Chronic Headaches
Doctors classify tension-type headaches as either episodic or chronic based on how frequently they occur:
- Episodic headaches occur on less than 15 days per month. (People who have frequent episodic tension-type headaches – more than 10 days a month—often also have migraine headaches.)
- Chronic headaches occur on more than 15 days per month. In about 25% of patients, episodic-type headaches evolve into chronic tension-type headaches.
Chronic daily headaches can begin as tension headaches, migraines, or a combination of these or other headache types. Chronic daily headaches are subdivided into two categories:
- Short-duration headaches, or those lasting fewer than 4 hours. The most common short-acting chronic headaches are cluster headaches.
- Long-duration headaches, which last more than 4 hours. Tension-type headaches are the most common type of long-duration chronic (recurring) headaches and, in fact, the most common type of chronic headaches in general.
Doctors are not sure what causes tension-type headaches. At one time, these headaches were blamed on abnormal muscle contractions but this theory has largely been discounted. (This is why this headache’s name has changed from “tension” to “tension-type.”) Researchers now think that tension-type headaches most likely occur due to an interaction of several factors that involve pain sensitivity and perception, as well as the role of brain chemicals (neurotransmitters).
Although muscle tightness does not necessarily cause tension-type headaches, certain triggers associated with muscle contractions or strain may contribute to this condition.
Pain Sensitivity and Perception
Research indicates that patients with tension-type headache may have abnormalities in the central nervous system, which increase their sensitivity to pain. The central nervous system includes the nerves in the brain and spine.
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.
Brain Chemicals (Neurotransmitters)
Neurotransmitters are chemical messengers in the brain. Several types of neurotransmitters affect how the brain reacts to pain stimulation. In particular, serotonin (also called 5-HT) and nitric oxide are thought to be involved in these chemical changes. Release of these chemicals may activate nerve pathways in the brain, muscles, or elsewhere and increase pain.
Triggers for Tension-Type Headache
Many different factors can trigger or aggravate tension-type headaches.
Stress. Stress certainly plays a role in tension-type headaches. Emotional and psychological factors that contribute to stress include include anxiety, depression, and anger. Lifestyle factors include fatigue, lack of sleep, dehydration, and hunger.
Poor Posture. Working or sleeping in an awkward position can contribute to posture problems that affect muscles in the neck and shoulders.
Medication and Substance Overuse. About a third of persistent headaches -- whether chronic migraine or tension-type -- are medication-overuse headaches. They result from a rebound effect caused by the repeated overuse of headache medications. Nearly any type of headache medication can produce this effect. This is especially true for brands that contain caffeine. Headaches can also occur after withdrawing from caffeine, nicotine, or alcohol.
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 exercise therapies that specifically address the dental condition.
Tension-type headaches are the most common type of headache. Nearly everyone has at least one tension-type headache during their lifetime. Episodic tension-type headaches are far more common than chronic tension-type headaches.
Headaches in Adults
Gender. Tension-type headaches are more common among women than men.
Age. Tension-type headaches are most likely to occur among people in their 30s. They tend to occur less as people become older.
Headaches in Children
Headaches are rare before age 4 but become more common throughout childhood, reaching a peak at around age 13. Children with tension-type headaches often suffer from an accompanying emotional or psychological disorder.
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.
- Mental health conditions. Many children with chronic tension-type headaches also have depression or an anxiety disorder.
- Family stress. Stressful family events can contribute to emotional problems that lead to tension-type headaches.
- 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 your child's headaches noting time of onset, length and intensity of attack, location of pain, and dietary triggers.
Make sure your child gets plenty of sleep at regular times.
Avoid changes in child's eating routine (hunger and eating at irregular times can trigger headaches).
Discuss any headache concerns with your child's doctor.
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, there is usually a migraine component occurring with the tension-type headache.
Nevertheless, although they are not medically dangerous, chronic tension headaches can have a negative impact on quality of life, families, and work productivity. Several studies have reported lower quality of life for people with any chronic daily headache compared to those with 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.
According to the International Headache Society, tension-type headaches tend to have 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 (such as walking or climbing stairs)
In episodic tension-type headaches:
- No nausea or vomiting
- Extreme sensitivity to bright light (photophobia) or extreme sensitivity to sound (phonophobia) 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, sensitivity to light, or sensitivity to sounds
- Some types of chronic tension headache may include discomfort triggered by manual palpitation of the head (pericranial tenderness)
Differentiating Tension-Type Headaches from Migraine Headaches
Migraines and tension-type headaches have some similar symptoms, but also some important differences:
- Migraine pain is usually throbbing, while tension-type headache pain is usually a steady ache.
- Migraine pain usually affects 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 moderate-to-severe nausea and vomiting.
- Migraine headaches, but not tension-type headaches, may be accompanied by sensitivity to both light and sound.
- Migraine headaches may be accompanied by visual disturbances called auras. Tension-type headaches do not have auras.
- Some people have both migraine headaches and tension-type headaches.
Medical and Personal History
The doctor may the patient to describe:
- Duration and frequency of headaches
- Recent changes in their character
- Location of the pain
- Type of pain (throbbing or steady pressure)
- Intensity of the headache
- Associated symptoms, such as visual disturbances or nausea and vomiting. (These are seen most often with migraines.)
- Behavior during a headache. Different behaviors may help distinguish between migraine and tension headaches. People with tension headaches tend to relieve pain by massaging the scalp, temples, or the nape of the neck. People with migraines are more likely to compress the forehead and temples or to apply cold to the area.
The patient should also report any other conditions that might be associated with headache, such as any:
Chronic or recent illness and their treatments
Injuries, particularly head or back injuries
Current medications or recent withdrawal from any drugs, including over-the-counter or natural remedies
History of caffeine, alcohol, or drug abuse
Serious stress, depression, and anxiety
The doctor will also ask about the patient's general medical and family history, particularly concerning headaches or other neurological diseases.
Headache Diary to Identify Triggers
Keeping a headache diary is a useful way to identify triggers that bring on headaches, and to help the doctor differentiate between migraine and tension-type headache. Be sure to include all events preceding an attack. Often two or more triggers interact to produce a headache.
Tracking medications is an important way of identifying medication-overuse headache. Many persistent headaches result from the rebound effect caused by the overuse of headache medications.
Be sure to attempt to define the intensity of the headache. There are different scoring symptoms available that help communicate the severity of the pain to the doctor. For instance, the following is a number system that can be helpful:
1 = Mild, barely noticeable
2 = Noticeable, but does not interfere with work/activities
3 = Distracts from work/activities
4 = Makes work/activities very difficult
5 = Incapacitating
In order to diagnose a chronic headache, the doctor will examine the head and neck to check for muscle tenderness. The doctor may also perform a neurologic examination, which includes a series of simple evaluations to test strength, reflexes, coordination, sensation, and mental function. The doctor may also recommend an eye examination.
Imaging tests look for any serious medical condition as the cause of headache. For patients who have stable headaches, they are generally not recommended except for sudden new or worsening symptoms. For imaging tests, MRIs are preferred over computed tomography (CT) scans because they do not expose patients to radiation.
Imaging tests of the brain may be recommended under the following circumstances:
- If the results of the history and physical examination suggest neurologic problems
- Changes in vision
- Muscle weakness
- Fever and stiff neck
- Changes in mental status including signs of disorientation
- Recent fall or head injury
- A sudden or extremely severe headache
- Worsening headaches or headaches that do not respond to routine treatment
- History of cancer
Headache Symptoms that Could Indicate A Serious Underlying Disorder
Most headaches, especially tension-type headaches, are not serious or life-threatening. Headaches indicating a serious underlying problem, such as cerebrovascular disorder or malignant hypertension, are uncommon. (A headache without other neurological symptoms is not a common first symptom of a brain tumor.)
People with existing chronic headaches may, however, overlook a more serious condition believing it to be one of their usual headaches. Such patients should immediately call a doctor if the quality of a headache or accompanying symptoms has changed.
Everyone should call a doctor for any of the following symptoms:
- Sudden, severe headache that persists or increases in intensity over the following hours, sometimes accompanied by nausea, vomiting, or altered mental states (possible hemorrhagic stroke)
- Sudden, very severe headache, worse than any headache ever experienced (possible indication of hemorrhage or a ruptured aneurysm)
- Chronic or severe headaches that begin after age 50
- Headaches accompanied by other symptoms, such as memory loss, confusion, loss of balance, changes in speech or vision, or loss of strength in or numbness or tingling in arms or legs (possibility of stroke)
- Headaches after head injury, especially if drowsiness or nausea are present (possibility of hemorrhage)
- Headaches accompanied by fever, stiff neck, nausea, and vomiting (possibility of meningitis)
- Headaches that increase with coughing or straining (possibility of brain swelling)
- A throbbing pain around or behind the eyes or in the forehead accompanied by redness in the eye and perceptions of halos or rings around lights (possibility of acute glaucoma)
- A one-sided headache in the temple in elderly people; the artery in the temple may be firm and knotty and without a pulse; the scalp may be tender (possibility of temporal arteritis, which can cause blindness or stroke if not treated).
- Sudden onset and then persistent, throbbing pain around the eye possibly spreading to the ear or neck unrelieved by pain medication (possibility of blood clot in one of the sinus veins of the brain)
Management of tension-type headaches focuses in the short term on treating attacks, and in the long term on preventing recurrence. 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, most headache pain can be relieved or reduced.
Treatment for Episodic Tension-Type Headaches
Most episodic attacks of tension-type headaches get better without any treatment. Simple over-the-counter pain relievers such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) can treat mild symptoms. Aspirin or ibuprofen (Advil, generic) are usually the first choices, followed by naproxen (Aleve, generic). Some patients may also find helpful medications that combine a pain reliever with caffeine. However, using pain relievers, especially those that contain caffeine, more than twice per week may cause rebound headache.
Some people find massage therapy helpful for treating acute episodes of tension-type headache.
Preventive Treatment for 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 will need to stop taking the drug. (If caffeine is the trigger, a person may only need to reduce coffee or tea intake.)
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 be 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.
- No matter which approach is used for stopping medication, there may be 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 in some cases headache symptoms can persist up to 16 weeks (and in rare cases even longer).
The standard treatments for episodic attacks of tension-type headaches are non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. The tricyclic antidepressant amitriptyline (Elavil, generic) is considered the most effective preventive medication for treating chronic tension-type headaches.
Due to the risks of overuse and dependence, opoids, opoid-like drugs, and sedative hypnotics are not recommended for treatment of tension-type headaches.
Several pain relievers are helpful for treating mild-to-moderate headaches. They cannot 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 (Advil, generic), naproxen (Aleve, generic), ketoprofen (Nexcede, generic)
- Prescription NSAIDs. Diclofenac (Cataflam, generic), tolmetin (Tolectin, generic), indomethacin (Indocin, generic)
Long-term use of high-dose NSAIDs may increase the risk for stomach bleeding and heart problems, including heart attack and stroke. Using NSAIDs more than twice a week may increase the risk for medication overuse (rebound) headache.
Acetaminophen. Acetaminophen (Tylenol, generic) is a good alternative to NSAIDs when stomach distress, ulcers, or allergic reactions prohibit their use. A high dose (1,000 mg) is recommended for treating headaches.
Acetaminophen does have some adverse effects, 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 (Coumadin, generic).
Tricyclics and Other Antidepressants
Antidepressants known as tricyclics are most often used for prevention of severe chronic tension-type headaches.
Tricyclic Antidepressants. Tricyclics are not only useful for depression but also appear to help relieve muscle pain and improve sleep. Amitriptyline (Elavil, generic) is the tricyclic most commonly used for tension-type headache prevention. Imipramine (Tofranil, generic) is another tricyclic sometimes prescribed.
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 side effect. Other side effects may 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 fluoxetine (Prozac, generic). Other antidepressants used for tension-type headache are mirtazapine (Remeron, generic) and venlafaxine (Effexor, generic), 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.
Muscle relaxants. Tizanidine (Zanaflex, generic) is a muscle relaxant that is sometimes used for prevention of chronic tension-type headaches.
Anticonvulsants. Anti-seizure drugs, which are used for treating epilepsy, are sometimes used for prevention of tension-type headaches. They include topiramate (Topamax, generic) and gabapentin (Neurontin).
Botulinum Toxin. OnabotulinumtoxinA (Botox) injections are used to relax muscles and reduce skin wrinkles. Botox injections are approved for prevention of chronic migraine in adults. However, Botox has not been approved as a treatment for tension-type headaches. Some studies indicate that Botox is not effective for tension-type headache.
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 for tension-type headache.
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 improving tension-type headaches.
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 patient’s 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 learn 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 are 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 somewhat 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 patient’s workplace environment.
Several reviews of clinical trials of acupuncture suggest that it may have some benefit for tension headache.
Diet and Exercise
Good health habits -- including adequate sleep, healthy diet, regular exercise -- are helpful for reducing stress. Quitting smoking is important in reducing the risks for all types of headaches.
Heat or cold packs may be helpful. Some people report more relief with cold, others with heat. Packs can either be frozen or heated.
Herbal and Other Natural Remedies
Numerous herbal remedies are promoted for tension-type headache. It is important that anyone taking herbal or so-called natural remedies be aware of the lack of regulations governing their quality and effectiveness. Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the Food and Drug Administration (FDA) to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. Always check with your doctor before using any herbal remedies or dietary supplements. Never give herbal remedies or dietary supplements to children without first consulting a doctor.
Essential Oils. Some patients find relief using two drops of peppermint, eucalyptus, or lavender oil added to one cup of water. The patient soaks a cloth in the solution and applies it as a compress to the head.
Magnesium. Some patients report that magnesium supplements can help prevent migraine headache attacks, but there is little evidence that magnesium is helpful for tension-type headaches.
Herbs. Butterbur and feverfew are two popular herbal remedies for headache relief. The American Academy of Neurology recommends butterbur as “effective” for migraine relief, and feverfew as “probably effective.” It is not clear if these herbs are effective for tension-type headaches.
The following are special concerns for people taking these herbs:
- Butterbur can cause an allergic reaction in people who are sensitive to ragweed and related plants. It is not certain if butterbur is safe for use during pregnancy.
- People who have a bleeding or blood clot disorder, or who take blood-thinning medications such as warfarin (Coumadin, generic), should not take feverfew. Feverfew can interfere with these medications and can affect the time it takes blood to clot. Pregnant women or women hoping to become pregnant should not take this herb, as it may potentially harm the fetus.
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- Last reviewed on 12/23/2013
- Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.
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