Tension Headache: Symptoms, Causes and What Helps (Medication, Habits, Exercise)

The diagnosis rests on the International Classification of Headache Disorders (ICHD-3, 3rd edition, 2018). Tension-type headache lasts from 30 minutes to 7 days and meets at least two of four features: bilateral location, a pressing or tightening (non-pulsating) quality, mild or moderate intensity, and no worsening with routine physical activity. In addition there is no nausea or vomiting, and photophobia and phonophobia do not occur together — at most one of them is allowed.

The classification divides tension-type headache by frequency. The infrequent form occurs less than once a month, the frequent episodic form on 1 to 14 days a month for more than three months, and the chronic form on at least 15 days a month for more than three months. This distinction is not academic: it decides whether acute treatment is enough or prevention should be considered, and how quickly medication overuse becomes a threat.

Tension-type headache and migraine are often confused, and both can occur in the same person. Migraine is usually one-sided, pulsating, of moderate to severe intensity, gets worse with movement and is accompanied by nausea or by a combination of photophobia and phonophobia; an attack lasts from 4 to 72 hours. Tension-type headache is milder, bilateral, does not pulsate and is not worsened by movement. If almost every headache forces you to lie down in a dark room, migraine is more likely — we cover its causes and treatment separately in our article on migraine.

The diagnostic trap is that mild migraine is mistaken for tension-type headache, and chronic tension-type headache, conversely, for 'migraine', leading to the wrong drugs (for example triptans, which do not work in pure tension-type headache). A simple test helps: for 4 to 6 weeks write down in a diary whether the pain pulsated, whether there was nausea, whether movement made it worse, how many hours it lasted and which drugs were taken. Such a record speeds up and simplifies the doctor's visit.

The first layer is peripheral. In episodic tension-type headache, increased sensitivity of the muscles and fascia of the skull, neck and shoulder region (so-called pericranial muscle tenderness) is thought to play a role, and it increases when one position is held for a long time, when the jaws are clenched and under stress. Painful trigger points and muscle contracture are sometimes present, but their causal link to the pain remains disputed — muscles may be both a cause and a consequence of the pain.

The second layer is central and is key to understanding the chronic form. With frequent and prolonged headaches the nervous system becomes hypersensitive: neurons in the dorsal horns of the spinal cord and in the trigeminal nucleus respond more strongly to stimuli that previously did not hurt, and pain-inhibiting mechanisms weaken. This process (central sensitisation) explains why in chronic tension-type headache neck massage or muscle relaxation is often not enough, and why drugs acting on central transmission, such as amitriptyline, help. It should be stressed that this is a mechanistic model, based mainly on neurophysiological studies; it does not translate directly into firm therapeutic conclusions.

Factors most often linked in observational data to attacks of tension-type headache include psychological stress and emotional tension, lack of sleep or disturbed sleep, long computer work in a forced posture, skipped meals and dehydration, teeth clenching (more in our article on bruxism), and too much or abruptly stopped caffeine. These are trigger and maintaining factors, not a 'cause' in the sense of one injury — which is why a good strategy is usually several small changes at once rather than a single intervention.

The two best-studied drugs, both available without a prescription, are ibuprofen and paracetamol (acetaminophen). Both analyses come from Cochrane reviews that pooled randomised placebo-controlled trials in adults with frequent episodic tension-type headache. Their conclusion is at once reassuring and sobering: the drugs work, but the difference from placebo is small, because placebo and the natural course of the headache provide a large part of the improvement.

The practical conclusion: if we reach for an acute drug, the dose matters — in the studies paracetamol worked only at 1000 mg for an adult (not 500 mg), and ibuprofen at 400 mg. The effect develops over an hour or two, so no improvement after 20 minutes does not mean the drug is not working. The limitations are also worth remembering: ibuprofen and other NSAIDs burden the stomach and kidneys and may raise blood pressure, and paracetamol above the recommended doses damages the liver — the daily dose is set by the leaflet and the doctor, especially with liver or kidney disease or ulcers.

Caffeine in combination products is therefore two-edged: it slightly strengthens the analgesic effect, but it also encourages overuse — tablets containing caffeine fall into the group of combination drugs, for which the overuse threshold is as low as 10 days a month (more in our article on medication-overuse headache). Caffeine rituals (several coffees a day plus a tablet) can themselves sustain the pain through a withdrawal cycle; we write about caffeine and sleep in separate texts on coffee.

Prevention is considered when headaches occur often (especially on 15 or more days a month), significantly interfere with functioning, or when tablets have to be taken so often that overuse is a risk. The best-documented preventive drug is amitriptyline — a tricyclic antidepressant used for pain at doses usually lower than in depression, introduced gradually and only on a doctor's prescription.

This result needs careful reading. The effect of amitriptyline is real in the trials, but the confidence interval is wide, the quality of evidence low, and the 100 mg dose (used in the analysed trials) can be hard to maintain in practice because of drowsiness, dry mouth, constipation, weight gain and heart-rhythm disturbances in susceptible people. The decision on prevention is therefore always individual: it takes into account heart disease, glaucoma, prostate enlargement, other medicines and age. Do not reach for antidepressants or raise doses on your own.

Non-drug methods make particular sense for tension-type headache because they carry no risk of medication overuse. The evidence, however, is less impressive than popular guides suggest. One of the most recent reviews is a component network meta-analysis of trials of exercise (aerobic, resistance and stretching) in adults with tension-type headache.

What follows? Encouraging regular exercise is reasonable: exercise reduced pain intensity, and resistance training performed best. At the same time, the conclusion that 'stretching alone is harmful' would over-interpret a single statistical model based on a very small number of trials. The honest version is: the evidence is preliminary, and the safest conclusion is that physical activity in general helps in chronic pain and does no harm.

The situation is similar with other methods. Relaxation techniques, biofeedback training (including EMG), cognitive behavioural therapy, manual therapy and acupuncture have positive results in tension-type headache in the literature, but the trials are usually small, hard to blind and very varied, so the certainty of evidence is low. From the patient's point of view this means: it is worth trying what is safe, available and enjoyable (walking, strength training, yoga, breathing exercises, workstation ergonomics), judging the effect after 6–8 weeks of regularity and not treating any of these methods as a guaranteed solution.

Irregular sleep is one of the most often described triggers of tension-type headache, and the headache itself disturbs sleep, creating a vicious circle. Fixed times for going to bed and waking, limiting caffeine in the afternoon and treating insomnia (best with cognitive-behavioural methods) are therefore a sensible part of the plan — without, of course, promising that they will eliminate the pain. We write about practical ways of improving sleep in our articles on insomnia and sleep hygiene.

Tension-type headache is a diagnosis made after excluding warning features, so it is worth knowing the situations in which the label 'tension-type' is not enough. The list below is based on commonly used lists of red-flag symptoms and is not exhaustive.

Tension-type headache is a complaint in which the greatest harm is often done not by the pain itself but by a badly chosen reaction to it: daily tablets, more coffees, skipped sleep — or, on the other side, ignoring a pain that needs investigation. The evidence for individual drugs is modest but consistent: small, real benefits and few adverse effects when used sensibly. The greatest value therefore lies not in searching for a miracle remedy but in a headache diary, a few fixed habits, a limit on days with a tablet and a quick consultation at any warning sign.