Tension headache: Symptoms

Brief overview

Symptoms: Bilateral, pressing and constricting pain in the head, pain does not worsen with physical activity, sometimes slight sensitivity to light and sound.
Treatment: Prescription painkillers for short periods of time, in children also Flupirtin, rub diluted peppermint oil on temples and neck, for mild symptoms home remedies (for example willow tea preparations)
Prevention: endurance training such as jogging or training of shoulder and neck muscles, relaxation methods, biofeedback, for chronic headaches, for example, the antidepressant amitryptiline, possibly the epilepsy drug topiramate or the muscle-relaxing drug tizanidine, combined with stress management therapy.
Diagnosis: Taking of medical history by physician, checking of special diagnostic criteria (duration, symptoms, exclusion of other diseases), neurological examination, blood pressure measurement, possibly blood or cerebrospinal fluid analysis, more rarely imaging procedures, recording of brain waves (EEG).
Course and prognosis: Basically good prognosis, since the disease often disappears by itself, in a minority of patients it becomes chronic, but even in the chronic form a cure is possible, in women during pregnancy the symptoms often decrease.

What are tension headaches?

Sufferers describe a tension headache as a dull, pressing pain (“vise feeling”) or a feeling of tension in the head. Worldwide, more than 40 percent of all adults experience a tension headache at least once a year. It usually first appears between the ages of 20 and 40.

Bilateral tension headache should be distinguished from unilateral tension headache or unilateral migraine.

Episodic or chronic tension headache?

The International Headache Society (IHS) distinguishes between episodic (occasional) and chronic tension headache.

Episodic tension headache is defined as the occurrence of tension headache within three months on at least one and at most 14 days per month.

The pain of chronic tension headache

occurs for 15 days or more per month over a three-month period, or
more than 180 days per year, and
they last for hours or do not stop.

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

Tension headache: symptoms

Everyday tasks may be more difficult, but can usually be performed. Unlike migraines, nausea, vomiting and visual disturbances are not typical symptoms of tension headaches. However, sufferers are sometimes more sensitive to light and noise. Often, tension headaches involve tense neck or shoulder muscles.

Differentiation between tension headache and migraine

Tension headache	Migraine
Localization	Bilateral, affecting the whole head as if it were clamped in a vice	Mostly unilateral, often on the forehead, temples or behind the eyes
Pain characteristics	Dull drilling, pressing	Pulsating, hammering
Phenomena during the headache	None, possibly moderate sensitivity to light and sound	Aura: visual disturbances, speech disturbances, nausea and vomiting
Aggravation of pain by physical activity	No	Yes

What to do about tension headaches?

Another remedy that helps against tension headaches is a compound combination of ASA, paracetamol and caffeine. This combination has been shown in studies 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 upset, and sometimes cause headaches themselves if used too frequently (painkiller-induced headache).

For this reason, the recommendation is to take them as infrequently as possible and in the lowest dose that is still effective. This means taking it for no more than three consecutive days and no more than ten days a month. In children, the analgesic flupirtine is also effective against tension headache.

For this reason, the recommendation is to take them as infrequently as possible and in the lowest dose that is still effective. This means taking it for no more than three consecutive days and no more than ten days a month. In children, the analgesic flupirtine is also effective against tension headache.

Prevention through non-drug measures

Relaxation techniques and stress management training have a positive effect. In most cases, these changes improve mild to moderate tension headaches, but a long-term cure is not expected. Whether acupuncture treatment helps patients is controversial.

In addition to the above-mentioned options, so-called biofeedback is said to reduce tension headaches. In this process, one learns to consciously influence one’s bodily functions. It is therefore particularly suitable for people who suffer from muscle tension during tension headaches, as they learn to relieve this themselves. The procedure has been shown to be very effective in some studies. Some health insurance companies therefore cover the costs of this treatment.

At some point, they succeed in doing this 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

Particularly in the case of a chronic course of tension headache, medication taken regularly sometimes improves the clinical picture. The antidepressant amitryptiline, which is also effective against pain, is the most commonly 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 increased slowly. The effectiveness becomes apparent after four to eight weeks at the earliest.

According to one study, about half of patients with tension headache benefit from this drug therapy. Among experts, however, the effectiveness is controversial.

Tension headache: Causes

Although tension headache is the most common type of headache of all, the exact causes have not been fully understood. In the past, doctors assumed that the headache was caused by tension in the muscles of the neck, throat and shoulders. This is where the name tension headache or sometimes even “tension headache” comes from. Although these tensions are probably indeed involved in the development of the headache, the exact mechanisms are still unclear.

Some researchers assume that certain trigger points in the muscles of the head, neck and shoulder are particularly sensitive to pain in sufferers of tension headaches. Other scientists suggest that blood and nerve fluids are altered in tension headaches, or that blood drainage disorders in the veins may cause the condition.

Although the exact processes leading to the development of tension headache are still unclear, there are some known risk factors: stress, febrile infections and muscular dysfunction are common triggers. Genetic factors do not seem to be very relevant in episodic tension headache, but play a role in chronic tension headache. If a family member suffers from the chronic form, the risk of also suffering from it is about three times higher.

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

A striking feature of chronic tension headache is its association with psychological complaints: It occurs more frequently in patients with panic disorder, anxiety disorders, depressive symptoms or sleep disorders.

Tension headache: examinations and diagnosis

How severe is the headache (mild, bearable, barely tolerable)?
Where exactly do you feel the headache (unilateral, bilateral, temples, back of head, etc.)?
How does the headache feel (dull, drilling, pressing or pulsating, pounding)?
Do other disturbances occur before or during the headache, for example, visual disturbances, speech disturbances, photophobia, nausea and vomiting?
Do symptoms worsen with physical exertion?
Do the headaches occur after a certain situation, or have you identified triggers for the headaches yourself?

Since forms other than tension headache are also caused by diseases or medications, the doctor will try to rule out these other causes. To do this, he will ask you questions such as the following:

Are you taking any medications? If so, which ones?
How much sleep do you get? Do you have any sleep problems?
Have you hurt or bumped your head recently?
Do you suffer from seizures?
Have you recently become very sensitive to light or are you experiencing vision problems?

Diagnostic criteria for tension headache

According to the International Headache Society (IHS) definition, tension 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 accompanying sensitivity to light or noise
At least two of the following characteristics occur: occurs on both sides, pressing/constricting/non-pulsating pain, mild to moderate pain intensity, not aggravated by routine physical activities
Not attributable to another medical condition

According to the IHS, dizziness is not one of the typical characteristics of tension headache.

In addition to the neurological examination, the physician palpates the muscles of the head, neck and shoulder with his hands. If the muscles in these parts of the body are obviously tense, this may be an indication of a tension headache. In addition, the doctor measures the blood pressure, since elevated blood pressure is also a possible cause of headaches. If necessary, a blood sample is useful to detect abnormalities in general (for example, increased inflammation levels).

If the doctor is not sure whether tension headaches or a secondary headache is behind the complaints, further examinations are necessary. These include, above all, procedures with which the brain is imaged. In addition, special examinations such as recording brain waves (EEG) and analyzing cerebrospinal fluid (CSF) are sometimes necessary.

Imaging procedures: CT and MRI

Electroencephalogram (EEG)

To distinguish a tension headache from an undiagnosed seizure disorder, brain tumor or other structural change of the brain, an electroencephalogram (EEG) is made. For this purpose, small metal electrodes are attached to the scalp, which are connected by cables to a special measuring device. The doctor uses this to measure brain waves at rest, during sleep or when exposed to light stimuli. This procedure is neither painful nor harmful and is therefore especially popular for examining children.

Nerve fluid examination (cerebrospinal fluid puncture)

To rule out altered cerebrospinal fluid pressure (CSF pressure) or meningitis, a nerve fluid puncture is sometimes necessary. The patient with the supposed tension headache usually takes a sedative or light sleep medication for this. Children usually receive a general anesthetic.

The physician then advances a hollow needle into a cerebrospinal fluid reservoir in the spinal canal, determines the cerebrospinal fluid pressure and extracts cerebrospinal fluid for laboratory examination. The spinal cord already ends above the puncture site, which is why it is not injured during this examination. Most people find the examination unpleasant but tolerable, especially since the CSF puncture usually takes only a few minutes.

Tension headache: course and prognosis

In general, the prognosis of tension headache is good. It often disappears by itself.