Tension Headache and Overlapping Factors

Do you recognize these symptoms?

Chances are you have experienced a tension headache (or two) in your life. 

Most people will describe or define a tension-type headache (TTH) as a throbbing sensation around the head. Some even say that a tension headache is like having a tight band around the head or a clamp squeezing the skull. 

Also known as “stress headaches,” tension headaches are experienced differently from person to person. But, most people feel like they have a lot of pressure or tightness. 

In adults, these stress headaches are the most common type of headache form.

Typically, they start later in the day. It is estimated that about 80% of Americans have experienced tension headaches at some point in their lives.

About Tension Headaches

Tension headaches are the most common type of headache in the adult population. Thus, if you’ve ever experienced them, now is your chance to learn about them. 

Overview

The following tension headache symptoms are common and likely to be localized to the forehead or in the back of the head/neck:

• Dull pain 
• Tightness
• Pressure
• Tenderness

These sensations may lead to the following:

• Mild sensitivity to noise or light (migraines are more severe)
• Difficulty focusing 
• Trouble falling asleep 
• General irritability

Less Disabling than Migraines

Tension headaches are painful, but still don’t prevent people from going on with their lives as migraines do.

Tension headaches are associated only with mild sensitivity to sound, movement, or light. 

Also, instances of vomiting or nausea do not occur in parallel with tension headaches. Since tension headaches are not severe, most people won’t seek medical or professional help. 

While tension headaches are not disabling in the way that migraines are, they are still a cause for concern. Your baseline status should be pain-free and not ‘managing.’

Types of Tension Headaches

For classification purposes, tension headaches fall under the following categories:

• Infrequent tension headaches: Infrequent tension headaches occur less than 12 times across the span of a year. 
• Episodic tension headaches: Episodic tension headaches occur less than 15 days per month or less than 180 days with a headache annually. 
• Chronic tension headaches: Chronic tension headaches occur 15 days (or more) per month for 3 consecutive months. 

The majority of people that experience tension-type headaches do not seek professional help. However, if the headaches become more frequent or chronic, patients are likely to seek treatment (discussed towards the end of this post).  

Furthermore, when it comes to diagnosis, tension headaches are divided into the following two classes:

• Primary tension headache: The tension headache is the primary issue that the patient is facing. The tension headache was triggered by other factors such as poor posture, excessive alcohol intake, or food intolerance. 
• Secondary tension headache: Here, the tension headache is a secondary issue and the real problem is an underlying condition. Since tension headaches use the same pathways as other conditions, overlapping pathophysiologies contribute to the manifestation of secondary tension headaches. This is a concern, as we will see later, because sometimes doctors treat the ‘classic tension headache’ and may overlook an underlying disease. 

Causes of tension headaches

There are more than 300 types of headaches, but only about 10% of them have a known cause. The root cause of tension headaches, or TTH (tension-type headaches) is still unknown.

However, multiple factors have been linked with a higher likelihood of developing tension headaches, including: 

• Dizziness 
• Jaw clenching
• Anxiety 
• Poor posture
• Eyestrain 
• Dehydration
• Alcohol use

All of these factors can increase your chances of experiencing a tension headache. 

Some of these are difficult to control - like feelings of anxiety or depression. Other factors, such as poor posture or eye strain (from prolonged screen time), are slightly more within our realm of control. 

Furthermore, tension headaches can be triggered by psychosocial stressors such as the following:

• Problems at home
• Loneliness
• School exams
• Work deadlines
• Overexerting yourself (being committed to too many activities)
• Lack of sleep 

While relationships, family, school, and work can be fulfilling and beneficial, sometimes they can be overwhelming, leading to tension headaches. 

Although the primary cause remains unknown, internal stressors and/or environmental factors play a big role in manifesting tension headaches. 

Previously used terms for describing tension headaches include psychogenic headache, psychomyogenic headache, ordinary headache, and idiopathic headache.  

These terms suggest how common, unpredictable, and related to psychological stressors tension headaches can be. 

In the later sections, we will take a look at why these triggers (and other underlying conditions) trigger or coincide with tension headaches.

Diagnostic Criteria 

Although tension headaches are difficult to pinpoint since they are so general, there are a few criteria that doctors use.

For a headache to be considered a tension headache it must fill the following criteria:

• Must last more than 30 minutes but less than 7 days. 
• Must have at least two of the following characteristics:

• Mild or moderate in severity
• Not further aggregated by any simple physical activity, such as going up the stairs or walking
• Bilateral location in the head or back of the neck which means it occurs on both your left and right sides/hemispheres (this is also sometimes referred to as the absence of unilaterality) 
• Either a tightening or pressing sensation (does not feel like it’s pulsing) 

• No instances of vomiting or nausea
• Either photophobia (light sensitivity) or phonophobia (loud sound sensitivity), but not both 

However, there is still a minority of people that experience tension-type headaches but lack the above-described criteria. For example, it has been found that more than 15% of patients experience pulsating tension-type headaches, about 10% may experience a unilateral pain, and 28% may feel aggravated as a result of physical activity. 

Confusion in Diagnoses 

Tension headaches are very common, but they are not very distinct. Besides the description of a ‘tight band’ wrapping around the head, there is no tell-all sign that indicates you have tension headaches. The pain could be a source of something else.

Since tension headaches are such a vague phenomenon, there is definitely some underlying confusion when it comes to diagnosis. 

The following factors have been found to skew simple diagnosis for tension headaches: 

• Medication overuse headache: Not using medication appropriately or developing side effects has been known to produce tension headaches. In this case, it’s the medication that is affecting you, not the tension headache itself (Jay et al., 2017). 
• Anxiety and/or depression: Any underlying anxiety or depressive-like feelings can also trigger tension headaches. Psychiatric conditions are implicated in tension headaches because they are a form of emotional stress which puts a toll on the body (Heckman & Holroyd, 2006). Tension headache patients with anxiety or depression have also been found to have more exacerbated headache symptoms (Song et al., 2016).     ‍
• Jaw clenching: If you constantly clench your jaw, you may be inadvertently creating tension headaches. Tense muscles mean that your nerves are constantly activated and sending signals to the muscles, keeping them clenched. This could lead to a bottom-up effect and create a headache. Excessive tension eventually generates pain in your temples. ‍
• Forward head posture: A forward head posture is associated with a greater strain on your neck muscles. Patients with tension headaches that also have a forward head posture typically experience longer and more intense tension headaches (Fernandez-de-las-Penas et al., 2006). ‍
• Sleep-related factors: Just as your posture during the day can determine whether you experience tension headaches, as can your sleeping habits. Excessive, unrefreshing, insufficient sleep can all lead to tension headaches. Also, a change in your sleep schedule or awkward sleeping posture may also act as triggers (Holroyd, 2002).‍
• Congestion: If you are congested, tension headaches may also come about. Many patients with tension headaches also experience nasal congestion or pressure. ‍
• Alcohol use: While the exact physiological reason why alcohol can trigger tension headache is unknown, there is plenty of evidence that has correlated the two. For centuries, alcohol has been known to be a way to self-medicate against pain. So, the association between alcohol and tension headaches may run deeper than it meets the eye (Panconesi, 2016). ‍
• Eye strain: Headaches and eye strain are likely to coincide, especially as a result of prolonged computer use (Palm et al., 2007). This pain occurs because focusing on a single object (like a computer screen) for a prolonged period of time is a function limiting activity that puts a strain on the muscles to maintain such a position. ‍
• Skipping meals: When you skip a meal, your blood sugar level drops. If it drops below a certain point, your body releases hormones to compensate for the decreased glucose level. As a result, your blood pressure increases and your arteries narrow. Narrowed arteries and increased pressure can result in headaches. ‍
• Dehydration: Not drinking enough water (remember, 8 glasses per day!) may trigger tension headaches. When your brain doesn’t receive enough water, brain cells can temporarily shrink (Luse & Harris, 1961). ‍
• Hormonal changes: Changes in hormones, such as a sudden decrease in estrogen levels, or menstrual-related changes, are associated with tension headaches (Karli et al., 2012). ‍
• Arthritis: If you have arthritis, inflammation of the spine or joints can produce pain and decrease your range of motion. The inflammation and swelling in the upper neck areas can cause tension headaches. ‍
• Post-traumatic headaches: If you have had a traumatic brain injury (TBI) you are also more likely to experience tension headaches. In fact, headaches are among the top complaints in TBI patients (Lew et al., 2006). Although the physiology behind this is unknown, it may be due to prolonged neuronal inflammation (Lucas, 2011). 

As we will see later, there is also confusion in diagnosis for more serious diseases. For example, while simply clenching jaw can be associated with tension headaches, jaw-related disorders, like TMJ syndrome, can be potentially more debilitating than simple tension headache.

In the next section, we will take a see how tension headaches look like on the neurological and physiological levels. 

Medical Explanation of Tension Headaches

While on the outside we use words to describe our experience of what a tension headache feels like, on the inside, there are bodily signals and systems that cause these sensations. 

While there is no unanimous consensus of what causes a tension headache, since there are no disease-specific features, the findings highlighted below represent the general scientific consensus (Fumal & Schoenen, 2008). 

Infrequent tension headaches may share the following physiological characteristics:

1. Peripheral in nature: The signals for infrequent headaches come from the body (peripheral inputs) and are not necessarily a brain-related issue. 
2. Pericranial tissue tenderness: Myofascial tissue pain (inflammation in the soft tissues of the body), specifically around the skull (pericranial), is highly associated with tension headaches. Therefore, tenderness in these soft tissues is associated with tension headaches as well (Do et al., 2018). 
3. Muscle stiffness: Patients with tension-type headaches show higher muscle stiffness on the days when they experience a headache as opposed to the days when they do not (Sakai et al., 1995). 
4. Altered peripheral pain pathways: If the pain pathways that can signal from the soft tissue around the head are altered, the result is probably an episodic tension headache (Jay et al., 2017). 
5. Change in cellular metabolism: On a cellular level, the tender feeling may be a result of changes in cellular metabolism and mitochondrial section. 
6. Inflammation: Substances and related brain chemicals (neurotransmitters) that act on muscle receptors include serotonin, potassium ions, and bradykinin. While this is a complex science, peripheral tension headache pain may be a result of  these (and many other) chemical substances interacting [27]. It has been shown that if patients with episodic tension headaches are injected with a mixture of these naturally-occurring chemicals (like histamine, serotonin, and bradykinin), they experience greater muscle tenderness and pain than healthy controls with no history of tension headaches  [40]. 

As these physiological symptoms occur more and more frequently, they are believed to have a bottom-up effect on the brain.

The change in cellular metabolism, constant inputs from soft tissues, and increased inflammation eventually lead to chronic headaches which are further characterized by:

1. Central sensitization: The prolonged input described to occur for episodic/infrequent tension headaches overtime leaves a toll on the body to such an extent that it affects brain cells and tissues. (Bezov et al., 2010). 
2. Myofascial trigger point activation: While this is still an area of debate, some studies have shown that activation of myofascial trigger points (hypersensitive nodules in muscles that when pressed can create pain) can lead to headaches in chronic patients (Alonso-Blanco et al., 2011).  
3. Hyperexcitability of neurons: Another study showed that after exercise, the blood flow in chronic patients’ trapezius muscles was not at the level of normal controls. This suggests that there are increased constrictions in their blood vessels (vasoconstriction) as a result of hyperexcitability in the brain’s neurons (Fernandz-de-las-Penas et al., 2007). 
4. Brain structure changes: Sufferers of chronic headaches have been found to have different brain structures than healthy volunteers without a headache history do. Chronic tension headache patients have decreased tissue mass in the hippocampus, temporal lobe, anterior cingulate cortex, insular cortex, pons, and the orbito-frontal cortex (Schmidt-Wilcke et al., 2005) (Cathcart, 2009). 
5. Stress and emotional factors: Current research efforts are also pointing out that it’s possible that anxiety and stress can also contribute to the chronic nature of tension headaches. For example, stress can influence already sensitized pain pathways. An experiment showed that if chronic headache patients are more sensitive to pain and if they are subjected to stress, they will develop a headache as a reaction to the stress (Cathcart, 2010).  

The implication of these signaling pathways leads to similar pain experiences for several medical conditions and are not exclusively unique to tension headaches. 

Therefore, since the body is a collection of blood vessels and nerves, any interruption or change in their flow and signaling to the brain and neck regions can be experienced as a tension headache. 

Before we move to the medical explanation of tension headaches, for those especially interested in details, below is the mechanism (from this study) that shows how episodic tension headache can be converted into chronic tension headache due to constant stress.

‍

How Is Symptom Overlap Possible? 

Since tension headaches are characterized by head and neck pain and stiffness, any condition that includes these features may be mistaken for a tension headache. 

For example, subarachnoid hemorrhage includes neck stiffness and in 50% of patients this is accompanied by a milder type of headache. As a result, symptoms may point in the direction of tension headaches instead of a serious underlying condition.

Also, if the head and neck arteries are inflamed (a condition known as giant cell arteritis), then, the patient will present symptoms of a tension headache, as well (Rana et al., 2014). But, in this case, tension headaches are not primary, but secondary. 

Symptom overlap between these and several other diseases is possible as changes to normal physiology can in turn affect pain pathways, change cellular metabolism and function, and result in perceived muscle tension and pain. 

In the next section, we will take a look at which disorders also often feature tension headaches. 

Potential Overlapping Disorders

Since tension headaches affect the blood vessels and pain pathways, there can be several conditions that feature or even look like a tension headache but are not.

For example, these overlapping disorders can feature or even mimic tension headaches:

• Chronic daily headaches/Mix headaches: Some people experience mixed headaches with joint characteristics of both migraines and tension headaches. People with chronic daily headaches (CDH) do not fall strictly into either category (of migraine or tension headaches). Studies have shown that CDH patients respond better to a combination of anti-stress and anti-migraine medications than they would if they’d only take one type of medication. Improvements as a result of this mix suggest that a mixed type of CDH headaches is clinically possible and should be considered by doctors (Aich et al., 2018). 
• TMJ syndromes: If there is an issue with the joint that connects your jaw to your skull, the temporomandibular (TMJ) joint, then you could have a TMJ syndrome. The TMJ syndromes lead to jaw spasms, but the swelling and inflammation can ultimately produce tension headaches, as well. This overlap may be partly explained by increased sensitization of nociceptive pathways and abnormalities in the pain modulatory systems (Svensson, 2007). 
• Chronic overlapping pain conditions: There is an overlapping nature in many of the most common pain conditions. Coexisting pain disorders, formally known as Chronic Overlapping Pain Conditions (COPCs), include conditions such as chronic tension headaches, migraines, chronic lower back pain, fibromyalgia, endometriosis, and TMJ syndromes. Therefore, the tension headaches you may be experiencing may be a result of an underlying COPC   (Maixner et al., 2016).
• Chronic fatigue syndrome: Feeling chronically tired, a hallmark of chronic fatigue syndrome (CFS). Patients with CFS exhibit more symptoms of tension headaches than healthy adults do. CFS patients also show symptoms of fibromyalgia. Since symptoms are used to diagnose conditions, overlapping symptoms demonstrate how these conditions overlap (Aaron et al., 2000).
• Fibromyalgia: Fibromyalgia is defined as widespread and chronic bodily pain, marked with symptoms such as sleep disturbance and fatigue (Fitzcharles & Hauser, 2018). The symptoms that fibromyalgia patients report overlap with other COPCs, such as chronic tension headaches and CFS (Aaron et al., 2000). 
• Tinnitus: Tinnitus, feeling of ringing in the ears, can occur as a result of muscle tension, and so can a tension headache. Although the mechanism is unknown, it has been proposed that the reason tinnitus and tension headaches coincide is because of the excitability of the trigeminal nerve or neck pain/TMJ (Langguth et al., 2017). 
• Giant celI arteritis: If you are over 50 years old, doctors must also consider giant cell arteritis (GCA), an inflammatory disease of large blood vessels). This condition can be confused for simple tension headaches since it includes pain in the temples corresponding with a headache. To screen for GCA, you must take a blood test that checks for c-reactive protein and erythrocyte sedimentation rate (ESR). There is a documented case where GCA was undiagnosed, rather the doctors thought the patient was experiencing tension headaches. As a result, irreversible vision loss occurred due to delayed GCA diagnosis (Rana et al., 2014). Because GCA affects the medium and large arteries that are spread in the upper part of the body, such as the neck and head, inflammation on these arteries can feel like a tension headache. 

In order to diagnose tension headaches as the primary cause of discomfort, all of the conditions we mentioned previously must be ruled out first. To do this, doctors consider your history and also perform a physical examination. 

Other conditions present similar symptoms with tension headaches include eye disease, sinus disease, intracranial mass, cervical spine disease, idiopathic intracranial hypertension, and dermatochalasis. 

Thus, it is important to receive professional guidance if you are experiencing tension headaches as they can be more than just the result of a ‘stressful’ day.  

Diagnosing Tension Headaches

Tension headaches are diagnosed via physical exams and medical tests. 

Physical Exam Questions

When your doctor is asking you about your tension headaches, you will likely encounter questions like these:

• What does your headache feel like?
• Where/when do you feel your headaches occurring?
• How long do these headaches last?
• If you sit up or move, do you experience changes in your headache?
• Have you had previous head injuries?
• Do you have difficulty sleeping?
• Have you had any recent changes in your personality and behavior?

If your doctor deems your exam to be normal, then your symptoms are due to a primary headache. However, if there is anything indicating an abnormality, you may have to go through other medical testing procedures as outlined below 

Medical Tests

The following medical tests are used to rule out other causes of tension headaches or to find underlying problems that could be causing the tension headaches:

• Blood tests: Blood tests can identify conditions like GCA which feel like tension headaches but are not. 
• X-rays: X-rays on sinuses are done in order to see whether there are congestion issues or related problems.  
• CT scan: A CT scan utilizes X-rays and computers to make more detailed body images. They can be used for creating detailed images of muscles, fat, organs, and bones. 
• MRI: An MRI can also capture detailed images of the body but relies on radio waves and large magnets to do so. 
• Spinal tap: During a spinal tap, doctors withdraw fluid from your spine and run tests to rule out infection or inflammation. 

While these tests are more invasive than answering a set of questions on how you feel, they are necessary in order to find out the underlying cause of tension headaches. 

In the next section, we will take a look at various research and test methods that researchers use in order to gather more knowledge about tension headaches.

Test Methods for tension headaches

To test specific signaling pathways and how the central system is compromised, brainstem reflex tools are used (Vandenheede & Schoenen, 2002). 

Pain perception studies are also important as they key for establishing that central nociceptive pathways are implicated in chronic tension headaches (Bendtsen, 2000). 

The most commonly used pain perception studies involve taking measurements of:

• Pain detection threshold
• Pain response to suprathreshold stimuli
• Temporal summation
• Pain tolerance thresholds
• Muscle tenderness
• Diffuse noxious inhibitory control (Bezon et al., 2010)

Together, these measurements inform researchers at what levels pain is detectable and how much you can tolerate.

Medication 

Generally, I believe we should not descend to medication. Especially, in case of mild headache and dizziness that does not show red flags.

But for the sake of a complete transparency, here's what generally prescribed for chronically painful and persistent tension headaches.

Chances are you might be prescribed pain and muscle relaxant medication.

pharmaceuticals

‍Commonly used medication for controlling tension headaches includes:

• Acetaminophen (e.g. Tylenol)
• Nonsteroidal anti-inflammatories (e.g. Aspirin)
• Naproxen (e.g. Aleve)
• Ibuprofen (e.g. Motrin, Advil)
• Tricyclic antidepressants (e.g. Amitriptylines like Elavil) (Bendsen, 2000)

Best Ways to Treat Tension Headaches

So, now that we have reviewed the science behind tension headaches, let’s go over commonly used treatments.

Most likely, you will need to combine a few of the treatments below in order to see a reduction in the pain you experience. 

Stress Management

After all, tension headaches are known as stress headaches. If stress is the primary cause of your headaches, maybe stress management is what you need (don’t we all?).

The idea behind stress management is that every day we perform behaviors that drive and reinforce our stress level, ultimately maintaining or increasing our level of tension headaches. Stress management is a way to teach yourself how to identify and cope with stress which could otherwise aggregate your tension headaches. 

Keep a Diary

Diary-keeping is a popular strategy for identifying the stressors that trigger tension headaches (Greene et al., 2018). 

Through this diary, you can take note of many things that will help a doctor guide you, including:

• Frequency of headaches: How often do you experience them?
• Severity: How would you describe the pain and where is it happening exactly?
• Medication: Have you been taking any medications on that day? At what dose?
• Work: What was your workday like? Were you sitting nonstop? Did your eyes ever leave the computer screen? How was your posture? 
• Social events: What is happening in your private life? Is something worrying you or causing you stress? 

If you’re not a paper and pen kind of person, that’s okay. You can always use your phone and keep your diary in the form of notes (Park et al., 2016).

Relaxation techniques

In addition to stress management, relaxation techniques will help you stay calm and stress-free. Yoga is particularly helpful as it can calm down both your mind and body and relax any tension in the back of your neck. 

Biofeedback

Biofeedback is another commonly used approach for controlling tension headaches. You receive information about physiological processes, such as your muscles. Then, you learn how to self-regulate the response/muscle tension.  

At-home Recommendations

Sometimes, doing soothing things at home may be enough to start feeling better. Harvard Health suggests that simple at-home remedies may be enough for some people like having a light snack, taking a short nap, or enjoying a warm shower. 

Self-awareness

Self-awareness is really important for nipping your headaches at the bud. By objectively evaluating yourself, your thoughts, emotions, and behaviors, you may be able to identify areas in your life that do not align with your best self. Investigate and fix these areas in your life as they may be negative sources that affect your health and well-being, ultimately triggering tension headaches. 

Improve Your Posture

As mentioned previously, your posture during the day plays a big role in the frequency and severity of the tension headaches you experience. Also, your sleeping posture may also be a factor here. If you have bad posture, make it a priority to fix it ASAP. 

We are moving on to the Self Help section of our journey.

If you don't want to hear about that but just need more information about tension headaches, I recommend this post by painscience.com. It's the best one I could find to date that clarifies many misconceptions.

So what's the problem and why nothing works?

Because probably you, like myself, experience symptoms on the intersection of several conditions such as ON, CGH, Migraine, Tension headaches, and more.

Since we are dealing with the mix symptoms (research is not yet clear on how it all manifests), targeting one symptom in isolation is a painful (and costly) waste of time.

We need to address underlying processes on a more global scale that sometimes means getting results which are not immediate but sustainable (assuming you are not fainting right at this moment because of unbearable pain; call emergency now if that's the case).

The idea is:  Let's deal with the pain and distress so we can have energy, motivation, and mental clarity for a more radical treatment.

‘The time to fix the roof is when the sun is shining.’

We're going to prepare ourselves (help the sun to come out) in order for the true healing process to even begin (fixing the roof).

Physical pain and emotional frustration (resulting from not understanding what's happening and how to deal with it) is what turns our lives into a miserable existence. Generally, we experience a lack of will to do anything until this continuous confusion goes away.

You can learn here why your emotional and mental states can literally generate physical pain.

We need to clear the fog, so to speak, in order to breath freely for a moment so we can gather energy and realize that there's a way out of all this.

Let's do it.

I've created a simple, easy-to-follow model for self-healing. It's simple. It's universal. It's free.

Here are some references used for this article:

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4. https://www.ncbi.nlm.nih.gov/books/NBK507859/
5. https://vestibular.org/migraine-associated-vertigo-mav
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7. https://health.clevelandclinic.org/vestibular-migraines-why-this-dizzying-type-of-migraine-is-a-little-strange/
8. https://www.webmd.com/migraines-headaches/vestibular-migraines#1
9. https://headacheaustralia.org.au/headachetypes/vestibular-migraine-vm/
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12. https://www.neurologyadvisor.com/topics/migraine-and-headache/carving-out-an-identity-for-vestibular-migraine/
13. https://migraine.com/migraine-treatment/natural-remedies/ginger-for-migraine-headaches/
14. https://pubmed.ncbi.nlm.nih.gov/22517298/
15. https://vestibular.org/migraine-associated-vertigo-mav
16. https://www.mayoclinic.org/diseases-conditions/dizziness/symptoms-causes/syc-20371787
17. https://www.healthline.com/health/head-mri
18. https://www.mayoclinic.org/diseases-conditions/vertigo/symptoms-causes/syc-20370055
19. https://www.mayoclinic.org/diseases-conditions/dizziness/symptoms-causes/syc-20371787
20. https://www.webmd.com/brain/types-of-vertigo#1