Chronic tension-type headache is a condition where you have a tension-type headache on at least 15 days every month for at least three months. Tension-type headaches are usually felt as a band or across the forehead. They can be uncomfortable and tiring, but they do not usually disturb sleep. Most people can carry on working with a tension headache. They are not usually made worse by physical activity, although it's not unusual to be a bit sensitive to bright light or noise. However, chronic tension-type headache can be a wearing and depressing condition, and the headaches can feel as though they are nearly constant.
The cause of chronic tension-type headache is often not clear. A medicine called amitriptyline may help to prevent the headaches from occurring.
What is chronic tension-type headache and whom does it affect?
Chronic tension-type headache is a condition where you have a tension-type headache on at least 15 days every month for at least three months.This can be tiring and depressing. Tension-type headache is the common type of headache that most people have at some time.
It's not known exactly how common chronic tension-type headache is as few studies have looked at this clearly. Some studies have estimated that around 1 in 30 of all adults suffer from chronic tension-type headaches - which means they have a headache on more than half of all days for three months or more. However, it is possible that a proportion of these patients actually have developed medication-induced headaches as a result of their tension-type headaches. Therefore, it can be difficult to be certain which is their main problem.
Chronic means persistent, it does not mean severe. The severity of the headaches can vary from mild to severe. Because of the persistent nature of the headaches, though, this condition is often quite disabling and distressing, and most patients take preventative medication.
What causes chronic tension-type headache?
This condition tends to develop in people who start off with having tension-type headaches with increasing frequency, until they occur on most days. However, the cause of the tension-type headaches is not always clear, and may be more than one thing. They may be due to tension in the muscles at the back of the head and neck, but it is now clear that this is not always the cause. Other causes reported by patients include stress, tiredness, hunger, and eye strain. This is why the term tension-type headache is now used rather than tension headache. Many develop for no apparent reason. Working long hours bent over a computer may trigger them.
Some people get tension-type headaches if they drink too much caffeine or alcohol, if they don't drink enough water or if they go for a long time between meals and become tired and hungry. Occasionally, tension-type headaches can be caused by poor vision, particularly if reading in low light for long periods. Some may be triggered by environmental discomforts such as heat, cold, brightness or wind.
Some research suggests that your genetic make-up may be a factor. This means that some people may inherit a tendency to be more prone to develop tension-type headaches than others when stressed or anxious.
By definition, tension-type headaches are not caused by other conditions. So, if you have chronic tension-type headache, a doctor's examination will be normal apart from the muscles around the head perhaps being fairly tender when a doctor presses on them. Any tests that may be done will be normal.
Note: medication-induced headache can be similar to chronic tension-type headache.
Medication-induced headache (sometimes called medication-overuse headache) is caused by taking painkillers (or triptan medicines) too often for tension-type headaches or migraine attacks. For example, you may take a lot of painkillers for a bad spell of headaches. You may end up taking painkillers every day, or on most days. Your body then becomes used to painkillers and develops extra pain sensors in the head so that the head becomes hypersensitive. A withdrawal headache then develops if you do not take painkillers each day. You think this is just another tension-type headache, and so you take a further dose of painkiller. When the effect of each dose of painkiller wears off, a further withdrawal headache develops, and so on. This is how medication-induced headache develops. It is a common cause of headaches that occur daily, or on most days. If you find that you are getting headaches on most days then this may be a cause. See a doctor for advice. A separate leaflet called Medication-induced Headache gives more details.
What are the symptoms of each tension-type headache?
- Typically, the pain is like a tightness around the forehead. Some people feel a squeezing or pressure on their head.
- It usually occurs on both sides, and often spreads down your neck, or seems to come from your neck. Sometimes it is just on one side.
- The pain is usually moderate or mild. Tension-type headaches can interrupt concentration but are usually not bad enough to send you to bed. Most people can work through a tension-type headache if they really need to.
- A tension-type headache can last from 30 minutes to seven days. Most last a few hours.
- The headache usually comes on during the day, and gets worse as the day goes on.
- There are usually no other symptoms.
- Some people don't like bright lights or loud noises, and don't feel like eating much when they have a tension-type headache.
- Tension-type headaches tend to get worse as the day goes on and are often mildest in the morning.
- An exception to this would be a headache caused by sleeping in an awkward position causing a sore neck, or an ache in the face and jaw due to tooth grinding.
- Sometimes migraines are mistaken for chronic tension-type headaches.
- You DON'T usually get marked dislike of light or loud noise, and visual disturbances like zigzag lines. These are suggestive of migraine.
- A mild feeling of sickness (nausea) can occur, especially if you are using a lot of painkillers. However, marked nausea is, again, more a feature of migraine.
The headaches you have with chronic tension-type headache occur frequently. In some cases, the headache can seem to be permanent, and hardly ever goes, or only eases off but never goes completely.
Many people with chronic tension-type headache put up with their headaches without seeing a doctor. In one study, two thirds of people diagnosed with chronic tension-type headache had had daily or near daily headache for an average of seven years before consulting a doctor. Most continued to function at work or school, but their performance was often not as good as it could be. Almost half had anxiety or depression, possibly as a result of coping with their frequent headaches.
If you think you have chronic tension-type headache, it is best to see a doctor, as treatment can often help.
How can I be sure it is not a more serious type of headache?
With tension-type headaches, you are normally well between headaches, and have no other ongoing symptoms. A doctor diagnoses tension-type headaches by their description. In addition, there is nothing abnormal to find if a doctor examines you (apart from some tenderness of muscles around the head when a headache is present). Tests are not needed unless you have unusual symptoms, or something other than chronic tension-type headache is suspected. Of particular note, medication-induced headache should be ruled out (described earlier) as this can often be mistaken for chronic tension-type headache.
Compared to migraine, a tension-type headache is usually less severe, and is constant rather than throbbing. Also, migraine attacks usually cause a one-sided headache, and many people with a migraine attack feel sick (nausea) or are sick (vomit). Some people have both migraine attacks and tension-type headaches at different times. In addition, some people find that one of the types of headaches is followed by another, perhaps because the pain and tiredness due to the first headache causes the second.
What are the treatments for chronic tension-type headache?
You may well be used to taking painkillers such as paracetamol, aspirin, ibuprofen, etc. Importantly though, you should not take painkillers for headache for more than a couple of days at a time. Also, on average, do not take them for more than two days in any week for headaches. If you take them more often, you may develop medication-induced headache (see above). Do not take painkillers to prevent headaches. Take each day as it comes. Perhaps reserve painkillers for days which are particularly bad.
Opiate painkillers such as codeine, dihydrocodeine and morphine are not normally recommended for tension-type headaches. This includes combination tablets that contain paracetamol and codeine, such as co-codamol. The reason is because opiate painkillers can make you drowsy. They are also the most likely type of painkiller to cause medication-induced headache if used regularly (described earlier).
Treating the cause: diary
It may help to keep a diary if you have frequent headaches. Note when, where, and how bad each headache is, and how long each headache lasts. Also note anything that may have caused it. A pattern may emerge and you may find a trigger to avoid. For example, hunger, eye strain, bad posture, stress, anger, etc.
Some doctors suggest reviewing your diet. The list of foods which can be triggers in some people includes caffeinated drinks, chocolate, cheese and alcohol. Other doctors suggest focus on a healthy balanced diet, with a good mixture of slow-release energy foods (taken in small regularly spaced meals) and a low intake of refined sugars.
Stress and depression
Stress is a trigger for some people who develop tension-type headaches. Avoid stressful situations whenever possible. Sometimes a stressful job or situation cannot be avoided. Learning to cope with stress and to relax may help. Breathing and relaxation exercises, or coping strategies, may ease anxiety in stressful situations and prevent a possible headache. There are books and tapes which can teach you how to relax. Sometimes a referral to a counsellor or psychologist may be advised.
Many people with frequent headaches say that they have fewer headaches if they exercise regularly. If you do not do much exercise, it may be worth trying some regular activities like brisk walking, jogging, cycling, swimming, etc. (This will have other health benefits too.) It is not clear how exercise may help. It may be that exercise helps to ease stress and tension, which can have a knock-on effect of reducing tension-type headaches. It also may be that it strengthens your core and upper back muscles and improves posture. This means you are less likely to 'droop' when you sit and increase tension in the upper back and neck. It could also be an effect of getting the heart rate, breathing and blood flow increasing around the upper body, improving the supply of oxygen to muscles generally.
Physiotherapy may help chronic tension-type headaches through teaching relaxation techniques and breathing exercises. It may also help through detecting and changing physical habits which may be contributing to the headaches. This might include poor posture. Patients must take an active part in this kind of therapy, and do their exercises regularly, in order to see an improvement.
There is some evidence that acupuncture, particularly when combined with medical therapy, can be helpful in the treatment of chronic daily headaches.
Cognitive behavioural therapy (CBT)
This talking therapy can be a helpful add-on in the treatment of chronic daily headache. Behavioural therapies work towards reducing or eliminating the stress which may contribute to the development of chronic tension-type headaches. Some patients dislike the idea of talking therapies, as they feel this suggests that the doctor thinks their headache is actually depression. However, there is good evidence that these therapies do help. This might be because chronic pain is in itself stressful and CBT and other talking therapies help to break the stress-headache-stress cycle.
Amitriptyline is the medicine most commonly used to treat chronic tension-type headaches. This medicine is not a painkiller and so does not take away a headache if a headache develops. It is an antidepressant medicine and you have to take it every day with the aim of preventing headaches. (One effect of some antidepressants is to ease pain and prevent headaches even in people who are not depressed. So, although amitriptyline is classed as an antidepressant, it is not used here to treat depression.)
A low dose is started at first and may need to be increased over time. It is slow to take effect - the low starting dose is to allow you to tolerate the medicine more easily. If higher doses are started immediately they can make you tired and sleepy. It can therefore take a couple of months of gradual dose increases before the medicine really works.
Once the headaches have been reduced for 4-6 months, the amitriptyline can be stopped. Treatment can be resumed if headaches return (recur). Other medicines are sometimes tried if amitriptyline is not suitable or does not help. These include topiramate (more often used to prevent migraine), gabapentin (more usually treatment for pain due to inflamed nerves) and tizanidine (more often used as treatment for muscle spasm). Modern selective serotonin reuptake inhibitor (SSRI) antidepressants such as fluoxetine (Prozac®) are not generally felt to be as helpful in treating chronic tension-type headaches.
The aims of preventative treatment are to reduce the number of headaches, or reduce their severity, or both. So, with treatment, the headaches may not go completely, but they will often develop less often and be less severe. Any headache that does occur whilst taking preventative medication may also be eased better than previously by a painkiller.
It is often difficult in retrospect to say how well a preventative treatment has worked. Therefore, it is best to keep a headache diary for a couple of weeks or so before starting preventative medication. This is to record when and how severe each headache was, and also how well it was eased by a painkiller. Then, keep the diary going as you take the preventative medicine to see how well things improve. The headaches are unlikely to go completely, but the diary may show a marked improvement.
Dr Tim Kenny
Dr Mary Lowth
Dr John Cox