Chronic tension headache is a condition where you have a tension headache on at least 15 days every month for at least three months. The cause of chronic tension headache is often not clear. A medicine called amitriptyline may help to prevent the headaches from occurring.
What is chronic tension headache and who is affected by it?
Chronic tension headache is a condition where you have a tension headache on at least 15 days every month for at least three months.This can be tiring and depressing. Tension headache (also called 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 headache is, as few studies have looked at this clearly. Some studies have estimated that around 1 in 30 of all adults have chronic tension 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-overuse headaches (medication-induced headaches) as a result of their tension 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, however, this condition is often quite disabling and distressing, and most patients take preventative medication.
What causes chronic tension headache?
This condition tends to develop in people who start off with having tension headaches with increasing frequency, until they occur on most days. However, the cause of the tension 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. Many chronic tension headaches develop for no apparent reason. Working long hours bent over a computer may trigger them.
Some people get tension 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 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 headaches than others when stressed or anxious.
By definition, tension headaches are not caused by other conditions. So, if you have chronic tension 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-overuse headache can be similar to chronic tension headache.
Medication-overuse headache is caused by taking painkillers (or triptan medicines) too often for tension headaches or migraine attacks. See the separate leaflet called Medication-overuse Headache (Medication-induced Headache).
What are the symptoms of each tension headache?
- Tension headaches are usually felt as a band or across the forehead. They can be uncomfortable and tiring, but they do not usually disturb sleep. 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 headaches can interrupt concentration but are usually not bad enough to send you to bed. Most people can work through a tension headache if they really need to.
- A tension headache can last from 30 minutes to seven days. Most last a few hours.
- Tension headaches tend to become worse as the day goes on and are often mildest in the morning. They are not usually made worse by physical activity.
- 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.
- There are usually no other symptoms.
Sometimes migraines are mistaken for chronic tension headaches. Some people don't like bright lights or loud noises, and don't feel like eating much when they have a tension headache. However, marked dislike of light or loud noise, and visual disturbances, like zigzag lines, are more 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 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 headache put up with their headaches without seeing a doctor. In one study, two thirds of people diagnosed with chronic tension 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 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 headaches, you are normally well between headaches, and have no other ongoing symptoms. A doctor diagnoses tension 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 headache is suspected. Of particular note, medication-overuse headache (medication-induced headache) should be ruled out (described earlier) as this can often be mistaken for chronic tension headache.
Compared to migraine, a tension 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 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 cause the second.
What are the treatments for chronic tension 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-overuse headache (medication-induced headache). 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 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-overuse headache if used regularly.
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 focusing 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 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 apps 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 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 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)
CBT 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 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 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 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.
Further reading and references
Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache; British Association for the Study of Headache (BASH) Guidelines, (2010 - reviewed 2014)
Guideline on the treatment of tension-type headache; European Federation of Neurological Societies (2010)
EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force; European Federation of Neurological Societies (August 2009)
Headache - assessment; NICE CKS, October 2017 (UK access only)
Headache - tension-type; NICE CKS, November 2017 (UK access only)
Prakash S, Patel P; Hemicrania continua: clinical review, diagnosis and management. J Pain Res. 2017 Jun 2910:1493-1509. doi: 10.2147/JPR.S128472. eCollection 2017.
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