Tension-Type Headaches

According to the International Headache Society, diagnostic criteria for tension-type headache include:

• Headache lasting from 30 minutes to 7 days
• Headache has at least two of the following characteristics:
  • Bilateral (both sides of the head)
  • Pressing or tightening (non-pulsating) quality
  • Mild or moderate intensity
  • Not aggravated by routine physical activity (e.g. walking, climbing stairs)
• Both of the following:
  • No nausea or vomiting
  • No more than one of photophobia (light sensitivity) or phonophobia (sound sensitivity)

Diagnosis is primarily clinical and based on symptom history and physical examination. Imaging studies are generally not required unless there are red flags such as new onset headache, progressive worsening, neurologic deficits, systemic symptoms, or concern for secondary headache causes.

The exact cause of tension-type headache is multifactorial and not fully understood. Contributing factors may include:

• Myofascial pain and muscle tension, particularly involving the:
  • Suboccipital muscles
  • Upper trapezius
  • Levator scapulae
  • Temporalis and masseter muscles
• Poor posture or prolonged static positions (desk work, screen time)
• Cervical spine dysfunction or reduced mobility
• Stress, anxiety, or emotional strain
• Sleep disturbances or poor sleep quality
• Jaw clenching or bruxism
• Visual strain
• Deconditioning and reduced physical activity

Treatment of tension-type headache typically involves a multimodal approach with emphasis on conservative and preventative strategies.

Conservative and lifestyle management

• Education and reassurance
• Optimization of posture and workstation ergonomics
• Regular aerobic exercise
• Stress management (mindfulness, relaxation training, cognitive behavioral therapy)
• Sleep optimization
• Limiting excessive screen time and taking regular breaks
• Addressing contributing factors such as jaw clenching or poor ergonomics

Physical and rehabilitative therapies

• Physical therapy focused on cervical spine mobility, postural correction, and strengthening
• Myofascial release techniques
• Massage therapy
• Chiropractic or manual therapy (when appropriate)
• Kinesiology or movement-based therapy

Medications

Acute treatment:

• Acetaminophen (Tylenol)
• Non-steroidal anti-inflammatory drugs (NSAIDs)

Preventive treatment (particularly for frequent or chronic tension-type headache):

• Tricyclic antidepressants (e.g. amitriptyline, nortriptyline)
• Serotonin-norepinephrine reuptake inhibitors (e.g. duloxetine, venlafaxine)
• Muscle relaxants (e.g. cyclobenzaprine, tizanidine, methocarbamol)

Injection and procedural options

For patients with refractory symptoms or significant myofascial involvement, interventional options may be considered, including:

• Trigger point injections targeting hyperirritable muscle bands
• Occipital nerve blocks when posterior head or upper neck involvement is present
• Botulinum toxin (Botox) injections, particularly in chronic tension-type headache with significant muscular contribution

These procedures are typically used as part of a broader treatment strategy rather than as stand-alone therapy.