Tension headaches are frequent, intermittent, moderate headache pain originating occipitally or bifrontally. Tension headaches may be episodic or chronic, characterized by a dull, persistent sensation of tightness, pressure, or stiffness that may spread to both temples and the entire head. With chronic tension headache, muscles in the neck, shoulders, and jaw may be tight and sore. Duration ranges from 30 minutes to several days, or longer. Tension (also called muscle contraction) headaches account for the majority of all headaches. Most resolve spontaneously. Surveys indicate higher incidence in women, which might be explained by women's greater likelihood of seeking medical assistance.

Prolonged contraction of shoulder, neck, face, and scalp muscles constricts blood vessels, which irritates surrounding nerves and triggers pain. Restricted circulation also causes oxygen deficiency in muscles, resulting in excessive accumulation and impaired circulatory removal of pain-producing toxins.

• Referred pain from forehead, scalp, mouth, throat, eyes, sinuses, and meninges serviced by the trigeminal nerve
• Prolonged sitting, sitting in an uncomfortable position, or immobility
• Anxiety or stress
• PMS, hypoglycemia, dehydration, food allergy, insomnia
• Depression

• Family history of tension headache; although tension headaches are probably not inherited, family members may share personality traits, behavior patterns, and poor stress management skills
• Chronic stress or anxiety
• Depression
• Poor posture
• Irritability
• Excessive caffeine intake (including caffeine withdrawal)
• Fatigue, lack of sleep, and overwork syndrome
• Deficient exercise pattern
• Eyestrain
• Temporomandibular joint dysfunction
• Cervical spine mechanical problems
• Hypothyroidism and low adrenal function
• Carbon monoxide exposures
• Artificial sweeteners (up to 14% incidence in aspartame [Nutrasweet] users)
• Trichloroethylene (industrial chemical) contamination of the water supply

• Originates bifrontally or occipitally, then spreads to entire head
• Often described as feeling as though one's head were being squeezed in a vise or constricted by a tight hatband
• Chronic or continuous headache lasting 30 minutes to days, or longer
• Morning or early afternoon onset with pain continuing through the day; headache may be present on waking but does not disrupt sleep
• Grinding teeth
• Insomnia
• Tight, sore muscles in neck and shoulders
• Pain is not aggravated by routine physical activity
• Headache is often associated with emotional stress or depression, or may occur premenstrually in women

• Acute headache
• Brain tumor or brain abscess
• Eye lesions, eyestrain, iritis, glaucoma
• Toxic states, including infections, alcoholism, uremia, lead, arsenic, morphine, CO poisoning, encephalitides
• Overuse of caffeine
• Premenstrual syndrome
• Migraine or sinus headache

Rule out organic disease and cranial trauma.

Patients are generally in good health. Patient may present with tight muscles in face, scalp, and neck.

Diagnostic tests for tension headache are not available. Laboratory tests may be used to rule out other causes of headache symptoms.

Educate patient in stress avoidance and stress management to prevent recurrence of tension headaches. Physical fitness should be encouraged. Biofeedback, yoga, and relaxation techniques can be quite effective for both acute relief and decreasing headache frequency.

• Nonprescription analgesics are usually effective temporary remedies; to prevent rebound headaches, educate patient about proper use of analgesics. Caffeine enhances effect of analgesics for some people; excessive caffeine or caffeine withdrawal may itself cause headaches. Prescription analgesics containing codeine or oxycodone relieve severe headache.
• For acute attack, NSAIDs: naproxen (500 mg bid), ibuprofen (400 mg tid)
• As prophylaxis for chronic headache, antidepressants: amitriptyline (50 to 100 mg/day), imipramine (50 to 100 mg/day)
• Beta-blockers as a prophylaxis: propanolol (80 mg/day), atenolol (50 to 100 mg/day)

The main emphasis of therapies is stress managment and muscle relaxation.

• Micronutrients: Because tension headache is so often related to increased stress, replacement of micronutrients which are depleted in times of stress is essential; the most critical are vitamins C, E, beta-carotene, B-complex and minerals magnesium, potassium, calcium, zinc, manganese, and selenium. Magnesium (aspartate or glycinate, up to 750 mg/day) is especially critical because of its antispasmodic action.
• Avoid caffeine: Increased caffeine intake is correlated with increased incidence of headaches. Cessation of caffeine may lead to withdrawal headaches that should resolve in two to four days.
• Essential fatty acids: regulate platelet aggregation and arachidonic acid metabolites. Dietary manipulation includes reducing animal fats and increasing fish. A mix of omega-6 (evening primrose) and omega-3 (flaxseed) oils may be most optimum (2 tbsp. oil/day or 1,000 to 1,500 IU bid).
• Vitamin E: 400 to 800 IU/day may decrease muscle cramping.
• Elimination/challenge diet: The most common allergic foods are wheat, dairy, corn, soy, and chocolate. Avoid these foods completely for two weeks, then reintroduce the foods one at a time, every three days, and note symptoms. Citrus, alcohol, red meat, flour products, spices, and carbonated drinks may also aggravate headaches.
• Calcium/magnesium: 1,000/500 mg/day may help to regulate muscle contraction and relaxation.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Peppermint oil (Mentha piperita)—a natural antispasmodic and diuretic, was shown in German studies to be as effective against tension as extra-strength Tylenol. Add two drops of peppermint or lavender essential oil to one cup of water. Soak a cloth in the solution and apply as a compress.
• White willow bark (Salix alba)—contains salicin, the pain reliever in aspirin.
• Meadowsweet (Filipendula ulmaria)—contains salicylic acid. Relieves pain, reduces nausea and heartburn; particularly effective for tension with digestive effects
• Valerian (Valeriana officinalis)—sedative and antispasmodic, digestive bitter, particularly for tension with anxiety and/or digestive effects
• Jamaica dogwood (Piscidia piscipula)—sedative, pain reliever, antispasmodic
• Ginkgo (Ginkgo biloba)—increases circulation to the brain, regulates platelet aggregation, particularly for tension with difficulty concentrating or circulatory problems
• Combine white willow, meadowsweet, and two of the above herbs. Use equal parts of either herb or tincture. Herbs: 1 tbsp. in 1 cup water tid. Tincture: 60 drops tid.
• Kava kava (Piper methysticum)—45 to 60 mg of kavalactone content tid, has a calming effect if anxiety is prominent.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Aconite for sudden onset tension headaches with anxiety that follow shock or are accompanied by a fever
• Bryonia for congestive headaches that feel worse with movement and better with pressure and/or eyes closed; headaches may start on the left and spread to the whole head
• Gelsemium for heavy feeling headaches and confusion, especially with blurry vision or vertigo
• Belladonna for throbbing headaches of sudden onset, that feel worse with motion, but the pain keeps the patient from being able to be still

During any of these therapies, patient should be instructed to practice deep breathing, visualization, or relaxation techniques.

• Biofeedback helps patients learn to control muscle tension and to relax problem areas.
• Neck stretches can relieve pain. Gently stretch by moving the head to one side, then the other, resting it against the palm of the hand. Shoulder rolls will also help to relax the upper torso.
• Press an ice pack to the forehead to constrict swollen blood vessels and relieve pain.
• Acupressure points at the web between thumb and first finger. Press in small circular motions at the tender points.
• Regular exercise, with an emphasis on both upper and lower back and abdominal areas increases muscle tone (better contraction but also better relaxation).

May be helpful for pain relief and decreasing frequency of headaches

Gentle massage of shoulders and neck to loosen tight muscles and relieve tension can be very helpful.

A sudden change in symptoms may indicate possible serious illness.

• Patient should learn to avoid stressors that trigger headaches.
• Psychological counseling may benefit patients whose headaches stem from suppressed emotions, depression, or anxiety.

Most tension headaches are self-limiting or rapidly remedied with patient education and analgesics. Underlying factors should be addressed to decrease frequency of occurrences.

Care should be taken when using analgesics or alternative remedies during pregnancy. Some headaches resolve during pregnancy.

Berkow R. The Merck Manual. 15th ed. Rahway, NJ: Merck Sharp & Dohme Research Laboratories; 1987.

Scalzo R. Naturopathic Handbook of Herbal Formulas. 2nd ed. Durango, Colo: Kivaki Press; 1994.

Walker L, Brown E. The Alternative Pharmacy: Break the Drug Cycle with Safe Natural Treatment for 200 Everyday Ailments. Paramus, NJ: Prentice Hall; 1998.