Chronic Tension-type Headache

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.Tension-type headache is the common type of headache that most people have at some time. One study found that, on average:

• About half of adults have a tension-type headache every 'now and then' - less than 1 a month. This is called infrequent episodic tension-type headache.
• About a third of adults have 2 or more tension-type headaches per month, but fewer than 15 a month. This is called frequent episodic tension-type headache.
• About 3 in 100 adults have a tension-type headache 15 or more times per month - that is, on most days. This is called chronic tension-type headache.

Chronic tension-type headache is sometimes called chronic daily headache, as many people have a headache every day. Chronic means 'persistent'. It does not mean severe as some people think. The severity of the headaches can vary from mild to severe. Because of the persistent nature of the headaches, this condition can be quite disabling and distressing.

What causes chronic tension-type headache?

This condition tends to 'evolve' in people who start off with having tension-type headaches more often than usual, until they occur on most days.

What causes tension-type headaches?

The cause is not clear. Some, but probably not most, may be due to tension. This is why the term 'tension-type headache' is now used rather than 'tension headache'. Many tension-type headaches develop for no apparent reason. Some may be triggered by things such as:

• Emotional tension, anxiety, tiredness or stress.
• Physical tension in the muscles of the scalp and neck. For example, poor posture at a desk may cause the neck and scalp muscles to tense. If you squint to read because you cannot see well, this may tense your scalp muscles too.
• Physical factors such as bright sunlight, cold, heat, noise, etc.

Some research suggests that your genetic make-up may be a factor. So, some may people inherit a tendency to be more prone to develop tension-type headaches more easily than others when stressed or anxious.

By definition, tension-type headache is not caused by other conditions. So, if you have a tension-type headache, a doctor's examination will be normal apart from the muscles around the head perhaps being a little tender when a doctor presses on them. Also, any tests that may be done will be normal.

Note - medication-overuse headache can be similar to chronic tension-type headache

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. 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-overuse 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 'Headache - Medication-Overuse' gives more details.

What are the symptoms of each tension-type headache?

• Typically, the pain is like a tightness around the 'hat-band' area. Some people feel a 'squeezing' or 'pressure' on their head. It usually occurs on both sides of your head, 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, but sometimes it is severe.
• A tension-type headache can last from 30 minutes to 7 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.

The headaches you have with chronic tension-type headache are the same as described above, but occur frequently. In some cases, the headache seems 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 7 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. Also, 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-overuse headache should be ruled out (described earlier) as this can often be mistaken for chronic tension-type headache.

Compared to migraine (the other common type of headache that comes and goes), a tension-type headache is usually less severe, and is constant rather than throbbing. Also, migraine attacks usually causes a one-sided headache, and many people with a migraine attack feel sick or vomit. In general, unlike migraine, you are usually able to continue with normal activities if you have a tension-type headache. Some people have both migraine attacks and tension-type headaches at different times.

What are the treatments for chronic tension-type headache?

Painkillers

You may well be used to taking painkillers such as paracetamol, aspirin, ibuprofen, etc. But note: 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 2 days in any week for headaches. If you take them more often, you may develop medication-overuse headache (see above). Do not take painkillers all the time 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-overuse headache if used regularly (described earlier).

Diary

It may help to keep a diary if you have frequent headaches. Note when, where, how bad, 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.

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.

Regular exercise

Some 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.

Medication

Amitriptyline is the medicine most commonly used to treat chronic tension-type headaches. This 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. Once the headaches have been reduced for 4-6 months, the amitriptyline can be stopped. Treatment can be resumed if headaches recur. Other medicines are sometimes tried if amitriptyline is not suitable or does not help.

The goals of preventative treatment are to reduce the frequency and intensity of headaches. 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.