Tension Headache

Tension headache is the most common cause of headache in the general population. It causes mild to moderate pain and is often caused by stress or fatigue.

Most people only experience tension-type headache occasionally and can treat their symptoms at home. However, chronic tension headache can be disabling, and requires medical consultation. This article provides a thorough review of tension headache including the symptoms, available treatments, and when to see a doctor.

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Medically reviewed by Dr Trudy Cheng. Last updated September 4, 2022.

What is tension-type headache?

Tension-type headache is one of the most common headache types. It causes mild to moderate pain which is felt on both sides of the head (1). It is often described as a tightening sensation, like a band around your head.

Almost everyone will experience a tension headache at some point in their life. It is also called a ‘stress headache’, because stress is a common trigger for this headache type.

Most people just have tension headache occasionally, but for some people it can be chronic.

Causes & triggers

The exact cause of tension headache is not known. Researchers used to think it was caused by muscle contractions, but this has since been disproven. While muscle tenderness & tension can aggravate tension headache, it is not the cause of the pain (2). 

Some studies suggest that it could be caused by the hyperexcitability of certain neurons or neurotransmitters (3). When these nerves are over-stimulated, they send out pain signals – even though you haven’t been physically injured. Some of the neurotransmitters involved in head pain include nitric oxide and calcitonin gene-related peptide (CGRP) (3).

Even though we don’t know the exact neurobiological cause of tension headache, many triggers have been identified. Some common triggers include:

  • Stress and anxiety
  • Fatigue
  • Depression or crying/being upset
  • Poor posture
  • Bright, noisy environments
  • Eye strain (i.e. long periods of reading, screen time)
  • Smoking
  • Caffeine dependence or withdrawal
  • Dehydration
  • Overuse of pain relief medications


The symptoms of a tension headache include (1):

  • Dull, aching pain (mild to moderate intensity) felt on both sides of the head
  • Pressing or tightening feeling
  • Tenderness around the forehead, scalp, neck, and shoulder muscles
  • Lasts between 30 minutes and 7 days 
What is tension headache - diagram showing pain in the shape of a headband across someone's forehead

Tension headache is not aggravated by routine physical activity such as walking or climbing stairs. It is not accompanied by nausea, but occasionally either sound or light sensitivity might be present. 

Is it tension headache or migraine?

Sometimes people mistake tension headache for migraine, or vice versa. However, there are a few tell-tale differences that can help you understand which type of headache you have.

MigraineTension headache
Moderate to severe painMild to moderate pain
Pulsating headache on one side of the headDull ache or tightening sensation, usually across the entire head
Typically lasts 4-72 hoursCan last between 30 minutes and 7 days
Associated with nausea, vomiting, sound & light sensitivityUnlikely to be accompanied by other symptoms
Aura symptoms may be present (may be described as flickering lights, zigzag lines or loss of part of the visual field, usually occurring just before or during the headache)No aura symptoms
Aggravated by physical activityNo aggravation by physical activity

The misdiagnosis of migraine and tension headache occurs partially because migraine is misrepresented as ‘just a headache’. This stigma affects the diagnosis of both headache disorders. If someone is having a bad tension headache, they might think it is migraine. On the other hand people with migraine tend to downplay their condition, especially if people in their life don’t take it seriously.

It is important to diagnose headache disorders accurately to reduce stigma and help people get the right treatment. If your headache begins to interfere with your day-to-day life, please consult your doctor.

Types of tension headache

Episodic tension headache

Episodic forms of tension headache are the most common causes of headache in the general population (2). It can be infrequent (0-1 headache days per month) or frequent (1-14 days per month). 

Most people treat episodic tension headache by themselves using over-the-counter pain medication (e.g. paracetamol, ibuprofen, aspirin). People with higher frequency episodic headache might consult a doctor. If you have headache more than once a week, it can start to affect your personal, professional, and social life.

Chronic tension headache

Chronic tension headache is much less common, affecting about 3% of the general population (2). It evolves from episodic tension headache and is diagnosed when someone has headache on 15 or more days per month. 

Chronic tension headache can be highly disabling and people often need to see a doctor to discuss their treatment. Managing this headache type usually involves a combination of lifestyle changes, preventive medication, and non-pharmaceutical treatments.

When to see a doctor

Tension headache is very common, and the occasional headache is often nothing to worry about. Most people treat attacks at home by resting, drinking water, or taking paracetamol/ibuprofen.

However, you should make an appointment with your doctor if it begins to disrupt your daily life, or if you need to take painkillers more than twice a week. Getting proper treatment can prevent frequent episodic headache from becoming a chronic disorder.

Generic image of a doctor

If you have already been diagnosed with frequent or chronic tension headache, you should also see a doctor if your attacks change or worsen in any way.

In some cases, a headache could be a symptom of a serious medical disorder. You should seek medical attention as soon as possible if you experience:

  • ‘Thunderclap’ headache – a sudden, severe headache
  • A headache that progressively gets worse over several weeks
  • A morning headache with nausea that doesn’t go away
  • Headache accompanied by:
    • Stiff neck
    • Fever
    • Change in personality or your level of consciousness
    • Double vision or loss of vision
    • Loss of balance or sensation
    • Nausea and/or vomiting
    • Convulsion
  • A new headache for patients with cancer, immunodeficiency, or suppressed immune system from medications
  • A family history of glaucoma
  • Headache after a head injury or accident
  • Aura symptoms (see migraine aura) that last longer than an hour, if they are different from usual, or occur for the first time when you take an oral contraceptive pill

If possible, seek emergency care or call 000 for any of these symptoms to get an accurate diagnosis as soon as possible.

Treatment of tension headache

Most of the time you can treat tension headache with home remedies or over-the-counter pain medication.

If your headache was triggered by something in particular, you can start by addressing the trigger. For example, drink water if you are dehydrated, or try relaxation techniques if you are stressed. Other non-pharmaceutical treatments include applying a heat pack or a neck massage.

Generic image of massage

If these strategies don’t help, you can take over-the-counter painkillers to treat an attack. Studies have found aspirin to be most effective, but ibuprofen and paracetamol are also recommended (4). Medications that combine painkillers with caffeine can be useful as well. Caffeine has been shown to significantly increase the efficacy of simple analgesics and ibuprofen in controlled clinical trials (4).

Over-the-counter medications should only be taken two to three times per week due to the risk of medication overuse headache. Medication overuse headache can increase the frequency and severity of your headache disorder, and make it less responsive to treatment.


Preventive treatment is recommended for people with frequent tension headache or those who don’t respond to over-the-counter pain medication (2). Your doctor can help you develop a headache management plan based on your lifestyle and medical history.

Given that stress is one of the most common triggers for tension headache, stress management techniques are often recommended as a preventive treatment.

  • Biofeedback training. This is a relaxation technique that teaches you to control certain body responses to manage pain and stress. Studies have shown that biofeedback is the most effective non-pharmaceutical treatment for tension headache (4).
  • Cognitive behavioural therapy (CBT). CBT is a type of psychological treatment that helps you identify situations that make you anxious or stressed, and gives you the tools to better manage that stress.
  • Relaxation classes or techniques. Doctors might recommend yoga, stretching, deep breathing or meditation to help prevent headache.
Image of biofeedback process using electromyography sensors.

Your doctor might also prescribe you a preventive medication. There are no medications developed specifically to prevent tension headache, however studies have shown that amitriptyline can be quite effective (4, 5). Other tricyclic antidepressants are sometimes used if you have an adverse reaction to amitriptyline. Mirtazepine and maybe venlafaxine can be effective (5).

In general, maintaining a healthy lifestyle is also recommended to prevent tension headache. 

This includes:

  • Exercising regularly
  • Drinking enough water
  • Maintain a regular sleep schedule
  • Eat regular, balanced meals

Taking care of your overall health can reduce stress and other major headache triggers.

Further information & resources

Headache is a much more complicated symptom than it appears, with many different types, causes, and symptoms. If you want to learn more about anything covered in this article, you can check out the following resources on our website:


  1. International Headache Society, 2018, 2. Tension-type headache. Retrieved from: https://ichd-3.org/2-tension-type-headache/ 
  2. E Loder & P Rizzoli, 2008, Tension-type headache. DOI: 10.1136/bmj.39412.705868.AD
  3. M Ashina, 2004, Neurobiology of chronic tension-type headache. DOI: 10.1111/j.1468-2982.2003.00644.x 
  4. R G Kaniecki, 2012, Tension-Type Headache. DOI: 0.1212/01.CON.0000418645.32032.32
  5. L Bendtsen, 2009, Drug and Nondrug treatment in tension-type headache. DOI: 10.1177/1756285609102328
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