Tension headaches
This is the commonest headache there is: most people will have one at some point in their lives.
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On this page
- What it feels like
- When a headache needs urgent help
- When to see a doctor the same day or this week
- This is not a migraine: how they differ
- When the painkiller is what keeps the pain going
- What turns an occasional headache into a frequent one
- What helps without tablets
- Medicines: for stopping and for preventing
- Online consultation
Medicines commonly prescribed for Tension headaches
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 1 gActive substance: paracetamolManufacturer: Italfarmaco S.A.Prescription requiredDosage form: ORAL SOLUTION/SUSPENSION, 600 mgActive substance: ibuprofenManufacturer: Laboratorios Normon S.A.Prescription requiredDosage form: EFFERVSCENT ORAL SOLUTION/SUSPENSION, 1 g paracetamolActive substance: paracetamolManufacturer: Italfarmaco S.A.Prescription required
This is the commonest headache there is: most people will have one at some point in their lives. It is not dangerous and it does not signal anything sinister — which may be why the thing most worth knowing about it is so rarely written down. And there is an awkward thing worth knowing: in people whose head aches several times a month, the culprit is usually not stress and not posture, but the tablet they use to take the pain away. We come to that a little further down; first, what this headache is like, and when a headache is not this at all.
What it feels like
The picture is quite recognisable.
- The pain is squeezing or pressing, like a band, a helmet or a hat that is too tight. Not throbbing.
- Usually on both sides — forehead, temples, back of the head — sometimes with a feeling of tightness in the neck and shoulders.
- Mild to moderate in strength. You can work through it, drive, finish the page.
- Ordinary activity does not make it worse. Climbing stairs, walking, bending down are all bearable.
- There is no nausea or vomiting. Bright light and loud noise may be mildly irritating, but you do not feel driven to a dark room.
- It lasts from half an hour to several days. The muscles of the neck and scalp are often tender when pressed.
Some people get these episodes now and then; others have them almost constantly. When the head aches on fifteen or more days a month over several months, it is called chronic tension-type headache, and the approach changes: what needs addressing is not each individual episode but why there are now so many.
When a headache needs urgent help
A tension headache produces none of the features below. If any of them appear, this is not tension, and time matters.
Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single European number 112 is in use) if:
- the pain came on suddenly and reached its peak within seconds, "like a blow to the head". That headache needs investigating even if it has eased an hour later;
- the headache comes with a high temperature, a stiff neck that will not let the chin reach the chest, dislike of light, a rash, or confusion;
- there is weakness or numbness in an arm or leg, a drooping face, disturbed speech or vision, unsteadiness, or a seizure;
- the person becomes drowsy or slowed, and stops taking in where they are and what is happening;
- a severe headache begins after a head injury — including several days afterwards, especially in older people and in anyone taking blood-thinning medicines.
When to see a doctor the same day or this week
These features do not call for an ambulance, but they cannot be left until some later date either:
- a headache has appeared for the first time after the age of fifty, or has clearly changed its character compared with the usual one;
- the pain is worse lying down, wakes you at night or is at its worst on waking, particularly with morning vomiting, and also if it worsens on coughing, sneezing or straining;
- the pain builds steadily from day to day over a period of weeks;
- someone over fifty has pain in the temple, a scalp that is sore to touch, and a jaw that tires and aches on chewing — and if vision changes in that setting, help is needed immediately;
- a headache appears in someone with cancer, with a weakened immune system, in pregnancy, or in the first weeks after childbirth;
- the pain comes with a red, painful eye and blurred vision with haloes around lights.
This is not a migraine: how they differ
The distinction matters not for the sake of precision but because the two are treated differently.
- Character. Tension headache squeezes and presses. Migraine tends to throb.
- Side. Tension headache is usually on both sides. Migraine is more often one-sided, though not always.
- Severity. Tension headache is mild or moderate. Migraine is moderate or severe and often stops the day.
- Response to movement. This is the most practical sign: migraine gets worse with ordinary physical activity, with walking or going up stairs, and people instinctively keep still. A tension headache is unchanged by it, and a walk sometimes even helps.
- What comes with it. Migraine brings nausea and vomiting, a marked dislike of light and sound, and a wish to lie down somewhere dark and quiet. None of that is typical of tension headache.
- Warning signs beforehand. In some people migraine is preceded by an aura: shimmering zigzags in the field of vision, a missing patch of vision, numbness in an arm or the face, difficulty speaking, usually lasting five to sixty minutes.
The two are not mutually exclusive: the same person can have both migraines and tension headaches, and each needs sorting out separately. The third possibility, the one that usually gets forgotten, is the subject of the next section.
When the painkiller is what keeps the pain going
This is the main thing worth taking away from this page.
If painkillers are taken on more than a few days a week, they start causing headaches themselves. The condition is called medication-overuse headache, and it is the commonest reason an occasional headache turns into a daily one.
The mechanism is circular, which is what makes it deceptive. You take a tablet, the pain lifts for a few hours and, as the effect wears off, it returns — sometimes worse than before. You take another. Within a few months the head aches almost every day, often from first thing in the morning, the tablets work less well and for less time, and yet without them things are worse still. From the outside it looks as though the illness has got worse, when what has grown is the treatment.
The thresholds worth watching:
- simple painkillers — paracetamol, ibuprofen and the like — taken on fifteen or more days a month;
- combination products (where caffeine or codeine is added to the painkiller), migraine drugs of the triptan group, and any painkiller containing codeine, taken on ten or more days a month;
- put simply: if a painkiller is needed on more than two days a week and that has gone on for months, the risk is already there.
The good news is that it is reversible: after withdrawal most people go on to have far fewer days of pain. The bad news is that the first week or two after stopping is usually worse than before, with more pain, nausea, irritability and poor sleep. That is exactly the point at which people give in and conclude they cannot manage without tablets.
So this is something to come out of with a doctor, not on your own. The doctor will decide what is stopped and how — abruptly or gradually — what to cover that period with, whether to start preventive treatment at the same time, and whether withdrawal needs to happen in hospital. One thing apart: medicines containing codeine and other opioids lead into this trap particularly quickly, and they must not be stopped abruptly without advice either.
What turns an occasional headache into a frequent one
Beyond the tablets, there are thoroughly ordinary things that make a real difference to the number of headache days.
- Sleep. Too little sleep and catching up at the weekend provoke headaches equally. The head prefers a fixed time of getting up to a particular total of hours.
- Caffeine. It works both ways: a lot of coffee provokes headaches, and dropping the usual amount suddenly causes a withdrawal headache for a few days. Cut down gradually.
- Missed meals and too little to drink. Long gaps without food are a common and easily fixed trigger.
- Clenched teeth. Clenching the jaw during the day and grinding the teeth at night produce exactly this kind of pain — in the temples and at the sides of the head, often on waking and with a tired jaw. Worth mentioning to a dentist.
- Long static positions. The issue is less "bad posture" than not moving: several hours in one position at a screen or behind the wheel.
- Eyesight. If the head aches towards the end of the working day and text blurs by the evening, an eye test makes sense: the glasses may be the wrong ones, or no longer the right ones.
- Alcohol, dehydration, emotional strain and anxiety — each contributing differently in different people.
To work out what matters in your own case, keep a diary: for two or three weeks, note the days with pain, how bad it was, the tablets taken, sleep and events. It is dull, but the diary is usually what reveals the connection you had not spotted — and, incidentally, the honest number of days on painkillers.
What helps without tablets
For occasional episodes, simple things are enough: get outside, move about, eat, drink some water, sleep. A warm shower or a heat pack on the neck and shoulders relaxes the muscles; other people do better with something cool on the forehead. Massaging the neck, temples and chewing muscles does not last long, but it works.
When headache days are counted in tens, something else is required — the things done regularly rather than at the moment of pain:
- Regular physical activity. Moderate but consistent: walking, swimming or cycling several times a week. It is one of the few measures with proven effect on how often headaches occur.
- Working on tension. Breathing exercises, progressive muscle relaxation, mindfulness. The effect accumulates: it shows after weeks of short daily practice, not after one attempt.
- Cognitive behavioural therapy and stress management training. For frequent tension headache this is a proven treatment, not optional hand-holding.
- Sessions with a physiotherapist where neck and shoulder tension is marked: exercises rather than passive treatments.
- Routine. Consistent sleeping and waking times, regular meals, a break every hour of work.
Medicines: for stopping and for preventing
Two quite different treatments need separating here.
Stopping an episode. Simple painkillers help: paracetamol and non-steroidal anti-inflammatories such as ibuprofen or naproxen. They work better taken early rather than after hours of putting up with it. Aspirin is also effective in adults, but it is not given to children and adolescents. In pregnancy, any painkiller is taken only in agreement with a doctor. And the rule that follows from the previous section: count days, not tablets. Stay within a few days a week, and combination products with caffeine and codeine are best avoided altogether when headaches are frequent.
Reducing the frequency. If headache takes up many days a month, painkillers will not solve it: preventive treatment is needed, taken daily whether or not the head aches that day. The usual choice is a tricyclic antidepressant at a low dose. It is not prescribed because the pain is "in your nerves": at low doses these drugs change the way the nervous system carries pain signals, and they work regardless of mood. Knowing that in advance matters, because otherwise the prescription reads as an insulting misunderstanding.
Three things are worth knowing about it: the dose is built up gradually from the bottom; no effect should be expected before four to eight weeks; and the course usually runs for several months, after which the drug is tapered off just as slowly. Stopping after a week because it "isn't working" is the commonest mistake. Other medicines are used at times, and where neck muscle tension is marked a doctor may add a local treatment.
Online consultation
Headache is a subject that a remote appointment handles almost better than a face-to-face one: what settles it is a detailed conversation rather than an examination. The doctor will ask how the pain is built, how many days a month it occupies and, without fail, how many days a month painkillers are taken — and it is often that question which makes the diagnosis. From there come three tasks: separating tension headache from migraine and from medication-overuse headache; planning the way out of the painkiller circle if it has already closed, and getting the person through the difficult first weeks; and choosing preventive treatment and running it over the months it needs to take effect. Going through a headache diary belongs here too, as does the decision about tests: with a typical picture and a normal neurological examination, scans are usually not needed, and that is also worth hearing plainly. Where any of the warning signs listed above are present, though, the conversation cannot wait, and some of them call for an ambulance rather than an appointment.
This material is for information only and does not replace medical advice.
Consult with a doctor about Tension headaches
Discuss your symptoms and possible next steps with a doctor online.
Online doctors for Tension headaches
Discuss your symptoms and possible next steps for Tension headaches with a doctor online.
