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If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
You feel a tight band of pressure on your forehead. Dull pain in the back of your head runs down to your stiff neck. You know you’re stressed out, but you probably wonder if this headache is due to stress or if it could be something more serious. Some late-night googling might have even made you worry about scary things like brain tumors.
Despite what some scary websites might tell you, most headaches are considered primary headaches. That means they happen without another disease (like a brain tumor) causing them (May, 2018).
In this article, we’ll look at stress headaches, a type of primary headache most of us have probably experienced at some point.
What is a stress headache?
Stress headaches, also called tension-type headaches, are the most common type of headaches in adults. There are two types of stress headaches (Shah, 2021).
The first type is episodic tension-type headaches. Episodic tension-type headaches are the most common, happening on average two to three times a month, up to a max of 14 headaches in that time. Episodic tension-type headaches can last for as little as 30 minutes or as long as a few days. They usually start in the middle of the day and have a long build-up, starting slowly with the pain increasing.
The second type is called chronic tension-type headaches. This type is when people have more than 15 stress headaches per month. The pain may lessen or get stronger, but it is relatively constant. Chronic tension-type headache pain occurs so frequently that it may feel like it never really goes away.
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Stress headache symptoms
Some people wonder what the difference is between stress or tension-type headaches or migraines. Tension-type headaches usually start later in the day. Most people feel a tight band of pressure around their entire head. Others may feel pain at the back of the head that moves forward to the front. Some people feel mild muscle tension, fatigue, and irritability. Even though it is painful and can affect your quality of life somewhat, tension-type headaches do not affect your vision or balance as migraine headaches do (May, 2018).
Let’s look a bit closer at the differences between tension headaches and migraine headaches.
Here are the distinguishing features of a tension headache (May, 2018):
- Location: The forehead, sides of the head, back of the head, around the neck. Some people feel a tension-type headache in their jaw or shoulders. The pain doesn’t increase even if you’re moving around.
- Sensation: Mild or moderate pain that can get stronger or ease up during the headache
- Notification: Some people feel stress before the headache starts.
- Duration: Thirty minutes to seven days
- Population: Usually, adults get tension-type headaches
Migraines have some different features than tension headaches (May, 2018):
- Location: Migraine headaches usually affect only one side of the head. Some people get migraines in one eye, back of the head, or temple.
- Sensation: The pain can be intense, throbbing, or pulsating. Migraine pain gets worse with activity. Some people feel nauseated during a migraine and may even throw up. Others are extremely sensitive to light and sound and may have trouble speaking or moving.
- Notification: Some people have an “aura” (a visual disturbance) or a tingling sensation in their arm or leg or on one side of the body before the headache begins.
- Duration: Four hours to three days
- Population: Anyone can have a migraine headache. Before puberty, boys tend to have more migraine headaches than girls. In adulthood, more women have migraine headaches than men.
Who is at risk for stress headaches?
Women are two times more likely than men to suffer from tension-type headaches. Close to 80% of adults have occasional stress headaches. About five percent of adults have chronic tension-type headaches (Shah, 2021).
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Causes of stress or tension-type headache
Tension-type headaches aren’t hereditary. That means that just because your parent had them, it doesn’t necessarily mean you will. Just like the name implies, tension-type or stress headaches are most often caused by stress. These stressors can come from any part of your life: family, work, or friends.
Episodic tension-type headaches can come from one stressful event. Chronic tension-type headaches usually come from constant daily stress.
Headache triggers can be either physical or emotional or a combination of both.
Physical triggers for tension-type headaches include being tired because of lack of sleep, bad posture, and dental and jaw problems. People with eye strain, a cold, or sinus infection are also at risk for a stress headache. Some headaches have a digestive component. People with low iron levels, those who skip meals because of fasting or dieting, or people who drink too much alcohol are also at risk for tension-type headaches. Others who stop drinking caffeinated beverages or drink too many can also get headaches (Lipton, 2017).
People who start or stop smoking also raise their risk for stress headaches. Stress can also cause emotional triggers for tension-type headaches. Depression, mental distress, and anxiety can all cause head pain (Shah, 2021; May, 2018).
Stress headache treatments
Over-the-counter (OTC) pain relievers are usually the first treatment for stress or tension-type headaches. Many people treat their stress headaches when the symptoms first start for immediate pain relief. These OTC pain relievers include (Shah, 2021):
- Acetaminophen (Tylenol)
- Nonsteroidal anti-inflammatory drugs (NSAIDs) including ibuprofen (Advil, Motrin) and naproxen (Aleve)
Naproxen: doses, uses, and side effects
There is evidence that a combination of acetaminophen and ibuprofen works best at relieving tension-type headaches. New formulations combining these two OTC medications are available for sale at drug stores and mass retailers (May, 2018).
People with chronic tension-type headaches may take these OTC drugs preventatively even before they have a headache. However, people who overuse these pain relievers may worsen their symptoms. They can get rebound headaches or medication overuse headaches from taking pain relievers more than three times a week. It’s best to follow medical advice and the directions on the bottle (Shah, 2021).
When to visit a healthcare provider
While most headaches are not a big cause for concern, it’s important to know when to seek medical attention. If you have a sudden, intense headache that feels like the worst headache of your life, or you’re unable to smile, feel weak or numb, can’t talk, think, or see, this is a medical emergency. Call 911 and go to the nearest emergency room immediately.
If you continue to have constant or severe headaches that affect your quality of life, it is best to make an appointment to see your healthcare provider.
Your healthcare provider may ask you specific questions to determine which type of headache you have. It’s important to diagnose tension-type headaches from other types of headaches, including migraine or cluster headaches, as the treatments differ.
Your provider will ask you about the frequency, duration, pain quality, and location of your headaches. They may also ask if you recently suffered a head or brain injury, have a constant stiff neck, or show a change in your personality. Some healthcare providers may ask you to keep a headache diary to get more information on your headache triggers (Shah, 2021; May, 2018).
If this information isn’t sufficient to give you an accurate diagnosis, they may order blood tests or imaging tests, including CT scans, MRI, or x-rays, to rule out other conditions.
Your provider may prescribe different medications to treat headaches or prevent them from occurring. Many recommend prescription-strength NSAIDs such as naproxen (Naprosyn), indomethacin (Indocin), and ketorolac (Toradol).
Some healthcare providers prescribe muscle relaxers including cyclobenzaprine (Flexeril) or selective serotonin reuptake inhibitor (SSRI) medications like fluoxetine (Prozac; see Important Safety Information) or paroxetine (Paxil). They are not considered as effective as the tricyclic antidepressant amitriptyline (Elavil) in both treating and preventing episodic and chronic-type headaches (Shah, 2021).
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All medications have side effects, even over-the-counter drugs. Most healthcare providers will seek to find the cause of the headaches and work to prevent them from occurring, rather than just treating the symptoms.
Preventing stress or tension-type headaches
These headaches are caused by stress and tension, so it makes sense to reduce stress in your life to the best of your abilities. While that may be challenging, there are some things you can do to manage your stress.
Active ways to manage stress include cognitive-behavioral therapy (CBT), biofeedback, or acupuncture. Others may try meditation or massage (Probyn, 2017).
Physical therapy to strengthen head, neck, and back muscles also helps to reduce and prevent tension-type headache symptoms (Jiang, 2019).
There are some people with chronic tension-type headaches who may not find relief with any of these treatments. There is evidence that botulinum toxin injections (Botox) in specific locations can help reduce the severity and frequency of stress headaches. This treatment is usually done after other treatments, including relaxation techniques, were tried without success (Wieckiewicz, 2017).
Wellness and lifestyle tweaks can also help decrease the severity and frequency of tension-type headaches.
There is evidence that low vitamin D levels can cause physical pain, including tension-type headache pain. Researchers haven’t yet determined optimal dosing of vitamin D to alleviate or prevent pain symptoms. You may want to check your vitamin D levels if you continue to have tension-type headaches and take a vitamin D supplement (Nowaczewska, 2020).
Good quality sleep is essential. Make sure you drink enough water as dehydration can also cause headaches. Try to exercise for at least 150 minutes a week to get your body moving. Work on your posture as well to strengthen your neck and shoulder muscles. Relax your jaw by saying “aaah” to remove tension from your head and neck (Jiang, 2019).
Get ahead of the headache
Tension-type headaches are a common complaint for most people. Over-the-counter pain relievers usually work quickly. If they don’t, or if the headaches become chronic, you may want to visit your healthcare provider. It’s always a good idea to try lifestyle modifications to reduce stress and improve your health to prevent stress headaches from occurring at all.
- Jiang, W., Li, Z., Wei, N., Chang, W., Chen, W., & Sui, H. J. (2019). Effectiveness of physical therapy on the suboccipital area of patients with tension-type headache: a meta-analysis of randomized controlled trials. Medicine, 98(19), e15487. doi: 10.1097/MD.0000000000015487. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531183/
- Lipton, R. B., Diener, H. C., Robbins, M. S., Garas, S. Y., & Patel, K. (2017). Caffeine in the management of patients with headache. The journal of headache and pain, 18(1), 107. doi: 10.1186/s10194-017-0806-2. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5655397/
- May A. (2018). Hints on diagnosing and treating headache. Deutsches Arzteblatt international, 115(17), 299–308. doi: 10.3238/arztebl.2018.0299 Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5974268/
- Nowaczewska, M., Wiciński, M., Osiński, S., & Kaźmierczak, H. (2020). The role of vitamin D in primary headache-from potential mechanism to treatment. Nutrients, 12(1), 243. doi: 10.3390/nu12010243. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019347/
- Probyn, K., Bowers, H., Mistry, D., Caldwell, F., Underwood, M., Patel, S., et al. (2017). Non-pharmacological self-management for people living with migraine or tension-type headache: a systematic review including analysis of intervention components. BMJ open, 7(8), e016670. doi: 10.1136/bmjopen-2017-016670. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629643/
- Shah, N., & Hameed, S. (2020). Muscle contraction tension headache. StatPearls [Internet]. Retrieved from: https://www.statpearls.com/ArticleLibrary/viewarticle/22615
- Wieckiewicz, M., Grychowska, N., Zietek, M., Wieckiewicz, G., & Smardz, J. (2017). Evidence to use botulinum toxin injections in tension-type headache management: a systematic review. Toxins, 9(11), 370. doi: 10.3390/toxins9110370. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5705985/
Dr. Steve Silvestro is a board-certified pediatrician and Senior Manager, Medical Content & Education at Ro.