Tension Headache

Also indexed as: Headache (Tension), Muscle Contraction Headache, Stress Headache

Tension-type headache is very common and is typically experienced as a dull, non-throbbing pain in the back of the neck or in a “headband” distribution.1 It may be associated with tender nodules in the neck called trigger-points,2 or with tenderness in the muscles around the head.3

Checklist for Tension Headache

Rating Nutritional Supplements Herbs
2Stars L-5-hydroxytryptophan (5-HTP) Peppermint oil (topical)
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of tension headaches? People with a headache may have symptoms including uncomfortable sensations described as pain, throbbing, aching, dullness, heaviness, and tightness in the head. People with a headache may also experience discomfort that is often worsened by movement or pressure and may be associated with irritability, problems sleeping, and fatigue.

How is it treated? Conventional treatment includes the use of oral medications, such as salicylate analgesics (e.g., Bayer®, Dolobid®), non-steroidal anti-inflammatory drugs (e.g., Advil®, Motrin®, Aleve®, Naproxen®), and acetaminophen (e.g., Tylenol®), for the relief of pain.

Lifestyle changes that may be helpful: Tension-type headaches often occur more frequently and may become more severe during or following times of mental or emotional stress.4 5 6 Several controlled studies have found tension-type headache sufferers to report higher levels of stress,7 8 9 and to have significantly higher levels of depression or anxiety,10 11 12 significantly greater levels of suppressed anger,13 or significantly greater muscle tension14 15 than those without headaches. Minimizing stress and getting enough sleep and regular exercise are often recommended to people with tension-type headaches. However, no research has investigated the effectiveness of these lifestyle changes.

One controlled study that included patients with muscle-contraction headache as well as other types of headache, revealed that smokers had significantly more severe headache episodes than nonsmokers.16 Although other studies have not found an association between smoking and headaches, stopping smoking is always a good idea for many health reasons.

Nutritional supplements that may be helpful: L-5-hydroxytryptophan (5-HTP) may be helpful for tension-type headaches. A recent double-blind study of adults with chronic tension-type headaches found 300 mg per day of 5-HTP reduced the number of headache days by 36%, but this was not significantly different from the 29% reduction in the placebo group.17 (Headaches often improve significantly even when an inactive [placebo] treatment is given).18 Headache severity was also similarly reduced by either 5-HTP or placebo. In this study, 5-HTP was significantly superior to placebo only in reducing the need for pain-relieving medications during headaches. Previous double-blind research studied 5-HTP in groups of patients suffering from many different types of headache, including some with tension-type headaches. Results from these studies also found substantial, but nonsignificant benefits of 5-HTP compared with placebo using either 400 mg per day in adults19 or 100 mg per day in children.20

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: A preliminary report suggested that peppermint oil has relaxing and pain relieving effects, and may be useful as a topical remedy for tension-type headache.21 In a double-blind study, spreading a 10% peppermint oil solution across the temples three times over a 30-minute period was significantly better than placebo and as effective as acetaminophen in reducing headache pain.22 Similar use of an ointment combining menthol and other oils related to peppermint oil was also as effective as pain relieving medication and superior to placebo in another double-blind study.23

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

Other integrative approaches that may be helpful: Studies treating tension-type headache with acupuncture have had mixed results.24 Two controlled trials of acupuncture compared to “fake” acupuncture found either significantly more pain reduction from real acupuncture25 or no difference between the two treatments.26 Two trials comparing acupuncture to traditional physical therapy (relaxation techniques, self-massage, cold therapy, transcutaneous electrical nerve stimulation [TENS], stretching, and/or preventive education) in tension-type headache patients found similar improvements from either treatment.27 28 Three controlled acupuncture trials treated patients with various types of headaches, including tension headache. Two of these studies,29 30 but not the third,31 found acupuncture significantly more effective.

Two preliminary studies32 33 reported benefits from using finger pressure on specific acupuncture points (acupressure) to relieve tension-type headache pain in some patients. However, no controlled research on this approach has been done.

Spinal manipulation may also help some tension-type headache sufferers. Several preliminary studies report reduction in frequency and severity of tension-type headaches with spinal manipulation.34 35 36 37 38 39 A controlled trial compared spinal manipulation to drug therapy for tension-type headaches.40 During the treatment period, both groups improved at similar significant rates, although the manipulation group complained of far fewer side effects. After a month following the end of treatment, only the manipulation group showed continued improvement. In another controlled trial, spinal manipulation resulted in fewer headache hours each day, decreased use of analgesics, and less intense pain per episode compared with massage.41 A third controlled study reported that spinal manipulation with muscle massage was equally as effective as massage plus a “fake” laser treatment, suggesting that manipulation did not provide additional benefit.42

As mentioned above, two controlled studies found physical therapy (relaxation techniques, self-massage, cold therapy, TENS, stretching, and/or preventive education) as useful as acupuncture in significantly reducing headache pain and frequency.43 44 A preliminary study also found that physical therapy, consisting of posture education, home exercises, massage, and stretching of the neck muscles, significantly improved tension headaches up to 12 months after treatment ended.45 Another preliminary study of massage, including deep penetrating techniques, reported significantly decreased pain in patients with chronic tension headache and neck pain.46 A controlled study of headache patients with muscle spasm in the neck and shoulders found that adding TENS to physical therapy (consisting of heat packs, massage, and ultrasound) brought a significantly faster and greater decline in headaches than physical therapy alone.47

Several controlled trials utilizing electromyogram (EMG)-biofeedback (which teaches people how to mentally relax their neck or head muscles) have shown this treatment to be helpful in about 50% of tension-type headache sufferers, both in adults48 49 50 51 52 and in children and adolescents.53 54 Progressive muscle relaxation is another muscle relaxation technique that has significantly reduced tension-type headache in controlled studies of adults,55 56 and children and adolescents.57 58

Relaxation with techniques for stress management was found to be significantly better than drug therapy in a controlled trial of chronic tension-type headache sufferers,59 although about half of all subjects continued to have headaches three to four days per week after the end of treatment.

Hypnotherapy was found to significantly reduce headache intensity and duration in chronic tension-type headache sufferers in one controlled trial.60

A large controlled study of tension headache patients compared relaxation therapies (including progressive muscle relaxation, hypnosis, and cognitive psychotherapy) with EMG-biofeedback, and found biofeedback to be significantly more effective than relaxation in decreasing headache pain and frequency.61

In a controlled trial, therapeutic touch, a type of hands-on healing, was found to significantly reduce tension headache pain for four hours following treatment.62 No further research has been done on this approach.

Reflexology, a specific treatment involving massage of various reflex zones on the feet, has only been investigated as a treatment for tension-type headache in one preliminary trial.63 A majority of people treated in this study reported being helped by this technique.

A controlled trial of homeopathy in headache patients, including tension-type headache, found no significant benefit of homeopathy compared to a placebo group.64

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38. Hoyt WH, Shaffer F, Bard DA, et al. Osteopathic manipulation in the treatment of muscle contraction headache. J Am Osteopath Assoc 1979;78:322–5.

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41. Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther 1997;20:326–30.

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43. Ahonen E, Hakumaki M, Mahlamaki S, et al. Effectiveness of acupuncture and physiotherapy on myogenic headache: a comparative study. Acupunct Electrother Res 1984;9:141–50.

44. Carlsson J, Augustinsson LE, Blomstrand C, Sullivan M. Health status in patients with tension headache treated with acupuncture or physiotherapy. Headache 1990;30:593–9.

45. Hammjill JM, Cook TM, Rosecrance JC. Effectiveness of a physical therapy regimen in the treatment of tension-type headache. Headache 1996;36:149–53.

46. Puustjarvi K, Airaksinen O, Pontinen PJ. The effects of massage in patients with chronic tension headache. Acupunct Electrother Res 1990;15:159–62.

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