Tension headache is defined as band-like pain encircling head and radiating down head. It is usually bilateral, and usually relieved by sleep. Tension headache is often precipitated by stress and/or poor sleep. Tension headache does not awaken one from sleep, but sleep may be disturbed by coincident anxiety or depression.

Just because a headache is associated with stress doesn't prove that it is tension headache. Many headaches are worsened by tension

• Migraine - stress triggers migraine.
• TMJ - grind teeth at night.
• Hypertensive - stress increases BP.

Some authors do not believe tension headache is a distinct entity from Migraine (e.g. Sapir et al, 1993; Silberstein, 1992).

There are numerous headaches that have the same time pattern (i.e. constant) as tension headache.

• Structural causes of headache (to name a few)
  • Brain tumor
  • AVM
  • subdural blood clots,
  • cervical spine disorders.
  • dental problems
• sleep apnea headaches - - commonly appear in the morning and are constant and intractable.

Tension headaches are generally posterior or band-like. The main alternative to tension is cervical headache (for posterior location).

Treatment:

Treatment of tension headache is generally eclectic: Common measures include

• Stress reduction
• Biofeedback.
• Amitriptyline (which causes weight gain)
• Tizanidine (which requires monitoring of liver enzymes)
• Fiorinal (which is addictive)
• Non-steroidal analgesics (Ibuprofen or Naproxen).
• Migraine drugs.
• Reassurance.

Recently a controlled trial comparing treatment with amitriptyline and stress management was completed by Holroyd and associates (2001). They concluded that both amitriptyline and stress management were more effective than placebo, but that amitriptyline was more rapid. Combined therapy was the best.

References:

Holyroyd and others. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy and their combiantion: A randomized controlled trial. JAMA 2001, 285: 2208-2215