Tension-Type Headache

What is a tension-type headache?

Tension-Type Headache (TTH) is the most common type of headache, and one that almost everyone suffers at some stage through their life. It is often mild, infrequent and easily self treated, however, for a significant number of people it is moderate to severe, debilitating, too frequent, and as much of a problem as migraines.

Tension Type Headache – Critical Features:

• Most common headache type
• Impact often minimised by medical professionals
• Neck muscles proven to play a critical role
• Shares many similar neurological features with migraine
  • Central sensitisation (lowered pain-pressure thresholds)
  • Overactive brainstem (trigeminocervical complex)
  • Symptoms rather than source dictate treatment
• Treatment often focussed on behavioural/psychological approach (e.g. mindfulness & relaxation) or medications, or manual ‘press and guess’ approaches.

The only neck treatment developed specifically for treating the sensitivity associated with primary headache disorders is the Watson Headache ® Approach. Other manual techniques for the neck adopt a ‘press and guess’ approach, hoping that by ‘loosening up’ the neck things will improve. This fails to fix the underlying problem and may aggravate the condition, but at best leads to short term relief and a treatment program that never ends.

We not only understand how debilitating TTH can be but provide an expert examination of the upper cervical spine using techniques designed to test and treat the sensitivity of the nerve pathways. This should be performed in all cases to at least eliminate the spine as a cause, and more commonly, provide a solution with reduced dependence on medication, avoiding years of escalating pain and side effects. We are the most experienced clinic in Melbourne, and one of the most experienced in Australia at using the Watson Headache ® Approach – and with complex and persistent headaches, experience matters.

[Read More on Watson Headache ® Approach]

Tension-type headache expert

Even purported experts continue to downplay the significance of tension-type headache. At the 2019 Migraine World Summit, headache specialist (Neurologist) Dr Lawrence Newman gave a presentation on the differences between migraine and tension-type headache and commented:

tension-type headache is not a headache that is disabling, or one that tends to drive people to see a doctor. There is no nausea, light or sound sensitivity. It’s just a mild to moderate headache that comes and goes’.

Very little of what he said reflects the diagnostic criteria and the reality of the condition for many.

• “Not a headache that is disabling”

TTH is a disabling headache. While the impact for an individual person is less than migraine, it is still impactful. So much so that due to the sheer numbers affected it causes more ‘years lost to disability’ than migraine.

• “There is no nausea, light or sound sensitivity.” 

TTH is often considered a ‘featureless’ headache devoid of associated symptoms as has been portrayed here. However episodic TTH allows one of photophobia or phonophobia, and when we include ‘chronic’ TTH (occurring more than 14 days per month) mild nausea is also permitted. 

• “It’s just a mild to moderate headache that comes and goes.”

Diagnosis requires only 2 of; bilateral location, pressing or tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity. So a severe one-sided headache with sensitivity to light is a tension-type headache if it is not pulsatile, not aggravated by routine activity, does not cause nausea or sensitivity to sound. 

• “TTH is not a headache that tends to drive people to see a doctor”

Only 1 in 6 people with TTH will see a doctor, and this is the only part of the statement that is true. One might think this is hardly surprising given the complete lack of understanding demonstrated by a world expert, of what tension-type headache is.

One can only imagine the responses sufferers have had to endure. There’s only so many times you can be told to relax, or that you really have depression or anxiety, rather than a headache problem!

Originally termed ‘psychogenic headache’ because it was believed that the ‘pressure’ type quality to the pain was muscle tension as an outward response to mental stress. We now understand that there are dysfunctions in brain regions, not the same as, but not unlike migraine, that

A number of (erroneous) factors have conspired in TTH not being taken very seriously;

• The ongoing perception amongst many even within the medical profession that people suffering TTH ‘just need to relax’
• The definition as a ‘mild to moderate and featureless headache. It is literally defined as a ‘not migraine’ headache.
• Commonality. Everyone has had a tension headache at some time in their life. For the vast majority it is very mild, and responds to doing just about anything (move or exercise, rest, drink water, take a panadol, have a rest and yes……..relax). So we all have some concept of what it is and will tend to minimise how debilitating it can be for those suffering moderate to severe (yes, they can absolutely be severe headaches).

The stigma of tension-type headache

TTH like migraine, has had a variable level of acceptance by the medical community over the centuries. Always considered a medical condition from ancient times, early medical science failed to provide an anatomical ‘source’ for the pain. With stress being a key trigger, tension-type headache became viewed as a psychological problem. The checkered history of tension-type headache is reflected in the number of names it has gone by over the years – muscle contraction headache, psycho-myogenic headache, stress headache, ordinary headache, essential headache, idiopathic headache and psychogenic headache. 

In 1962 the Ad Hoc committee for the classification of headache defined 15 headache types for further investigation and validation. Second on their list (after “vascular headaches”) was Muscle Contraction Headache;

associated with sustained contraction of skeletal muscles in the absence of permanent structural change, usually as a part of the individual’s reaction during ‘life stress’. The ambiguous and unsatisfactory terms “tension,” “psychogenic,” and “nervous” headache refer largely to this group.

While the name had shifted away from directly calling this a psychological disorder suffered by those with nervous tension, the finger is still pointed at ‘life stress’ as a key underlying part of the pathophysiology. The term ‘tension’ remains embedded in the diagnosis of this ‘featureless’ headache, and sadly the notion that this is largely a psychological problem dismissed in large by those who purport to be experts in the area shows we still have a long way to go to bring tension-type headache into focus as a medical disorder.

Tension-type headache and the sensitised brainstem

While it was believed that the cause of tension-type headache was increased muscle tension in the muscles of the head due to ‘life stress’, this has been debunked. Scalp and neck muscle activity is relatively easy to measure and shows very mild (if any) increase and is unrelated to headache status.

Reflex studies have produced mixed results. When looking at the nociceptive blink reflex there inconsistent findings, however the trigeminocervical reflex shows signs of brainstem excitability, especially in chronic TTH.

Interestingly, the more frequent the headaches (i.e. as you move towards becoming ‘chronic’) the more neck dysfunction is apparent. This is not a coincidence.

Many studies in recent times have demonstrated repeatedly that the small muscles in the top of the neck are dysfunctional in tension-type headache sufferers. Often not in a way that limits movement or causes pain from the muscles themselves (this would be call a ‘cervicogenic headache’), but in a way that creates a constant underlying ‘noise’ disrupting the normal functioning of multiple brainstem regions including the TCC. In other words the increasing neck dysfunction may be responsible for the ‘hyper-excitability’ seen in reflex studies – essentially creating the ‘powder keg’ waiting for a trigger to ‘blow it up’.

These small muscles are extremely sensitive. Rather than just helping to ‘turn your head’ (in fact they don’t actually help do that at all), the sub-occipital muscles play a critical role in:

• Vestibular function; they help your head distinguish between ‘looking down’ and falling forwards. In other words, head-on-body versus whole body movement.
• Cardiovascular function; they signal ahead to blood pressure centres (solitary nucleus – also the centre for nausea) that you are moving from laying down to sitting up. This preempts this system to compensate for the changes in blood pressure as we move against gravity.
• Visual system; coordinating with the eye muscle at multiple sites they control the direction of our gaze.
• Headache production; 40% of the nerves coming in from these muscles converge onto the  same nerves that come in from the head and face (trigeminal nerve). Overstimulation sets off the bodies ‘alert’ system, and the focus shifts to the most important structure – the head. Testing this ‘convergence’ or the cross-wires from the neck to the head is a cornerstone of the Watson Headache ® Approach, and also proven to decrease the overactivity in the TCC

Watson Headache ® Approach and tension-type headache

The most significant non-pharmacological research undertaken has targeted TCC, the brainstem area that is constantly irritated and sets off the hypothalamus when migraines start. In a key study published in Headache in 2012 the familiar pain of headache was reproduced in 100% of tension-type headache sufferers with manual pressure, or palpation of the upper neck. The same occurred in 95% of migraineurs. By using this technique (Watson Headache ® Approach) as a treatment the researchers decreased the underlying sensitivity of the TCC as indicated by normalising the nociceptive blink reflex – a key marker of activity in the TCC.¹ .

This highly targeted technique treats the sensitivity, or ‘decreases the noise’, and calms the brainstem down. Treatments that aim to loosen tight muscles and stretch stiff joints can be far too heavy handed, and often are not sustained – resulting in short term relief, or aggravation. At the Melbourne Headache Centre you have access to the most experienced Watson Headache ® Practitioners in the world aside from Dean Watson himself. No drugs and no cracking of the neck. Treatment that gets to the heart of the problem.

Stress is a common trigger for both migraine and TTH, simply because they are essentially disorders of your ‘threat response system’ which is in a state of constant irritation. When a stressor does arrive in the form of emotional stress, change in sleep habits, skipping a meal, or hormonal fluctuations, the capacity of the ‘threat response system’ is pushed to, and beyond it’s limit.  The symptomatic presentation of this will depend on how you have ‘trained’ your nervous system by everything you have done and experienced since you were born – and indeed some genetic predisposition may favour certain presentations.

If you are a clencher/grinder, likelihood is you will get pain in your temples. If you have a ‘weak stomach’ you are likely to experience nausea and vomiting (a.k.a. migraine), if you have motion sickness or some inner ear sensitivity then you are more likely to get vestibular migraine with vertigo.

Are these all completely different things, or just different manifestations of the same problem?