Causes of Tension-Type Headaches
Tension-type headaches are primarily caused by muscle tension, stress, poor posture, and sleep disturbances, with potential contributions from central sensitization mechanisms in chronic cases. 1
Primary Mechanisms
Muscle-Related Factors
- Pericranial muscle tension: Sustained contraction of muscles in the head, neck, and shoulders is a key contributor 1, 2
- Poor posture: Improper ergonomics leading to strain on neck and shoulder muscles 1, 3
- Myofascial trigger points: Localized areas of muscle hyperirritability that can refer pain to the head 2
Neurophysiological Mechanisms
- Central sensitization: Increased excitability of the central nervous system from repetitive and sustained pericranial myofascial input, particularly important in chronic tension-type headache 2
- Nitric oxide (NO) pathways: Evidence suggests NO plays a significant role in pain transmission and central sensitization in tension-type headache 2
- Altered pain processing: Abnormal processing of sensory inputs in the trigeminal nucleus and higher brain centers 2
Contributing Factors
Psychological Factors
- Stress and anxiety: Strong association with onset and exacerbation of tension-type headaches 1
- Depression: Often comorbid with chronic tension-type headache 1, 4
Sleep Disturbances
- Poor sleep quality: Strongly associated with tension-type headache frequency and severity 5
- Insomnia: More prevalent among individuals with tension-type headache 5
- Insufficient sleep: Can trigger or worsen tension-type headaches 1, 5
- Shift work: Disruption of normal sleep patterns associated with increased headache risk 5
Other Contributing Factors
- Systemic medical disorders: Conditions such as hypothyroidism, hypertensive crisis, and fibromyalgia can present with or exacerbate tension-type headache 4
- Dehydration: Can trigger or worsen tension-type headaches 1
- Skipped meals: Irregular eating patterns may contribute to headache onset 1
Differences Between Episodic and Chronic Tension-Type Headache
- Episodic tension-type headache: More commonly associated with peripheral mechanisms (muscle tension, trigger points) 2
- Chronic tension-type headache: Stronger association with central sensitization, sleep disturbances, and psychiatric comorbidities 2, 5
Diagnostic Considerations
- Diagnosis is based on clinical features and careful exclusion of other headache causes 4
- No specific diagnostic tests exist for tension-type headache 1
- Red flags that suggest alternative diagnoses include:
- Abnormal neurological examination findings
- Headache awakening patient from sleep
- Headache worsened by Valsalva maneuver
- New onset after age 50
- Sudden or abrupt onset
- Onset during pregnancy or postpartum 1
Clinical Implications
- Understanding the multifactorial causes of tension-type headache is essential for effective management
- Treatment should address both peripheral factors (muscle tension) and central mechanisms (sensitization)
- Lifestyle modifications targeting stress reduction, improved sleep hygiene, and proper posture are important preventive measures 1
- Medication overuse can lead to chronic daily headache and should be limited to ≤2 days per week 1
The pathophysiology of tension-type headache remains incompletely understood, with ongoing research needed to develop more targeted and effective treatments beyond the current reliance on simple analgesics 6.