Triggers for Severe Tension Headaches
The most common triggers for severe tension-type headaches are stress, missed meals, sleep deprivation, and fatigue, though it's critical to understand that tension headaches typically lack the extensive trigger profile seen in migraines. 1, 2
Primary Triggers Specific to Tension Headaches
- Missed meals are explicitly recognized as a trigger for tension-type headaches by the American Academy of Family Physicians 1
- Stress is a significant trigger, though it affects tension headaches less consistently than migraines (66.7% of headache patients report stress as a trigger across both types) 2, 3
- Sleep problems and fatigue have at least some scientific evidence as trigger factors for tension-type headaches 2
Environmental and Lifestyle Factors
- Weather changes are reported by 82.5% of headache patients as triggers, though this applies to both migraine and tension-type headaches 3
- Environmental factors including lights, noise, and odors may play a role, though the evidence is stronger for migraines 2
- Mental exertion can trigger headaches, particularly in post-traumatic contexts, though this is less specific to tension-type headaches 4
Important Clinical Distinctions
Tension-type headaches fundamentally differ from migraines in their trigger sensitivity. 1, 5
- Tension headaches are bilateral with pressing, tightening, or non-pulsatile character and are not aggravated by routine physical activity, unlike migraines 1
- They typically lack nausea/vomiting (though anorexia may occur) and don't have both photophobia and phonophobia together 1
- The pain is mild to moderate in severity, described as tightness, pressure, or dull ache, often radiating to neck muscles 1, 5
Critical Pitfalls to Avoid
- Do not assume all headache triggers apply equally to tension-type headaches - many commonly cited triggers (alcohol, caffeine withdrawal, specific foods, dehydration) have stronger evidence for migraine than tension-type headaches 2
- Scientific evidence is lacking that food additives or most specific foods trigger tension-type headaches, despite popular belief 2
- Patients often confuse theoretical knowledge with personal experience - the difference is largest for chocolate (61.7% know vs. 14.3% experience) and cheese (52.5% know vs. 8.4% experience) 3
- Most triggers occur occasionally and inconsistently, not reliably with each exposure 3
Red Flags Requiring Further Investigation
Always rule out secondary headaches when patients present with concerning features such as sudden onset, fever, focal neurological symptoms, or new onset after age 50 1, 6