Causes of Tension Headache
Tension-type headaches have a multifactorial etiology involving both genetic predisposition and environmental triggers, with the primary mechanisms being muscle tension in the head and neck region, though the exact pathophysiology remains incompletely understood. 1
Primary Etiologic Factors
Muscle Tension and Myofascial Mechanisms
- Sustained muscle contraction in the pericranial and cervical muscles is a central mechanism, producing the characteristic pressing or tightening sensation described as a "tight band around the head" 2, 1
- Cervical osteoarthritis frequently contributes to tension headaches, particularly in elderly patients, where neck discomfort progresses to involve the temples and forehead 3
- Poor posture and prolonged static positioning can perpetuate muscle tension in the neck and shoulder regions 1
Genetic and Constitutional Factors
- Genetic predisposition plays a significant role, with familial clustering observed in tension-type headache patients 1
- The condition has a worldwide lifetime prevalence of 46% to 78%, making it the most common primary headache disorder 1
Environmental and Lifestyle Triggers
Dietary Factors
- Missed meals are a recognized trigger for tension headaches 2
Psychological Factors
- Depression can be a significant contributing factor, particularly when headaches become chronic 3
- Stress and emotional tension are well-established precipitants, though the exact mechanisms linking psychological stress to muscle tension remain complex 1, 4
Sleep Disturbances
- Sleep disorders may worsen preexisting tension-type headaches or present with overlapping clinical features 5
Secondary Medical Causes to Consider
Metabolic and Endocrine Disorders
- Hypothyroidism can present with headaches that mimic tension-type features 5
- Various metabolic disturbances may produce tension-type headache symptoms 3
Cardiovascular Factors
- Hypertensive crisis can present with headache features overlapping with tension-type headache 5
- Congestive heart failure may produce venous congestion in the cranial cavity, resulting in headache 3
Comorbid Conditions
- Fibromyalgia frequently coexists with tension-type headache 5
- Psychiatric disorders commonly present as comorbidities 5
Critical Clinical Pitfalls
Medication Overuse
- Use of pain relievers more than twice weekly places patients at risk for progression to chronic daily headache, which can perpetuate and worsen the underlying condition 4
- Analgesics combined with butalbital or opiates carry increased risk of causing chronic daily headache despite short-term efficacy 4
Red Flag Conditions to Exclude
- Always rule out secondary headaches, particularly when "red flags" are present: sudden onset, fever, focal neurological symptoms, or new-onset headache after age 50 2
- Giant cell arteritis in elderly patients produces severe vascular headaches resistant to standard analgesics and requires immediate recognition 3
- Increased intracranial pressure and transient ischemia must be excluded in appropriate clinical contexts 3