Causes of Tension Headache
Primary Pathophysiological Mechanisms
Tension-type headache has a multifactorial etiology involving both peripheral myofascial mechanisms and central nervous system sensitization, with the relative contribution varying by headache frequency and chronicity. 1
Peripheral Mechanisms (Predominant in Episodic Forms)
- Myofascial nociception from pericranial muscle tenderness and increased muscle tension represents the primary peripheral driver, particularly in infrequent and frequent episodic tension-type headache 1
- Cervical osteoarthritis can contribute to muscle tension headaches, especially in elderly patients, with pain often starting as vague neck discomfort before progressing to temples and forehead 2
Central Mechanisms (Predominant in Chronic Forms)
- Central sensitization of pain pathways becomes the dominant mechanism in chronic tension-type headache, with evidence of generalized pain hypersensitivity in both skin and muscles 3
- Inadequate endogenous pain control and abnormal central pain modulation contribute significantly to chronification 1, 3
- Decreased volume of gray matter in specific brain structures has been documented in patients with chronic tension-type headache 3
Environmental and Behavioral Triggers
- Missed meals can precipitate tension headache episodes 4
- Stress and psychological factors, including depression, represent significant contributing factors, particularly when headaches become chronic 2
- Sleep problems are identified as risk factors for poor outcomes and progression to chronic forms 3
Risk Factors for Development and Chronification
- Genetic predisposition combined with environmental factors contributes to susceptibility 5
- Coexisting migraine increases risk of poor prognosis 3
- Not being married (likely reflecting social support factors) is associated with worse outcomes 3
- The prevalence of frequent tension-type headache increased significantly from 1989 to 2001, suggesting evolving environmental or lifestyle factors 3
Clinical Distinction from Secondary Causes
While the question asks about tension headache causes, it's critical to recognize that secondary headaches must always be excluded before attributing symptoms to primary tension-type headache, particularly with red flags such as sudden onset, fever, focal neurological symptoms, or new onset after age 50 4