Tension headache

The exact mechanism that creates a tension headache is unknown, but certain triggers may play a role.

Stress and anxiety

Tension headaches often occur at the end of a hectic day, or at just the time when you feel yourself pulled in several directions at once. As stress and anxiety mounts up, our neck and scalp muscles tighten, which brings with it a tension affecting the head: a tension headache.

Inactivity and working from home

Poor posture or a sedentary lifestyle can certainly contribute to a tension headache, as pain builds up in the muscles in the back of the neck while you’re stooping at your desk all day and straining to look at your laptop.

Poor eyesight

Squinting not only tires your eye muscles as they try to focus, and your brain as it tries to make sense of images or text, but if you’re working at a computer or reading, you will be leaning forward to try to decipher what you’re seeing, and this poor posture adds further to neck strain and tension headache.

If it’s been more than a year since you saw an optician, it’s worth booking an eye test.

Sense of smell

Certain smells can contribute to a tension headache, such as a particularly pungent perfume from your work colleague.

Noisy environments

Any bothersome constant noise can bring on a headache – at the extreme end of the spectrum is that pneumatic drill outside your office, but even the low persistent buzzing from a fluorescent light can do the same.

Tiredness

This can often go hand-in-hand with the wakeful nights related to stress. Getting a good night’s sleep will help you better process any stressful or hectic times, and will rest your brain to be prepared for the next day.

Dehydration

If exercise or a hot climate has you sweating, you will have lost water, and this can cause headaches, as the brain has a large water component, and this can deplete even with mild dehydration. Sweating can also cause loss of important salts like sodium, which, when low, can add further to a headache.

External compression

It sounds trivial, but if you’re getting regular tension headaches, especially at the end of the day, just check that your ponytail isn’t pulled too tight, causing the scalp to stretch and bringing on a tension headache. Any tight restrictive device can cause a headache, such as tight swimming goggles, a headband or a hat, especially if elasticated or too small.

Caffeine withdrawal

While most of us don’t feel right without our first coffee or tea in the morning, some people fall into the excessive use category, and their bodies can become reliant on caffeine. If they have to go without, their body goes into withdrawal, causing symptoms like tension headache, nausea and tiredness.

How can I tell it apart from other headaches?

Migraine

This causes a severe throbbing or pulsating headache, usually around one temple. Many self-diagnose migraine thinking it describes a severe headache, but certain criteria need to be present to make the clinical diagnosis.

A migraine causes sensitivity to movement, noise, light or smells, and prevents you from carrying out normal activities. It’s common to feel or be sick, and symptoms are eased by laying down in a dark quiet room. Some sufferers experience an aura – a warning that a migraine is about to happen – which can be flashing lights, numbness, tingling, dizziness or muscle weakness.

Medication overuse headache

This is an over-reliance on headache medication, and you get a withdrawal headache on the days you don’t take painkillers. Unfortunately the treatment for medication overuse headache is to avoid all painkillers, including over-the-counter ones, for a few weeks or months, and then restrict use – it's usually best to plan this out with your doctor.

Cluster headache

This is relatively rare, where you get an excruciating pain over one eye and often extending to the temple and cheek, with many describing it as a piercing or burning pain. The eye often becomes red and watery and the eyelid might droop or swell. It can last minutes to hours, but a cluster headache can keep recurring over the day, and continue for several days or weeks in a row. Men are more often affected, and these usually start in the 30s to 40s. You should see your doctor the first time you get one of these, and you may be referred to a neurologist for treatment options.

Sinus headache

This is one of the symptoms of sinusitis, an infection that causes a deep throbbing pain and a feeling of pressure radiating from the bridge of the nose to the cheeks and the middle of the forehead. It goes alongside a blocked or runny nose and possibly fevers. For most, this infection clears in 2 to 3 weeks, but some with chronic sinusitis find this headache persists for several months.

Hormone changes

Women are more likely to suffer from tension headaches and migraines in general, and many experience this with hormone changes, such as before or during menstruation and during menopause. Pregnancy may bring on worse or more frequent headaches and migraines.

Infection

Certain viral infections including the flu and COVID-19 can affect multiple body systems, and a headache is one symptom along with body or joint aches and pains, a cough, a runny or blocked nose, a sore throat, fever and feeling run-down or exhausted. The headache will improve once your body has fought off the virus.

Brain tumour

Brain tumours always seem at the forefront of most people’s minds with new headaches, and while a scary prospect, it's actually fairly rare in adults. Signs to look out for alongside headaches include having a seizure or fit, persistent nausea or vomiting, progressive weakness or numbness on one side of the body, or persistent unsteadiness or lack of balance, problems with your speech, problems with cognition like memory or word-finding ability, a personality change or behavioural problems. These are all reasons to see your doctor urgently.

Metastatic cancer

Unfortunately cancers can spread to other parts of the body, and the brain is one of these target organs. The most likely of these cancers originate in the lung, breast, kidney, skin (as melanoma) or bowel, so if you have new headaches and have been diagnosed with any of these, see your treatment team or doctor with urgency.

Brain bleeds

The head is well protected by the hard bone of the skull, but it’s still vulnerable to damage from knocks and injuries. You should consult a doctor for any significant knocks, in case of fracture or intracranial bleeding.

The lining of the brain can bleed over days to weeks, so you should see a doctor even if a mild injury, if your new headaches persist for up to 3 months afterwards, especially if they are getting worse, as this could indicate a subdural haemorrhage.

A headache that starts suddenly, and builds up to the worst headache you’ve ever experienced within 5 minutes, could indicate a subarachnoid haemorrhage and needs immediate medical attention. This can lead to vascular dementia if not treated urgently.

Some people are born with a Budd-Chiari malformation, where blood vessels in the brain form in an irregular way. This may only become apparent in adulthood, when you notice that any brief pressure build-up in the head causes a headache, such as straining for a poo, coughing, sneezing, exercising or bending over. You should see your doctor in this case.

Intracranial hypertension

This is a build-up of pressure around the brain, which may be the result of a severe head injury or a stroke, in which case it will come on suddenly. Rarely it can come on gradually and persist, making you feel sleepy, confused or irritable, and nauseous. It will worsen if you change your head position, like getting up in the morning or looking at something on the bottom shelf, or if you’re coughing or straining. The same movements might cause a temporary change to vision, like you’re blacking out.

Brain infections

Rarely you can get infections in the brain itself or the brain lining, such as meningitis or encephalitis, in which case you will feel feverish, have neck stiffness and pain and you may have a rash. Those who are immunocompromised with HIV or other conditions occasionally suffer a brain abscess. These conditions require immediate medical attention.

If you are after a non-medicated method, we have a detailed guide on tension headache relief.

You don’t usually need to see your doctor for the management of a tension headache. Instead, you can buy medications from your pharmacy. Paracetamol or ibuprofen can be very effective either on their own or in combination. Codeine or other opioid painkillers are not usually recommended.

For the treatment of headaches, painkillers should only be used for a short period of time.

This is because taking painkillers over a long period (usually 10 days or more) may conversely lead to medication-overuse headaches developing. This happens when your body gets used to the painkiller and when you stop, the headache returns or gets worse.

Most people experience headaches from time to time, and they are rarely a sign of something serious. However, there are certain symptoms and signs that can alert us to underlying causes that may need further examination and investigation. You should see a doctor urgently if you have any of the following:

• a new headache that feels different in location or intensity to your usual headache, especially for those over 50
• a new headache that came on suddenly and feels like the worst pain you’ve ever experienced
• a headache with sudden loss of vision or you have persistent visual changes despite a recent eyesight test
• a headache with any persistent weakness or numbness in your arms or legs or lack of balance
• a headache with fever, vomiting, neck stiffness, drowsiness or rash
• a headache with a new seizure or collapse
• a headache with any drowsiness or altered consciousness, especially if household members have the same
• a headache with any change to thinking or behaviour, or any change in personality
• a headache following any type of head injury, even if days later (or up to 3 months), but persistent and worsening
• a headache in your final trimester of pregnancy or up to 6 weeks after birth, especially with known high blood pressure or ankle swelling
• a headache triggered by coughing, sneezing, bending or exertion

Other reasons to visit your doctor are if you're suffering headaches on a regular basis and they are having a significant impact on work, studies or family life, if you are requiring pain relief for headaches at least 5 times a week, most weeks, if you experience visual symptoms such as aura for the first time, or you have a painful red and watery eye without diagnosis.