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What the hell is a “tension” headache?

Paul Ingraham

Picture of a very cute little puppy holding his temples with his paws.

Puppy has too much stress!

Recently I completely rebooted the intro to my tension headache guide. My impossible mission? To define this awkward, vague, weird term.

I was also trying to change the scope of the article, so that it will include cervicogenic headache going forward. While it will never be a guide to all kinds of headache, it’s clear that “tension headache” alone was too limiting: what I’m really interested in is helping readers troubleshoot any non-migraine, non-ominous headache… which covers a lot more ground than just “tension” headaches.

The two major classifications of common headaches are tension-type headaches and migraines. Although there are literally hundreds of more specific types of headaches, based either on symptoms or pathology, tension and migraine are The Big Two.

And yet it’s impressively hard to precisely define a “tension headache” is. If you ever end up in a conversation with a curious child who just keeps asking for clarification on this point, you’re going to hit a brick wall surprisingly quickly.

So what is a "tension" headache?

“Tension headache” is a weird, traditional catch-all term for any unexplained headache that isn’t a migraine and doesn’t appear to be scary in any other way.

So a better name for tension headache might be musculoskeletal headache, or just undiagnosed headache, rather than blaming “tension,” which is painfully unclear. The moment there’s a better and more specific explanation for a headache than “tension,” it ceases to be a tension headache. But until then…

The concept of a tension headache comes from a simple fact, which most of us know from experience: stress and anxiety are strongly linked to headaches. Which is because they either cause pain directly, or they cause other things to go wrong that hurt.

Such as? The “other things” are usually assumed to be musculoskeletal problems — trouble with bones, joints, and especially uncomfortably tight muscle — as opposed to the neurological “brain ache” of migraine, or the pathological and traumatic causes of some other headaches (inflamed arteries, brain damage, drug side effects, etc).

Clear as mud? Another way of putting it: a tension headache is a diagnosis of exclusion, so “idiopathic primary minor headache” would be the most technically accurate label, but instead we call it a “tension” headache, which implies a cause that basically no one can actually explain. It’s quite odd.

Can stress itself hurt heads?

Is there such a thing as a pure stress headache, where literally the only problem is with your feelings? A completely sensory phenomenon, where there is no physical stress or mechanism of any kind? Probably, yes: we humans are quite good at transmogrifying emotional distress more or less directly into discomfort (somatization). Either headache or abdominal pain is probably the best example.

But it is debatable whether there is no biological mechanism at all. We tend to assume there is some intermediate, physical step between feelings and pain.

Other ways stress can cause head pain

Stress probably has other ways of making us hurt, and this rabbit hole has no bottom. Musculoskeletal headaches are probably simpler than the exotic physiology of migraine, but you would be surprised how murky the nature of musculoskeletal pain is. For instance, many headaches are probably cervicogenic headaches (“from the neck”) — but that’s a bit controversial.

For instance, muscle pain is a strong specific candidate, and it’s the most common sensical interpretation of a tension headache: stress causes painful muscle tension. Specifically, neck, head, and jaw muscles may be painfully tight, full of (hypothetical, controversial) “trigger points” (knots) that are radiating pain all over your head, and sometimes down into your neck, shoulders and even arms as well. These sensitive spots in muscle are either literally tense (contracted), or just feel like it, which is one of the reasons we probably call it a “tension” headache.

The problem is that these sensitive spots are barely understood, and their role in headache remains unconfirmed: a perfect example of how surprisingly primitive pain and musculoskeletal medicine still are, even as the 21st Century gets well under way.

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