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  • Writer's pictureDr. Donald Littlewood

The most common headache out there is...

You get a request for a Zoom meeting from your boss. You log into the meeting only to get more work added to your plate. You know you are going to have to work late, but that means not getting dinner in before taking the dog out for a walk. You can feel the stress rising. Your heartbeat rises & you can feel your palms start to go cold & clammy. And, boom! Headache.

In this blog post, I am going to talk about one of the headaches that I commonly treat in my office and that is a tension-type headache. I’ll give you the ins & outs of the TTH as well as some quick & easy strategies you can use to help kick them when they rear their ugly head.

What is a tension-type headache?

Tension-type headaches (or TTH) are actually fairly difficult to define because of the wide variety of their presentation. They can be frequent or infrequent, episodic or chronic; but the one thing they (almost) all have in common is pericranial tenderness.

Pericranial tenderness is just a fancy way of saying the muscles around the head are tender to the touch. There is a specific scoring system that tests the muscles, and the muscles in question are: frontalis, temporalis, masseter, SCM, upper trapezius, and lateral pterygoid.

But, pericranial tenderness does not a tension headache make. There are some other symptoms & characteristics we look out for when diagnosing a TTH:

Episodic TTH

  1. Headache can last anywhere from 30 minutes to 7 days

  2. Two of the four following symptoms: bilateral in location (meaning the headache is on both sides); mild-moderate in severity; pressing or tightening in quality; not aggravated by routine physical activity

  3. No nausea or vomiting

  4. Sensitivity to either light or sound [not both, and sometimes neither]

Episodic TTHs can be further broken down into frequent & infrequent. In order to be classified as an infrequent TTH, there can only be one headache attack per month. Frequent episodic TTHs, on the other hand, require 12-180 headache days per year in order to fit the diagnostic criteria.

Chronic TTH

These headaches are the evolution of the episodic TTH. They have the same basic criteria as episodic TTH, but they are much more frequent. Those that experience chronic TTHs experience 15+ headache days a month. Often times these headaches are unrelenting to the point where one constantly has a headache. Chronic TTH sufferers often present with a migraine as well which adds nausea & vomiting as well as a pulsing quality to the head.

Epidemiology of TTH

It has been well documented that TTHs are the most common form of headache seen in the general population. Studies quote almost ~80% of the population will have a TTH at some point in their life, peaking in your 30s and then declining as you get older.

But how/why? What are the risk factors to developing a TTH?


Well the most documented risk factor is stress. And during COVID19, who isn’t stressed? Stress is key to survival; our bodies need it to some extent but chronic stress has been linked to many chronic diseases. TTHs are no exception, but why?

A stressful event causes a whole cascade of reactions in the body & brain. I don’t want to go full neuroscience on you, but essentially what happens is when your body experiences something stressful, a chemical is released in the brain called NFKB. Additionally, when you are stressed your body releases an amino acid called glutamate that binds to an NMDA receptor. This triggers even more NFKB to be released. Once this is released, COX-2 is pushed out into the body, which plays a role in pain and nitric oxide (NO).

[NB: COX-2 activation is what non-steroidal anti-inflammatories like Advil & Tylenol are trying to stop]

NO is what causes the blood vessels to open which brings more blood into the protective layers of the brain & other structures. This is where the pain & tenderness is thought to come from.

So stress is clearly a risk factor, but what else?

Well, if we’re being honest, not much.

In the case of TTH, stress is really the only known causative factor. It comes into play in many ways: increases muscle tension, increases the sensitization of your central nervous system, and alters the psychological perception & physical processing of pain.

Why is stress so intimately tied to headaches & pain processing? Well, stress & pain share neural, endocrine, autonomic & behavioural features. So essentially, our bodies process stress in a very similar way that they would process pain coming from an external stimulus.

Now, all this being said, we still need to get to the bottom of what these stressful events are. Historically, research on stress & TTH has been focused on major life events, like the death of a loved one, as the main cause. We now know that isn’t the case.

TTHs are actually more likely to come from the daily life stressors that present themselves to us every day. Things like: when is the dog going to go for her walk, how is dinner going to get on the table, or a particularly busy day at work.

Treatment of TTH

We know that stress is their main causative stimulus, but what do we do when it comes to treating these headaches? Well because there are two components, we need to treat both. The muscle tension & joint restrictions that are present need to be addressed as does stress.

This can be done in many ways. Personally, I like to get in there and treat the muscles and joints. Once the pain has been mitigated (which usually doesn’t take a terribly long time), we can then talk stress reduction.

Chiropractic care & TTH

Here, the main goal is to get the muscles to chill out and the joints to move.

The goal of soft tissue therapy is to relax the muscles & tendons so that they can adequately do the job that they are meant to do. When a muscle is tight or too contracted, it is not able to perform the range of motion that it needs to and so pain occurs.

In the case of TTHs, I like to go in and treat temporalis, the muscles of the jaw & neck to help dissipate the trigger points and get them back to a more relaxed state.

This can look different for different people. Sometimes I use acupuncture, sometimes I use pressure and movement, and sometimes it is only pressure. It all depends on the patient and how they respond to care; everyone is different.

Once the muscles feel a little softer and the pain isn’t as intense, I go in with an adjustment. Adjustments (or spinal manipulative therapy) are performed where the joints aren’t moving super well. The goal of the adjustment is to get the joints moving again so that the muscles don’t have to do the extra work.

Rehab exercises are also an important part of the treatment plan. When muscles and joints don’t move properly, part of getting them moving is teaching them how to move. This acts as prevention for future headache bouts.

Stress Reduction

I think it goes without saying that stress reduction is a crucial part of managing a TTH. I think it also goes without saying that this is easier said than done.

I want to offer you up a really great stress reduction technique: abdominal breathing.

I know you are thinking: okay Dr. Donald - breathing, really?

Yes, breathing.

Abdominal breathing has been shown time and time again to be the most beneficial strategy when it comes to stress management both anecdotally & scientifically.

I’ve written a whole blog on stress that you can read here, but essentially stress activates the sympathetic nervous system which is the cause of the fight or flight stress response we all know. On the other hand, abdominal breathing activates the parasympathetic nervous system which does the exact opposite.

How to: abdominal breathing

Traditionally, this is done laying down but there is no reason why you can’t do it sitting if you prefer!

Place your right hand on your stomach and your left hand on your chest. Then you are going to take a deep breath in through your belly and try and push your right hand out. Your chest & left hand shouldn’t be moving while you are practicing this.

My suggestion is to try this for a minute a few times a day. You will feel better immediately and, with time, you will also notice that you don’t react to stress with the same intensity as you did before.

Final thoughts

TTHs affect ~80% of the population at some point in their lives. Stats report a 35% yearly prevalence rate, but my guess is that 2020 saw those numbers go up. Managing your stress is the one most important thing you can do in order to decrease your tension headaches. This is why I am also including my guide on stress busting techniques. Abdominal breathing is just one way to manage your stress and I want you to master it.

Want my free guide on busting through stress? Head on over to to get your copy today!

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