• Maria Arini Lopez, PT, DPT, CSCS, CIMT, CMTPT

Tension-Type Headaches

June 17, 2022 - Written By: Maria Arini Lopez, PT, DPT

Headaches can be debilitating, making focus and concentration at school or work incredibly difficult. They are one of the top health reasons for missed days at work or school.

Headaches cause a variety of symptoms. Some cause dull, nagging pain in the back of your head, while others feel like a sharp ice pick is drilling through your skull. Some cause severe nausea, sensitivity to sound and light, and make you curl up on your bed in a dark room waiting for it to pass. Others cause an intense pressure build-up that makes the top of your head feel like it wants to explode. Yet others result in a pulsing, throbbing sensation in the temples.

According to the International Headache Society, over 150 types of headaches exist.1 The four main types of primary headaches are:

  • tension-type headaches

  • migraines

  • trigeminal autonomic cephalalgias (TACs) which include cluster headaches among others, and

  • other headaches caused by factors such as cold, cough, exercise, sexual activities, and external pressure, among others.2

Secondary headaches are symptoms of something else going on. For example, secondary headaches may result from many things, including, but not limited to:

  • a traumatic accident to the head or neck

  • infections

  • blood vessel disorders in the head or neck

  • problems instead the skull unrelated to blood vessels, and

  • substance use or withdrawal.2

Let’s talk about tension-type headaches.

Tension-type headaches may happen infrequently, frequently (less than 15 days per month for 3 months), or chronically (persistent and long-lasting). Tension-type headaches occur when the muscles surrounding the head and neck tense up or shorten (contract).3 Triggers include physical or emotional stress, eye strain, fatigue, infections, alcohol or caffeine use, dental problems, and excessive smoking.3 These muscles frequently have knots or trigger points in them which can cause specific patterns of pain throughout the head, resulting in headaches.

Here are pictures of some of those patterns.4

Figure 1 Sternocleidomastoid


The muscles in the front of the neck (called the sternocleidomastoid muscles) often get tight from leaning your head forward to look at a computer screen or possibly when you are driving. These muscles can cause pain either surrounding your eye, on the top of your head, across your forehead, and right behind your ear or even inside your ear. Sometimes, these muscles can also cause ringing in the ears (known as tinnitus).

Figure 2 Upper Trapezius


Most people have experienced the feeling of tight muscles in between the neck and the shoulders. These would be the infamous “upper traps”—the muscles that lift your shoulders up when you shrug. In some people, these muscles can be so tight that very little space exists between the shoulders and ears. These muscles often respond by tensing up during stressful times, in the cold, and following heavy or repeated lifting.

When these muscles are tight and have knots, they cause headaches that follow the pattern of a ram’s horn, called Ram’s Horn Headaches. The upper traps also attach to the back of the skull, so if they are tight, they can cause a dull ache in the back of the head.

Figure 3 Temporalis Figure 4 Masseter

The pair of muscles that close the jaw during talking or chewing (temporalis and masseters) can cause tooth pain, jaw pain, pain in the temples, and pain arching over the eyes.


When you are stressed and clench your teeth without knowing it during the day or if you grind your teeth at night, these muscles might tense up and cause these pain patterns.

Figure 5 Frontalis and Occipitalis


The muscles in the front (frontalis) and back (occipitalis) of the skull can also cause more localized pain in the forehead and in the back of the head.

Figure 6 Semispinalis and Multifidi (Cervical) Figure 7 Splenius Capitis Figure 8 Splenius cervicis

Last, but not least, the layers of muscles in the back of the neck can also cause pain in the back of the head and neck, at the base of the skull, and the top of the head. Headaches or pressure on the very top of the head are called vertex headaches.

Headache pain patterns are complex and often require targeted professional treatment by neurologists who specialize in headaches, physical therapists, pain management clinics, and other providers. Ways to reduce the intensity and frequency of tension-type headaches include medications prescribed by the neurologist to help relax the muscles, trigger point releases or injections, stress management, and stretching exercises to help keep the muscles lengthened and relaxed.

Adjusting your workstation set-up to change your posture may help decrease the tension in your neck and shoulders. You should not lean forward or strain to see the computer screen and your forearms (including the elbows) should be fully supported on your chair’s armrests so that your shoulder muscles don’t have to work hard to hold up your arms. Avoiding prolonged position by trying to stretch and move throughout the day may also help with muscle relaxation.

References and Resources

  1. What a pain in the head: there are more than 150 types of headaches. Meridien Research. Accessed June 9, 2022.

  2. Headache Classification. International Headache Society. Accessed June 9, 2022.

  3. Tension headaches. MedlinePlus. Accessed June 9, 2022.

  4. The Trigger Point and Referred Pain Guide. MyoRehab. Accessed June 9, 2022.

Maria Arini Lopez, PT, DPT

Maria Arini Lopez, PT, DPT, CSCS, CIMT, CMTPT is a freelance medical writer and Doctor of Physical Therapy from Maryland. She has expertise in the therapeutic areas of orthopedics, neurology, chronic pain, gastrointestinal dysfunctions, and rare diseases, especially Ehlers Danlos Syndrome.

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