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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Tension-type headache

Neurology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Time-critical presentation

Tension-type headache does not cause thunderclap onset, papilloedema, fever with meningism, persistent focal deficit, impaired consciousness, jaw claudication, a painful red eye or a major pregnancy-related change. Any such feature needs urgent secondary-headache assessment.

Overview

Diagnose tension-type headache from a bilateral, non-disabling pressure phenotype, distinguish frequent and chronic patterns from migraine or secondary disease, and manage pain without driving medication overuse.

Tension-type headache is the most common primary-headache phenotype and is diagnosed from attack behaviour. Pain is usually on both sides, pressure-like rather than pulsating, mild or moderate, and permits routine activity without clear aggravation. It lacks vomiting and is not accompanied by the combined nausea, light sensitivity and sound sensitivity typical of migraine. Pericranial muscle tenderness may be present but is not necessary. Ask the patient what they stop doing during an attack: continuing ordinary tasks is more characteristic than retreating from movement and sensory stimulation. Many people experience both tension-type headache and migraine, so classify individual attack types rather than forcing every headache into one label.

Frequency determines consequences. Infrequent episodic attacks require little more than diagnosis, safe intermittent analgesia and reassurance. Frequent episodic or chronic headache deserves a diary, disability assessment, sleep and mood review, examination and a search for medication overuse. Chronic tension-type headache means at least 15 days monthly for more than 3 months, usually lasting hours or continuously; chronic migraine remains an important alternative when at least 8 days have migraine features. A steadily progressive new daily headache, new onset after 50, systemic illness, positional or Valsalva provocation, neurological abnormality or papilloedema is not explained by the word tension and changes investigation.

Key points

  • Typical tension-type headache is bilateral, pressing or tightening, mild to moderate and not aggravated by ordinary activity such as walking or climbing stairs.
  • Nausea or vomiting argues against tension-type headache; either photophobia or phonophobia may occur, but both together support migraine more strongly.
  • Attacks can last from 30 minutes to days, and the diagnosis is positive when the recurrent phenotype fits and examination reveals no secondary concern.
  • Infrequent episodic disease occurs on fewer than 1 day monthly, frequent episodic disease on 1–14 days monthly, and chronic disease on at least 15 days monthly for more than 3 months.
  • Offer paracetamol, aspirin or an NSAID for acute treatment after considering comorbidity, pregnancy and age; do not offer opioids.
  • Consider up to 10 sessions of acupuncture over 5–8 weeks as preventive treatment for chronic tension-type headache under NICE guidance.
  • Ask about analgesic days and combination products because frequent self-treatment can transform an episodic disorder into medication-overuse headache.
  • A normal scan is not required to validate a secure stable diagnosis, and routine imaging for reassurance can expose patients to incidental findings and anxiety.

Aetiology

01

Primary headache susceptibility

Tension-type headache is a primary pain disorder arising from interacting peripheral and central sensitivity rather than structural brain disease.

02

Pericranial nociceptive input

Muscle and fascial tenderness around scalp, jaw and neck can contribute, particularly in episodic disease, without proving a simple mechanical cause.

03

Physiological and psychosocial modifiers

Stress, sleep disruption, posture and sustained concentration may increase attacks but should not be framed as blame or evidence that pain is imaginary.

Pathophysiology

  1. 1
    Peripheral nociceptor activation

    Pain-sensitive pericranial tissues send sustained nociceptive signals through trigeminal and upper-cervical afferents during recurrent headache attacks.

  2. 2
    Central pain processing

    Brainstem and thalamic networks integrate the input as bilateral pressure or tightness without the stronger sensory-autonomic pattern of migraine.

  3. 3
    Sensitisation in chronic disease

    Repeated headache lowers pain thresholds and increases central responsiveness, helping episodic symptoms evolve into a frequent or chronic pattern.

Clinical features and red flags

Pressure phenotype

Bilateral tightening or pressing pain of mild-to-moderate intensity that does not worsen with ordinary activity is characteristic when secondary features are absent.

Limited associated symptoms

No vomiting and no more than one of photophobia or phonophobia supports tension-type headache; prominent nausea and combined sensory sensitivity point towards migraine.

Frequent episodic pattern

Headache on 1–14 days per month for more than 3 months creates a meaningful cumulative burden without meeting the chronic threshold.

Chronic pattern

Headache on at least 15 days monthly for over 3 months can be chronic tension-type headache, but migraine-feature days and medication use must be counted carefully.

Mixed headache disorder

Some days may show non-disabling pressure while others have activity-aggravated pain, nausea and sensory sensitivity, indicating coexisting tension-type headache and migraine phenotypes.

Secondary mismatchRed flag

Thunderclap onset, systemic illness, positional provocation, focal signs, papilloedema or progressive personality and cognitive change is incompatible with uncomplicated tension-type headache.

Investigations

  1. 01
    Headache phenotype historyFirst step
    Why
    Differentiate tension-type headache from migraine and identify an onset or associated feature suggesting secondary disease.
    Interpretation and limitations
    Bilateral pressure without activity aggravation, vomiting or combined sensory sensitivity supports the diagnosis; abrupt or progressive red flags override it.
  2. 02
    Headache and medicine diary
    Why
    Measure headache-day frequency, associated features, analgesic exposure and functional consequences over at least several weeks.
    Interpretation and limitations
    Separate migraine-feature days and count every treatment day; thresholds distinguish episodic, chronic and medication-overuse patterns.
  3. 03
    Neurological and funduscopic examination
    Why
    Look for an objective clue to an intracranial, ocular or systemic secondary headache.
    Interpretation and limitations
    Normal findings support a primary phenotype but do not erase a high-risk history; papilloedema or persistent deficit mandates urgent investigation.
  4. 04
    Mood, sleep and musculoskeletal assessment
    Why
    Identify modifiable amplifiers and comorbidities that sustain frequent pain and disability.
    Interpretation and limitations
    Treat depression, anxiety, insomnia, sleep apnoea or neck dysfunction on their own merits without presenting them as proof that headache is psychogenic.

Differential diagnosis

01

Migraine

Nausea, vomiting, both light and sound sensitivity, pulsation and activity aggravation favour migraine over uncomplicated tension-type headache.

02

Medication-overuse headache

Frequent analgesic use can increase headache days and coexist with either tension-type headache or migraine, making a treatment-day history essential.

03

Cervicogenic headache

Consistent provocation by neck movement, restricted cervical range and unilateral referred pain support a cervical structural or joint origin.

04

Secondary headache

Thunderclap onset, fever, papilloedema, focal signs, malignancy or a progressive new pattern require prompt targeted investigation.

Management

01First presentationMake a positive low-risk diagnosisFirst stepA person describes recurrent non-disabling headache without obvious emergency features.+
  1. 1Characterise onset, duration, frequency, quality, laterality, activity effect, nausea, sensory sensitivity and medication use, comparing separate attack types when necessary.
  2. 2Check systemic and neurological red flags, blood pressure and a targeted examination including optic discs when feasible.
  3. 3Explain why the phenotype fits tension-type headache and why routine imaging is unnecessary when history and examination are reassuring.
  4. 4Offer safe intermittent acute treatment, a diary if frequent, and precise advice on when pattern change needs reassessment.
02Frequent patternPrevent progression and overuseHeadache occurs repeatedly each month or analgesic reliance is increasing.+

Complications

01

Chronic daily headache

Increasing frequency causes persistent pain, fatigue, reduced work and difficulty distinguishing individual attacks over prolonged periods.

02

Medication-overuse cycle

Regular rescue analgesia can sensitise pain pathways and create withdrawal recurrence, worsening the original disorder over time.

03

Sleep and mood impairment

Chronic pain disrupts sleep, concentration and mood, while anxiety and depression can amplify disability over time.

04

Analgesic organ toxicity

Repeated NSAID, aspirin or paracetamol exposure can cause gastrointestinal, renal, hepatic or cardiovascular harm according to context.

Monitoring and follow-up

  • Count headache days and acute-treatment days monthly when attacks are frequent, because progression and medication overuse are defined by frequency rather than pain intensity alone.
  • Record whether headache remains non-aggravated by activity and free of migraine-associated symptoms; phenotype drift may reveal coexisting or chronic migraine.
  • Measure functional effects such as concentration, sleep, attendance and activity, not only a numerical pain score.
  • After acupuncture or another planned intervention, compare a defined baseline and follow-up period rather than relying on the most recent attack.
  • Reassess promptly for new age-related, systemic, positional, visual or neurological features instead of assuming a longstanding label remains explanatory.

Special situations

Activity is diagnostically useful

Asking whether walking upstairs worsens pain often distinguishes migraine behaviour from tension-type pressure more clearly than asking whether pain feels 'bad'.

Two phenotypes can coexist

A person may need a simple analgesic plan for tension-type days and a triptan-based plan for distinct migraine days, supported by careful diary classification.

Tender muscles are not causation

Pericranial tenderness can accompany the disorder, but does not prove a postural lesion or justify unnecessary spinal imaging.

Chronic needs recounting

At 15 or more days monthly, revisit migraine features and acute medicine exposure before finalising chronic tension-type headache because management pathways diverge.

Validation is therapeutic

Explaining that a primary headache is biologically real, while offering measured self-management, avoids the false choice between serious structural disease and imagined symptoms.

Common pitfalls

  1. 01

    Calling every bilateral headache tension-type without checking nausea, activity aggravation, attack duration and combined light-and-sound sensitivity.

  2. 02

    Interpreting the word pressure as reassuring when the onset was thunderclap or the pattern is newly progressive with systemic features.

  3. 03

    Offering opioids for frequent attacks and thereby increasing dependence, sedation and medication-overuse risk.

  4. 04

    Increasing analgesic quantities without counting use days or recognising that simple medicines themselves can perpetuate chronic headache.

  5. 05

    Ordering a routine scan to prove a primary diagnosis instead of explaining the clinical reasoning and reserving imaging for a secondary question.

  6. 06

    Attributing pain dismissively to stress or posture and failing to address disability, sleep, mood or coexisting migraine through shared decisions.

Practice

Two practice questions

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Question 1 of 2
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NeurologyOriginal SBA

Recognising the phenotype

A patient has recurrent bilateral pressing headaches lasting most of a day. They remain able to walk normally, have no nausea or vomiting and report phonophobia but not photophobia. Which diagnosis fits best?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG150 tension-type headache recommendationsDiagnostic features, acute analgesia, treatments to avoid and acupuncture.
  • BNF analgesics treatment summaryUK analgesic doses, contraindications and safety considerations.
  • British Association for the Study of Headache guidelinesUK specialist classification and management of tension-type headache.
  • International Classification of Headache Disorders tension typeFrequency and phenotype criteria for episodic and chronic subtypes.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

For an acute episode, NICE advises paracetamol, aspirin or an NSAID, considering preference, comorbidity and adverse effects, and advises against opioids. The minimum effective intermittent exposure is preferable. Frequent analgesia risks medication-overuse headache, so quantify days and do not simply increase pack size. For chronic tension-type headache, NICE supports considering a course of up to 10 acupuncture sessions over 5–8 weeks. Evidence for routine pharmacological prevention is less clearly standardised in this NICE pathway; specialist or local services may use off-label options after confirming phenotype and overuse, but the rationale, adverse effects and review plan should be explicit. Advice about regular sleep, movement, breaks, relaxation and addressing psychosocial strain should be collaborative and proportionate.

Stress, posture, sleep and pericranial tenderness may modify symptoms but do not mean the pain is imaginary; frame self-management as adjunctive, not blame.
  • 05
    Neuroimaging only when indicated
    Why
    Answer a specific secondary-headache concern rather than confirm tension-type headache.
    Interpretation and limitations
    Stable typical headache with normal examination needs no routine scan; select modality according to any newly identified vascular, pressure, inflammatory or structural question.
    • 1
    Use a diary to count total days, migraine-feature days and each class of acute medicine rather than relying on recalled tablet totals.
  • 2Review sleep, mood, activity, work ergonomics, caffeine and other pain conditions, agreeing realistic changes that match the patient's priorities.
  • 3Reduce unsafe or overused acute medicines through a clear plan and consider whether migraine prevention or medication-overuse withdrawal is the better pathway.
  • 4For confirmed chronic tension-type headache, discuss a NICE-supported acupuncture course and define how benefit will be measured.
    • 03Diagnostic changeReopen the differentialThe familiar headache becomes abruptly severe, progressive, systemic, positional or neurologically different.+
    1. 1Treat the altered episode as a new presentation, documenting onset to peak and repeating neurological, visual and systemic assessment.
    2. 2Identify the specific competing cause, such as haemorrhage, pressure disorder, infection, giant cell arteritis or ocular emergency.
    3. 3Arrange urgent imaging, eye review, laboratory tests or hospital assessment according to that mechanism rather than merely switching analgesics.
    4. 4Return to long-term primary-headache management only after the secondary concern is resolved and the revised diagnosis is explained.
    Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
    A simple acute analgesic for intermittent tension-type headache when used within safe dosing and frequency limits.

    Paracetamol

    Usually 1 g orally when required for an adult at least 50 kg, with at least 4–6 hours between doses and maximum 4 g daily.

    Lower maxima may be needed with low body weight, frailty, liver disease, malnutrition or harmful alcohol use; count all combination products and prevent frequent-use escalation.

    An NSAID alternative for acute tension-type headache in a person without important inflammatory-drug risk.

    Ibuprofen

    A common adult non-prescription dose is 400 mg orally when required, following licensed intervals, duration and the local daily maximum.

    Review ulcer, kidney, heart-failure, anticoagulant, asthma and pregnancy risks; use the shortest intermittent course and do not combine with another NSAID.

    An additional simple analgesic choice for adults with episodic tension-type headache when other considerations permit.

    Aspirin

    NICE lists aspirin as an acute option; use the current adult analgesic regimen and product maximum after checking suitability.

    Do not use under age 16; avoid with relevant bleeding, ulcer, anticoagulant, aspirin-sensitive asthma and pregnancy concerns, and do not combine with another NSAID.