01OverviewDefinition, clinical context and the essential points that orientate the chapter.
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.
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.
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.
- Stress, posture, sleep and pericranial tenderness may modify symptoms but do not mean the pain is imaginary; frame self-management as adjunctive, not blame.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Primary headache susceptibility
Tension-type headache is a primary pain disorder arising from interacting peripheral and central sensitivity rather than structural brain disease.
Pericranial nociceptive input
Muscle and fascial tenderness around scalp, jaw and neck can contribute, particularly in episodic disease, without proving a simple mechanical cause.
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.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Peripheral nociceptor activation
Pain-sensitive pericranial tissues send sustained nociceptive signals through trigeminal and upper-cervical afferents during recurrent headache attacks.
- 2Central pain processing
Brainstem and thalamic networks integrate the input as bilateral pressure or tightness without the stronger sensory-autonomic pattern of migraine.
- 3Sensitisation in chronic disease
Repeated headache lowers pain thresholds and increases central responsiveness, helping episodic symptoms evolve into a frequent or chronic pattern.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Bilateral tightening or pressing pain of mild-to-moderate intensity that does not worsen with ordinary activity is characteristic when secondary features are absent.
No vomiting and no more than one of photophobia or phonophobia supports tension-type headache; prominent nausea and combined sensory sensitivity point towards migraine.
Headache on 1–14 days per month for more than 3 months creates a meaningful cumulative burden without meeting the chronic threshold.
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.
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.
Thunderclap onset, systemic illness, positional provocation, focal signs, papilloedema or progressive personality and cognitive change is incompatible with uncomplicated tension-type headache.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 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.
- 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.
- 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.
- 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.
- 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.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Migraine
Nausea, vomiting, both light and sound sensitivity, pulsation and activity aggravation favour migraine over uncomplicated tension-type headache.
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.
Cervicogenic headache
Consistent provocation by neck movement, restricted cervical range and unilateral referred pain support a cervical structural or joint origin.
Secondary headache
Thunderclap onset, fever, papilloedema, focal signs, malignancy or a progressive new pattern require prompt targeted investigation.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01First presentationMake a positive low-risk diagnosisFirst stepA person describes recurrent non-disabling headache without obvious emergency features.+
- 1Characterise onset, duration, frequency, quality, laterality, activity effect, nausea, sensory sensitivity and medication use, comparing separate attack types when necessary.
- 2Check systemic and neurological red flags, blood pressure and a targeted examination including optic discs when feasible.
- 3Explain why the phenotype fits tension-type headache and why routine imaging is unnecessary when history and examination are reassuring.
- 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.+
- 1Use 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.+
- 1Treat the altered episode as a new presentation, documenting onset to peak and repeating neurological, visual and systemic assessment.
- 2Identify the specific competing cause, such as haemorrhage, pressure disorder, infection, giant cell arteritis or ocular emergency.
- 3Arrange urgent imaging, eye review, laboratory tests or hospital assessment according to that mechanism rather than merely switching analgesics.
- 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+
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.
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.
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.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Chronic daily headache
Increasing frequency causes persistent pain, fatigue, reduced work and difficulty distinguishing individual attacks over prolonged periods.
Medication-overuse cycle
Regular rescue analgesia can sensitise pain pathways and create withdrawal recurrence, worsening the original disorder over time.
Sleep and mood impairment
Chronic pain disrupts sleep, concentration and mood, while anxiety and depression can amplify disability over time.
Analgesic organ toxicity
Repeated NSAID, aspirin or paracetamol exposure can cause gastrointestinal, renal, hepatic or cardiovascular harm according to context.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- 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.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
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.
11Common pitfallsFrequent interpretation and management errors.
- 01
Calling every bilateral headache tension-type without checking nausea, activity aggravation, attack duration and combined light-and-sound sensitivity.
- 02
Interpreting the word pressure as reassuring when the onset was thunderclap or the pattern is newly progressive with systemic features.
- 03
Offering opioids for frequent attacks and thereby increasing dependence, sedation and medication-overuse risk.
- 04
Increasing analgesic quantities without counting use days or recognising that simple medicines themselves can perpetuate chronic headache.
- 05
Ordering a routine scan to prove a primary diagnosis instead of explaining the clinical reasoning and reserving imaging for a secondary question.
- 06
Attributing pain dismissively to stress or posture and failing to address disability, sleep, mood or coexisting migraine through shared decisions.