Synopsis
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.
- 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.
Key red flags
Thunderclap onset, systemic illness, positional provocation, focal signs, papilloedema or progressive personality and cognitive change is incompatible with uncomplicated tension-type headache.
Investigation priorities
Differentiate tension-type headache from migraine and identify an onset or associated feature suggesting secondary disease.
Management branches
A person describes recurrent non-disabling headache without obvious emergency features.
- Characterise onset, duration, frequency, quality, laterality, activity effect, nausea, sensory sensitivity and medication use, comparing separate attack types when necessary.
- Check systemic and neurological red flags, blood pressure and a targeted examination including optic discs when feasible.
- Explain why the phenotype fits tension-type headache and why routine imaging is unnecessary when history and examination are reassuring.
- Offer safe intermittent acute treatment, a diary if frequent, and precise advice on when pattern change needs reassessment.
Key medicines
ParacetamolUsually 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.
IbuprofenA 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.