Headache - tension-type
Exam Tips
- ICHD-3 frequency split is high yield: infrequent episodic (<1 day/month), frequent episodic (<15 days/month for >3 months), chronic (>=15 days/month for >3 months).
- Core phenotype: bilateral, pressing, non-pulsatile, mild-moderate, not worsened by routine activity, and no vomiting.
- If clear migraine features are present (for example disabling throbbing headache with typical migrainous accompaniments), treat as migraine even if some tension-type features overlap.
- Normal neurological examination supports primary headache; any red flag (sudden thunderclap onset, focal deficit, fever/meningism, papilloedema, altered cognition, cancer/immunosuppression) mandates urgent secondary-cause work-up.
- In OSCEs, always counsel on medication-overuse headache and explicitly advise against opioid use for routine acute treatment.
Definition
Tension-type headache is a primary headache disorder characterized by recurrent, typically bilateral, pressing or tightening head pain without an alternative underlying cause. Episodes last from 30 minutes to 7 days, are usually mild to moderate, and are not worsened by routine physical activity; chronic disease is defined by headache on at least 15 days per month for more than 3 months (without medication overuse).
Pathophysiology
The mechanism is multifactorial and differs by phenotype: episodic tension-type headache is more linked to peripheral nociceptive input (including pericranial myofascial tenderness), whereas chronic tension-type headache is more associated with central sensitization and increased pain-processing gain. Trigger points in pericranial/neck muscles may refer pain in characteristic patterns, and repeated triggers (psychological stress, sleep disturbance, excess caffeine or withdrawal) may promote CNS hyperexcitability. Genetic susceptibility is likely but incompletely defined. For visual revision, see a standard headache textbook figure showing peripheral nociception vs central sensitization pathways in tension-type headache.
Risk Factors
- Psychological stress and anxiety/depressive symptoms
- Sleep disturbance or insomnia
- Pericranial muscle tenderness, neck pain, and poor posture
- Caffeine excess or withdrawal
- Frequent use of acute analgesics (risk of medication-overuse headache and chronification)
- Female sex (slight predominance) and possible genetic susceptibility
Clinical Features
Symptoms
- Recurrent headache lasting 30 minutes to 7 days
- Bilateral, pressing/tightening, non-pulsatile pain ("band-like" or "vice-like")
- Mild to moderate intensity
- Not aggravated by routine activity (for example walking or stairs)
- No nausea or vomiting; at most one of photophobia or phonophobia
- Pain may arise from or spread to the neck
Signs
- Normal neurological examination
- Pericranial tenderness on manual palpation may be present
- No focal neurological deficit or meningism in uncomplicated primary tension-type headache
Investigations
Management
Lifestyle Modifications
- Reassure and explain benign primary headache pattern when criteria are met
- Use a headache diary to identify trigger patterns and attack frequency
- Address modifiable contributors: stress management, sleep hygiene, hydration, regular meals, reduced caffeine fluctuation
- Treat associated neck/postural strain (ergonomics, physiotherapy-style neck/shoulder exercises where appropriate)
- Warn explicitly about medication-overuse headache and limit acute analgesic days
Pharmacological Treatment
Acute simple analgesia (episodic attacks)
- Paracetamol 1 g orally every 4-6 hours when required (maximum 4 g/day)
- Ibuprofen 200-400 mg orally up to three times daily with food (OTC maximum 1.2 g/day)
- Aspirin 900 mg orally every 4-6 hours when required (maximum 4 g/day; adults only)
Take early in attack. Avoid opioids (including codeine combinations) due to dependence, reduced long-term efficacy, and medication-overuse headache. NSAID cautions: peptic ulcer/GI bleeding risk, renal impairment, cardiovascular risk, and NSAID-sensitive asthma; use lowest effective dose for shortest duration. Aspirin is contraindicated under 16 years and generally avoided in pregnancy (especially third trimester). Paracetamol overdose risk is hepatotoxic, including with combination products.
Preventive therapy (frequent episodic or chronic tension-type headache)
- Amitriptyline 10 mg at night initially, increase by 10-25 mg every 1-2 weeks according to response/tolerability (typical effective range 25-75 mg at night)
Consider when headaches are frequent/disabling despite trigger management and prudent acute analgesia use. Review efficacy after an adequate trial and deprescribe if ineffective. Safety: anticholinergic effects, sedation, falls risk, weight gain, QT-prolongation risk, and overdose toxicity; caution in glaucoma, urinary retention, significant cardiac disease, bipolar disorder, and suicidality risk.
Complications
- Medication-overuse headache from frequent acute analgesic use
- Progression from frequent episodic to chronic tension-type headache
- Reduced quality of life, work/school productivity loss, and social impairment
- Comorbid mood and sleep disturbance perpetuating headache burden
Prognosis
Infrequent episodic tension-type headache is often self-limiting and usually responds to simple analgesia. Symptoms in primary headache disorders often lessen with age, but a subgroup develops persistent frequent or chronic disease. Long-term cohort data suggest mixed outcomes: many improve or remit, while a minority progress to chronic, high-burden headache.
Sources & References
✅NICE Guidelines(1)
- Headache - tension-type[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 277, 278)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1844)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 274, 275)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 29)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 28, 29)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1803)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 276)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 276, 277)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 53)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 54, 55)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 52, 53)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 54, 55)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 678, 679)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 473)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 470, 471)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 470, 471)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 473)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 795)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 794, 795)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 472, 473)[context]