Neurology

Tension-Type Headache

Pericranial myofascial nociception, with central sensitisation in chronic disease, produces a bilateral pressing headache that is mild to moderate and not worsened by routine physical activity.

In a nutshell

Tension-type headache is bilateral pressing pain, mild to moderate, that does not stop routine activity and lacks the pulsation and nausea of migraine. Treat attacks with paracetamol 1 g orally (maximum 4 g in 24 hours) and cap all acute analgesia at 2 days a week.

Classic presentation

A 32-year-old office worker describes a band of pressure round both temples by the end of the day, works through it, and has no nausea and a normal examination.

Key points

Episodic disease is fewer than 15 headache days a month. Chronic is 15 or more a month for more than 3 months.
Attacks last 30 minutes to 7 days; chronic disease can be unremitting.
Pericranial tenderness on palpating scalp, neck and shoulder muscles is the only positive physical sign.
Do not refer a diagnosed primary headache for neuroimaging solely for reassurance.
It is the commonest primary headache, with a mean global lifetime prevalence of about 42%.
Chronic tension-type headache affects roughly 0.5 to 4.8% of people worldwide.

First-line investigation

None routinely: the diagnosis is clinical, supported by an 8-week headache diary, and imaging happens only if a red flag is present.

Management

Screen for secondary headache

Ask about thunderclap onset, fever, deficit, seizure, papilloedema, cough or posture trigger, head injury in 3 months, immunosuppression, malignancy.^1,8
Any red flag present means same-day assessment, not analgesia. Painful red eye with haloes goes to ophthalmology the same day.^1,8
New headache over 50 with scalp tenderness, jaw claudication or visual change: same-day assessment for giant cell arteritis, before sight is lost.^1,8

Confirm the phenotype and count the days

Confirm bilateral, pressing, mild to moderate pain not worsened by walking or stairs, with no vomiting. Examine fundi and pericranial muscles.^1,6
Start an 8-week diary: headache days, severity, every drug taken including over the counter, and precipitants such as stress, sleep and caffeine.^1,7

Treat the attack

Paracetamol 1 g orally, at least 4 hours between doses, maximum 4 g in 24 hours.^5,9,12
Or ibuprofen 400 mg orally with or after food, up to three times a day, maximum 1.2 g in 24 hours over the counter.^5,10,13
Or aspirin 300 to 900 mg orally, at least 4 hours between doses, maximum four doses in 24 hours. Not under 16 (Reye's syndrome).^5,11,1
Never opioids. Cap all acute analgesia at 2 days a week and explain medication-overuse headache at the first prescription.^1,4

Prevent chronic disease and undo overuse

Chronic disease (15 or more headache days a month for over 3 months): consider up to 10 acupuncture sessions over 5 to 8 weeks.^1,5
Amitriptyline 10 mg orally at night, increased by 10 to 25 mg weekly, maximum 150 mg daily. Off-label, recommended by the British Association for the Study of Headache.^5,14
Medication overuse: stop all overused acute drugs for at least 1 month, abruptly. Taper opioids. Start prevention at the same time.^15,1,4

Review, refer and safety-net

Review the diagnosis and management 4 to 8 weeks after withdrawal starts. Chronic migraine is the commonest alternative diagnosis.^1,15
Refer if diagnosis is uncertain, strong opioids are overused, comorbidity complicates withdrawal, or withdrawal has failed before.¹
Safety-net: call 999 for sudden severe headache, weakness, confusion, loss of vision, or fever with a non-blanching rash.⁸

Exam traps

When chronic tension-type headache and chronic migraine overlap, any migraine feature makes the chronic diagnosis migraine. Do not apply this shortcut to every episodic headache.
Nausea, vomiting or pulsating pain excludes episodic tension-type headache; chronic disease permits mild nausea only.
Opioids are never appropriate for tension-type headache, however severe it feels.
Aspirin is withheld under 16 because of Reye's syndrome, not because it fails to work.
Overuse thresholds differ by drug: 10 days a month for triptans, opioids, ergots and combination analgesics, 15 days for simple analgesics.
Headache worsens for 2 to 10 days after withdrawal begins. That is expected, not treatment failure.
NICE recommends no preventive drug for tension-type headache; amitriptyline is off-label and comes from BASH, not NICE.

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.