Tension-type headache

Tension-type headache is a common primary headache disorder.

Tension-type headaches can occur sporadically or represent a debilitating chronic illness. Onset tends to be in a patients' 20's, and gradually becomes less common with advancing age.

It is a clinical diagnosis based on criteria outined by the International Headache Society (detailed below). It is important to consider and exclude sinister, secondary causes of any headache.

Treatment tends to target symptomatic relief. The benefits of prophylactic therapies are modest at best.

Tension-type headaches may be classified as episodic (infrequent, frequent) or chronic.

The International Headache Society classify tension headaches in their International Classification of Headache Disorders - III (ICHD-3).

Headache types can be difficult to distinguish. Many advise the patient keep a headache diary for a number of weeks to help better identify the type.

Infrequent episodic tension-type headache

The headaches are normally described as bilateral with a pressing/tight sensation of mild-moderate intensity. They last minutes to days.

Frequency: At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year) 

Time: 30 minutes to 7 days

Characteristics: At least two of the following:

1. Bilateral location
2. Pressing or tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity such as walking or climbing stairs

Both of:

1. No nausea or vomiting
2. No more than one of photophobia or phonophobia

Not better accounted for by another ICHD-3 diagnosis

Frequent episodic tension-type headache

The headaches are normally described as bilateral with a pressing/tight sensation of mild-moderate intensity. They last minutes to days.

Frequency: At least 10 episodes of headache occurring on 1-14 days/month on average for >3 months (≥12 and <180 days/year)

Time: 30 minutes to 7 days

Characteristics: At least two of the following:

1. Bilateral location
2. Pressing or tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity such as walking or climbing stairs

Both of:

1. No nausea or vomiting
2. No more than one of photophobia or phonophobia

Not better accounted for by another ICHD-3 diagnosis

Chronic tension-type headache

The headaches are normally described as bilateral with a pressing/tight sensation of mild-moderate intensity. They last hours to days and may be unremitting. It may be associated with mild nausea, photophobia or phonophobia.

Frequency: Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year)

Time: Hours to days, may be unremitting 

Characteristics: At least two of the following:

1. Bilateral location
2. Pressing or tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity such as walking or climbing stairs

Both of:

1. No more than one of photophobia, phonophobia or nausea 
2. Neither moderate or severe nausea or vomting

Not better accounted for by another ICHD-3 diagnosis

Serious types of secondary headache should be excluded.

Primary headaches

• Migraines
• Trigeminal autonomic cephalalgias
• Other primary headache disorders

Secondary headaches

• Trauma
• Idiopathic intracranial hypertension
• Subarachnoid haemorrhage 
• Space occupying lesion
• Giant cell arteritis
• Infection
• Drugs and medications
• Venous sinus thrombosis
• Malignant hypertension
• Temporomandibular disorder

You must consider potentially serious secondary causes of headaches and/or auras.

Whenever a patient presents with a headache, it is crucial as part of the assessment to exclude a potentially serious secondary cause of headache. Some of the key red flag signs that may indicate an underlying sinister cause of headache can be remembered by the mnemonic ‘HEADACHE PAINS’:

• H - Head injury (any history of trauma?)
• E - Eye pain +/- autonomic features
• A - Abrupt onset (i.e. thunderclap headache)
• D - Drugs (analgesia overuse or since new drug started)
• A - Atypical presentation or progressive headache
• C - Change in the pattern or recent-onset new headache
• H - High fever and systemic symptoms
• E - Exacerbating factors (worse on lying/standing, sneezing, coughing, exercise)
• P - Pregnancy or puerperium
• A - Age (onset > 50 years)
• I - Immunosuppressed (e.g. systemic therapy, HIV)
• N - Neoplasia (current or past history of cancer)
• S - Swollen optic discs (papilloedema)

Urgent referral

The NICE clinical practice guideline CG150 recommends further investigations (e.g. cerebral imaging) and/or referral for patients with new-onset headache and any of the following:

• Immunosuppressed or compromised immunity
• < 20 years old and a history of malignancy
• History of malignancy known to metastasise to the brain
• Vomiting without other obvious cause.

Other key precipitating factors that may suggest a secondary cause of headache include trauma (e.g. subdural haematoma) and headache triggered by Valsalva manoeuvre (e.g. posterior fossa lesion).

Associated features

In the assessment of headache always remember to determine these features from the history or examination:

• Fever, photophobia, neck stiffness: consider meningitis, encephalitis
• Papilloedema: consider BIH, venous sinus thrombosis, space-occupying lesions
• Dizziness/vertigo: consider stroke
• Visual changes: consider giant cell arteritis, glaucoma
• Vomiting: consider space-occupying lesions, carbon monoxide poisoning

NOTE: If multiple close contacts present with headache consider carbon monoxide poisoning!

Management aims to treat symptoms and reduce possible precipitants. 

Episodic tension type headache

• Analgesia: Simple painkillers such as paracetamol of NSAIDs (if no contra-indications), to be taken when headache occurs.
• Lifestyle: Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses. Some patients find regular excercise helps.

Chronic tension type headache

• Acupuncture: Offer a course of acupuncture. There is weak evidence that a 8 week course reduces the number of days the patient is affected.
• Prophylaxis: Consider low dose amitriptyline. This should be done with care and represents an off label use. Stop if there is no improvement. If the patient show improvement, aim to wean off after 4-6 months. There is significant debate as to whether this offers benefit, with many contradictory guidelines published.
• Lifestyle: Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses. Some patients find regular excercise helps.
• Referral: If there is no improvement or diagnostic uncertainty refer to neurology.

Medication ‘overuse’ itself has been shown to result in chronic headaches.

As the name suggests this occurs when regular analgesia taken for symptomatic relief of headache causes or perpetuates the condition.

The International Headache Society defines it as 'Headache occurring on 15 or more days/month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped'.

Last updated: March 2021