Tension-Type Headache
NICE clinical guideline [CG150] Headaches in over 12s: diagnosis and management. Last updated: Jun 2025.
NICE CKS Headache – tension-type. Last revised: Jul 2022.
Guidelines
Headache Ref Flags
If headache and ANY of the following, consider the need for further investigations and/or referral:
-
worsening headache with fever
-
sudden‑onset headache reaching maximum intensity within 5 minutes
-
new‑onset neurological deficit
-
new‑onset cognitive dysfunction
-
change in personality
-
impaired level of consciousness
-
recent (typically within the past 3 months) head trauma
-
headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
-
headache triggered by exercise
-
orthostatic headache (headache that changes with posture)
-
symptoms suggestive of giant cell arteritis
-
symptoms and signs of acute narrow angle glaucoma
- a substantial change in the characteristics of their headache
If new-onset headache and ANY of the following, consider the need for further investigations and/or referral:
- Immunocompromised (e.g. HIV, use of immunosuppressive drugs)
- <20 y/o + history of malignancy
- History of malignancy known to metastasise to the brain
- Vomiting without other obvious causes
Investigation and Diagnosis
NICE recommends considering the use of a headache diary for at least 8 weeks to aid the diagnosis of primary headaches. The person should record the following:
- Frequency, duration and severity of headaches
- Any associated symptoms
- Possible precipitants
- Relationship of headaches to menstruation
- All medications taken to relieve headaches
Do not refer people diagnosed with tension‑type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.
NICE recommends clinical diagnosis, according to the following headache features:
| Headache feature | Seen in tension-type headache |
|---|---|
| Pain location | Bilateral |
| Pain quality | Pressing / tightening (non-pulsating) |
| Pain intensity | Mild or moderate |
| Duration | 30 minutes to continuous |
| Effect on activities | Not aggravated by ADLs |
| Other symptoms | None |
Management
Acute Management
- Aspirin, or
- Paracetamol, or
- NSAID
Do not offer aspirin in those <16 yo due to risk of Reye's syndrome
Preventive Treatment
Consider the following for frequent episodic or chronic tension-type headache
- Acunpuncture
- Amitriptyline – used instead of acute treatment for attacks
- CBT and/or relaxation techniques
- Physiotherapy and/or regular exercise
References
Original Guideline