Tension-Type Headache
Tension-type headache is a common primary headache disorder, meaning it is not caused by another underlying condition.
This updated UKMLA guide to tension-type headache is based on NICE CG150, which covers causes, risk factors, symptoms, diagnosis, and management.
Causes and Risk Factors
The exact underlying cause and pathophysiology remain unknown.
Epidemiology:
- Slightly more common in females
- Average age of onset: 25-30 y/o, peaking at 30-39 y/o
Triggering / exacerbating factors include:
- Psychological stress
- Excessive caffeine intake or caffeine withdrawal
- Sleep disturbance
Susceptibility to tension-type headache may be influenced by genetic factors
Headache Red Flags
If the headache has ANY of the following red flags, consider the need for further investigations and/or referral:
| Category | Red Flag | Explanation |
|---|---|---|
| Infection / inflammation | Worsening headache with fever | Suggests possible central nervous system infection (e.g., meningitis, encephalitis) or inflammatory disease. |
| Symptoms suggestive of giant cell arteritis (e.g., jaw claudication, age >50, visual symptoms) | Points to vasculitis with risk of vision loss or stroke. | |
| Immunocompromised status (HIV, immunosuppressive drugs) | Increases risk for opportunistic infections and neoplastic processes. | |
| Vascular / haemorrhagic | Sudden-onset headache reaching maximum intensity within 5 minutes (thunderclap) | Characteristic of subarachnoid haemorrhage, reversible cerebral vasoconstriction syndrome, or other acute vascular events. |
| New-onset neurological deficit | May indicate stroke, intracranial mass, encephalitis, or other structural or metabolic brain disorders. | |
| New cognitive dysfunction, personality change, or impaired level of consciousness | Suggests stroke, intracranial mass, encephalitis, or other significant brain pathology. | |
| Raised ICP / structural | Headache triggered by cough, valsalva manoeuvre, sneeze, or exercise | Can be a sign of increased intracranial pressure (e.g., due to intracranial mass). |
| Vomiting without other clear cause | May reflect increased intracranial pressure or mass effect. | |
| Substantial change in headache characteristics | May signal a new secondary process, such as neoplasm or infection. | |
| Intracranial hypotension | Orthostatic headache | Typical of intracranial hypotension, often due to CSF leak. |
| Trauma-related | Recent head trauma (within 3 months) | Raises concern for traumatic intracranial haemorrhage (e.g. subdural haematoma). |
| Oncology-related | Age <20 with history of malignancy | Raises suspicion for metastatic or recurrent disease affecting the CNS. |
| History of malignancy known to metastasise to the brain | Increases risk for intracranial metastases. | |
| Ophthalmic emergencies | Symptoms/signs of acute narrow-angle glaucoma (painful red eye, visual loss) | Requires urgent ophthalmological evaluation. |
If there is a new-onset headache with 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
Clinical Features and Diagnosis
Tension-type headache, like other primary headache disorders, is primarily a clinical diagnosis.
Consider using a headache diary for at least 8 weeks to help diagnose primary headaches. The patient 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.
Typical diagnostic clinical features of tension-type headache:
- Recurrent episodes of headache lasting 30 min to 7 days, and
- The headache is NOT associated with nausea or vomiting, and
- The headache may be associated with either photophobia or phonophobia, but not both, and
- The headache has at least 2 of the following
- Bilateral location
- Pressing, tightening pain (non-pulsating quality) – like a tight band around the forehead
- Mild to moderate intensity
- Not aggravated by (and does not cause avoidance of) routine physical activity (e.g. walking or climbing stairs)
The headache may spread into the neck or arise from the neck; there may also be pericranial tenderness on palpation.
Neurological examination should be normal in tension-type headache.
Frequencies of tension-type headache:
- Infrequent episodic: less than 1 day of headache per month
- Frequent episodic: at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months
- Chronic: 15 days or more of headache per month, for more than 3 months, in the absence of medication overuse
Management
Acute Management
Take simple analgesia ASAP after the onset of an acute attack, options include:
- Aspirin, or
- Paracetamol, or
- NSAID
Advise to avoid the frequent and excessive use of acute analgesia due to the risk of developing medication-overuse headache.
Do not offer aspirin in those <16 yo due to risk of Reye’s syndrome
Preventive Treatment
Assess for, and manage any underlying triggers or other associated conditions (e.g. stress, mood disorders, poor posture, neck pain, sleep disorders)
Consider the following for frequent episodic or chronic tension-type headache
- Acupuncture
- Amitriptyline – used instead of acute treatment for attacks
- CBT and/or relaxation techniques
- Physiotherapy and/or regular exercise
References