Tension Headache


Has at least two of the following characteristics:

  • mild to moderate in severity
  • bilateral
  • often felt as a pressure or constriction
  • not accompanied by significant systemic upset or neurological deficits
  • not aggravated by routine physical activity

Episodes last from 30 minutes to 7 days. Nausea or vomiting does not occur but can have photophobia or phonophobia. Cause of the headache cannot be attributed to another disease e.g. - post trauma, brain tumours, neck pathology etc

The following general measures may help in the management of tension-type headaches:

  • avoid: overwork & stress, excess alcohol, lack of exercise
  • clinical depression should be treated
  • avoid analgesic abuse:
    • a maximum of 12 analgesic doses per week should be allowed
    • withdrawal of analgesics may cause rebound symptoms for up to 14 days
  • keeping a headache diary to help in the diagnosis and management
  • physiotherapy/massage – specially for musculoskeletal symptoms
  • strategies to counteract stress – relaxant,CBT, NB:reassurance

Drugs in tension type headaches can either be used for acute episodes or for prophylaxis

Episodic tension headaches happening on fewer than 2 days per week can be treated symptomatically with over the counter analgesics. The drug treatment of episodic tension-type headaches consists of:

  • paracetamol - appears to be less effective
  • NSAID or aspirin >16yrs.  Codeine and dihydrocodeine should be avoided.

NB: beware of medication overuse headaches. Episodic tension headaches occurring for >2 days per week trial of prophylaxis needed:

  • prophylaxis treatment
    • tricyclic antidepressants: amitriptyline  10-25mg or Propranolol 40-160mg, minimum 3 months
    • A course of acupuncture is now recommended by NICE

Referral: Neurology if failure of trial of treatment and prophylaxis, uncertainty of diagnosis, no improvement with withdrawal of analgesia for 3 weeks if suspected overuse. 

Neurology suggest www.bash.org.uk  publications, headache guidelines for further information.