Tension-Type Headache

The most common primary headache. See headache for the broader differential.

Presentation

Lasts 30 minutes to 7 days.

• Infrequent episodic — <1 day/month.
• Frequent episodic — 1–14 days/month.
• Chronic — ≥15 days/month.

Pain characteristics: dull, tight/pressure sensation, non-throbbing, typically bilateral, mild–moderate intensity. No nausea/vomiting; photophobia/ phonophobia are uncommon; not aggravated by physical activity. May feature neck/head/shoulder muscle tenderness or a “tight band”/“heavy weight” sensation.

Management

• Same lifestyle measures as migraine.
• For frequent episodes, non-pharmacological therapy (CBT, relaxation training) may help; acupuncture may help (needs ≥6 sessions); physiotherapy (neck stretching/endurance programme) plus general aerobic exercise can help.

Acute episode

Usually self-limiting, no treatment required. Simple analgesics (NSAIDs, paracetamol) — limit to ≤3 days/week.

Long-term management

Offer prophylaxis if analgesia is needed >2–3 days/week.

• Amitriptyline (first choice) 10mg 1–2h before bed, increase by 10mg every 7 days over 4–6 weeks to max 75mg/day.
• Nortriptyline or dothiepin (less sedating alternatives) if amitriptyline isn’t tolerated — nortriptyline 10mg nocte, increase by 10mg every 7 days to max 75mg nocte, trial 8 weeks then review.
• Mirtazapine, venlafaxine, topiramate and gabapentin are sometimes considered but evidence for benefit is limited.
• Physiotherapy, massage and stretching exercises can help chronic cases.