Tension headache

Tension-type headache is the most common primary headache disorder, which is not associated with another underlying condition.

Tension headache is defined as:

• Recurrent episodes of headache lasting from 30 minutes to 7 days which are not associated with nausea or vomiting. The headache may also be associated with no more than one of photophobia or phonophobia, and
• The headache has at least two of the following:
  • bilateral location
  • pressing, tightening, non-pulsating quality
  • mild or moderate intensity
  • not aggravated by routine physical activity (such as walking or climbing stairs).
• Note: neurological examination should be normal and headache should not be better accounted for by another cause.

Tension headaches may be:

• Infrequent episodic — less than 1 day of headache per month (usually self-limiting).
• Frequent episodic — at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months.
• Chronic — this evolves from frequent episodic attacks, with 15 days or more of headache per month, for more than 3 months, in the absence of medication overuse.

Management is largely reassurance and self management

• Stress the importance of avoiding frequent/excessive use of simple analgesia to avoid medication overuse headache
• Suggest exercise/physio/yoga/massage
• Consider referring for computerised CBT
• The use of a headache diary may be helpful

For severe symptoms not responding to self management consider tricyclic antidepressants, particularly amitriptyline 10–150mg two hours before bed, titrating dose depending on effect and tolerability. This is an off label indication but established practice.

Referral is generally not needed but refer to neurology if there is diagnostic uncertainty or atypical symptoms