Tension Headache
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Tension headaches are thought to account for about 40% of all headaches. They are also sometimes referred to as muscle contraction headaches. They typically last for several hours, and often recur daily.

  • Symptoms usually bilateral
  • Tight band sensation
  • Pressure behind the eyes
  • Can be across the whole top of the head, from occiputs to frontal region. Typically frontal, with or without radiation to the occiput
  • Typically occur frequently – can be daily
  • Does not wake patient from sleep – typical onset is after waking, often worse during the middle of the day
  • Not sensitive to head movement
  • No feeling of need to vomit
  • Generally – no neurological signs
  • Tension headache should NOT wake the patient from sleep – if this is occurring consider an alternate diagnosis

Along with migraine, they are a common source of presentation especially to general practice. Differentiating from migraine is important:

LocationUnilateral – can later become bilateralBilateral
FrequencyTypically < weeklyDaily
DurationUsually hours – can be daysTypically days
AlcoholMakes it worseMakes it better
Nausea or vomitingYesNo
Age of onsetOften < 20 yearsUsually > 20 years



  • Stress
  • Noise
  • Concentrated visual effort
  • Fumes / smells
  • There is little evidence for association with:
    • High BP
    • Refractive errors
    • Cervical spondylitis (inflammation of the vertebra)
These are the most common type of headache, and are thought to be caused by increased tension in scalp muscles, and neurovascular irritation.


Tension headache can be diagnosed using the International Headache Society (IHS3) criteria for the diagnosis of tension headache. These criteria state:

  • At least x10 episodes of similar headache
  • Head duration 30 min – 7 days
  • At least two of:
    • Non-pulsating
    • Mild or moderate intensity
    • Bilateral
    • Not aggravated by routine activity
  • Must have both of:
    • No nausea or vomiting
    • No photophobia or phonophobia (or only one of these)
  • Not attributable to another disorder


  • Reassurance
    • Some patients may be very persistent about investigations!
  • Avoiding perceived causatory factors (e.g. bright light)
  • Stress relief
  • Massage
  • Consider stress management techniques such as:
    • Mindfullness / meditation
    • CBT – either self direct (online or book) or via psychology referral
    • Regular exercise
    • Healthy diet advice
  • Consider anti-depressants if associated features of anxiety or depression warrant this
  • Analgesia
    • Stick to simple analgesia such as:
      • Paracetamol 1g QID PRN
      • Ibuprofen 400mg TDS PRN
      • Aspirin 900mg QID PRN
      • Discourage the use of stronger analgesia and regular analgesia use due to the risk of medication overuse headache
    • In chronic tension headache, limit analgesia to 2-3 days per week
  • Other medications may be considered – especially in chronic cases resistant to the above management:
    • Amitriptyline – e.g. 10-25mg nocte
    • Mitrazapine 15mg nocte
    • Topiramate 25mg OD – titrate up to 100mg OD
    • Beta-blockers – e.g. propranolol 40-80mg daily
    • SSRIs are no more effective than placebo unless there is an underlying mental health disorder


  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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