Tension-type headache: symptoms, triggers, treatment and red flags

The NHS says tension headaches are very common and that many people get them. NHS inform calls tension-type headache the most common type of headache, the everyday kind, felt as a constant ache that affects both sides of the head as though a tight band is stretched around it. It is normally not severe enough to prevent you carrying on with everyday activities.

The NHS lists the typical symptoms as pain on both sides of the head, face or neck, a feeling that something is pressing on or tightening around the head, and tenderness of the affected area so that the head hurts more when touched. The NHS also says tension headaches are not a sign of an underlying condition, which is reassuring but should not stop you checking for the warning features described below.

The exact cause is unclear, according to NHS inform. It has been linked to stress, poor posture, skipping meals and dehydration. The NHS lists stress, sleep problems and caffeine as common causes, and notes that taking painkillers too often or for too long can itself cause headaches, called overuse or rebound headaches.

Keeping a simple diary of headache days, sleep, meals, drinks and stress often reveals a pattern. The NHS says a GP may suggest exactly that if you have regular tension headaches, recording how often they occur and how long they last, how painful they are, other symptoms, possible causes and any medicines you take.

The NHS suggests seeing a GP if you have a throbbing pain at the front or on one side of the head, or feel sick, vomit and find light or noise painful, because those can be signs of a different headache such as migraine or cluster headache. NHS inform describes migraine as moderate to severe throbbing pain at the front or side of the head that can stop you doing normal activities, and cluster headache as rare, very painful, one-sided pain around the eye with watering or a runny nose.

The NHS recommends painkillers such as paracetamol, aspirin and ibuprofen, noting that paracetamol is the first choice if you are pregnant and that children under 16 should not take aspirin. NICE guidance for the public says a healthcare professional should offer aspirin, paracetamol or an NSAID, taking into account your preferences, other health problems and side effects, and that opioids should not be offered for tension-type headache.

Non-drug measures include relaxation activities such as exercise, yoga and massage, changing sleep habits if insomnia is a factor, a low firm pillow and heat or cold packs if neck pain accompanies the headaches, and cutting down caffeine. NHS inform adds resting, drinking plenty of fluids and regular exercise. A pharmacist can advise on the best painkiller, on what is suitable in pregnancy (ibuprofen is not recommended in some pregnancies) and on medicines for insomnia.

NHS inform explains that frequent painkiller use can produce a chronic daily headache, especially in people with frequent tension-type headache or migraine. It says you should normally not take painkillers on more than 10 days every month, that medication overuse headache usually gets better a few weeks after stopping the medicine responsible, and that pain may get worse for a few days before it improves.

If you find yourself reaching for tablets most days, speak to a GP or pharmacist rather than increasing the dose. That is the moment to look at the underlying pattern and consider prevention.

The NHS says a low-dose antidepressant, amitriptyline, is sometimes recommended to help prevent tension headaches, usually started low, increased later, and taken for several months before it starts working. NICE says that if you have tension-type headaches on 15 days per month or more you may be offered a course of up to 10 sessions of acupuncture to help prevent future headaches.

The NHS says you may be referred to a specialist if painkillers and activities like exercise do not help or it is not clear what is causing the headaches. Do not start preventive medicines without a prescriber, and do not stop them abruptly.

The NHS says to call 999 or go to A&E after a head injury, or if a headache comes on suddenly and is extremely painful, or is extremely painful with sudden problems speaking or remembering, loss of vision, drowsiness or confusion, a very high temperature with signs of meningitis, or a red white of the eye. Seek an urgent GP appointment or call 111 for a severe headache with jaw pain when eating, blurred or double vision, a sore scalp, or numbness or weakness in the arms or legs.

NHS inform adds that you should contact your GP urgently if a headache does not go away and gets worse over time, is triggered by coughing, laughing, sneezing or physical effort, is new or worsening with dizziness, vomiting or weakness, or occurs if you are pregnant, have a clotting disorder or take blood thinners, and also suggests contacting the practice for a headache that wakes you from sleep or if you have, or have had, cancer. For children under 12 the NHS lists additional warning signs, such as headache on waking or one that gets progressively worse.

Most people with tension headache need no more than pharmacy advice and a GP review. Referral to neurology on the NHS is reserved for unclear or worsening patterns, and waits vary by area.

Private neurology, physiotherapy or acupuncture can be arranged directly. A good assessment should include a careful history and examination rather than automatic scanning, and the clinician should discuss medication overuse, sleep, posture and stress. Be wary of expensive packages that promise a cure for chronic headache.