Tension headache: symptoms, triggers, red flags and treatment

The NHS describes common symptoms as pain on both sides of the head, face or neck, a feeling of something pressing on the head or being tightened around it, and a tender area where the head may hurt more when touched. Importantly, you should be able to carry on with daily activities without making the headache worse. That last feature separates it from migraine, in which movement usually aggravates the pain.

NICE CKS uses the International Classification of Headache Disorders: recurrent episodes lasting from 30 minutes to 7 days without nausea or vomiting, with no more than one of light or sound sensitivity, and at least two of: both sides of the head, a pressing or tightening rather than throbbing quality, mild or moderate intensity, and no aggravation by routine activity such as walking or climbing stairs. A neurological examination should be normal.

CKS also divides tension-type headache by frequency: infrequent episodic, fewer than one day a month and usually self-limiting; frequent episodic, at least 10 episodes on fewer than 15 days a month over more than 3 months; and chronic, 15 or more days a month for more than 3 months.

The NHS lists stress, sleep problems and caffeine as common causes, and notes that overusing painkillers can cause headaches of its own. CKS says the exact mechanism is unknown, with peripheral pain mechanisms thought to be involved in episodic tension-type headache and central pain mechanisms and heightened pain sensitivity more important in chronic forms.

The wider NHS headache page adds other common headache causes: having a cold or flu, drinking too much alcohol, bad posture, eyesight problems, not eating regular meals, not drinking enough fluids, taking too many painkillers, and having a period or being in menopause. A headache diary can help work out triggers.

• Stress and tension in the neck and shoulders.

• Poor or irregular sleep, including insomnia.

• Caffeine, either too much or sudden withdrawal.

• Long periods looking at a screen or poor posture.

• Skipped meals or too little to drink.

• Frequent use of painkillers, which can lead to medication overuse headache.

Different headache types overlap, and many people have more than one. The table puts the features side by side using NHS and CKS descriptions.

The NHS tension headache page lists urgent advice (urgent GP appointment or 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. For a child under 12 it adds a headache that wakes them at night, is present on waking, gets progressively worse, is triggered or worsened by coughing, sneezing or bending, comes with vomiting, or comes with a squint or inability to look upward.

The NHS says to call 999 or go to A&E for a head injury, or a headache that came on suddenly and is extremely painful. It also lists an extremely painful headache with sudden problems speaking or remembering, loss of vision, drowsiness or confusion, a very high temperature and symptoms of meningitis, or the white of the eye being red. The wider NHS headache page lists additional emergency features: a seizure, numbness or weakness of the body or face, difficulty with balance or walking, a rash that does not fade under a glass, a stiff neck or discomfort with bright lights, and a head injury within the last 3 months.

Other urgent features on the NHS headache page are headaches triggered or worsened by coughing, sneezing, bending or exercise, headache with being sick, and headache with vision or eye problems.

• A sudden, extremely painful headache that peaks within moments.

• Headache after a head injury, including within the previous 3 months.

• Headache with fever, stiff neck, rash that does not fade, or dislike of bright lights.

• Weakness, numbness, speech or vision problems, drowsiness or confusion.

• Jaw pain when eating, a tender scalp, or visual disturbance, particularly in later life.

• A headache that is worse when coughing, sneezing, bending or exercising, or that wakes you at night.

The NHS says a GP may suggest a headache diary for regular tension headaches, recording how often they occur and how long they last, how painful they are and any other symptoms, possible causes and medicines taken. CKS says a diary or calendar helps monitor response to treatment and detect coexisting migraine or medication overuse.

The examination includes a neurological check, which should be normal in tension-type headache, along with looking for neck or scalp tenderness. The GP also asks about analgesic use, sleep, mood, caffeine, eyesight and any features of secondary headache. Referral to a neurologist is considered by CKS if the diagnosis is uncertain or symptoms are atypical, or persist despite optimal primary-care management.

For occasional headaches the NHS recommends paracetamol, aspirin or ibuprofen, noting that paracetamol is the first choice in pregnancy and that under-16s should not take aspirin. CKS recommends simple over-the-counter analgesia and the avoidance of opioids, with a warning about the risk of medication overuse headache. A pharmacist can advise on the best painkiller and on sleep aids if insomnia is a trigger.

The NHS suggests relaxation activities such as exercise, yoga and massage, changing sleeping habits if insomnia contributes, a low firm pillow, heat or cold packs for neck pain, and reducing caffeine. For frequent or chronic forms CKS lists acupuncture, physiotherapy, regular exercise, CBT or relaxation, and a trial of low-dose amitriptyline (an off-label use) for prevention; the NHS says it is started at a low dose, usually needs several months before it works and may be increased later.

A GP is the right person for tension headaches that are frequent, severe or unresponsive to simple measures, or when the pattern changes. A pharmacist can help with painkiller choice. A neurologist sees those with diagnostic doubt or persistent headaches. An optometrist can check eyesight if reading or screen use brings on headaches.

Any red-flag feature goes through the urgent routes above rather than waiting for a routine review.