GPAtlas🧭 When to suspect
Tension-type headache (TTH) is the most common primary headache and one of the most frequent presentations in general practice. It is a positive clinical diagnosis, not a diagnosis of exclusion.
Suspect it in a patient describing a headache that is:
• Bilateral
• Pressing or tightening (“band-like”)
• Mild to moderate in intensity
• Not aggravated by routine physical activity
• With no significant associated features
There is no diagnostic test – the diagnosis rests on the history, a normal examination, and the absence of red flags.
Classically the pain is featureless: no throbbing, no vomiting, and no aura.
• Mild sensitivity to light or sound (but not both) is permissible.
• Mild nausea may accompany chronic TTH.
Anything more should move migraine up your differential:
• Moderate or severe nausea
• Vomiting
• Photophobia and phonophobia together
• Throbbing pain made worse by activity
Two things matter most in primary care:
• Make the diagnosis positively so you can reassure with confidence.
• Decide whether the pattern is episodic or chronic – because that determines whether prophylaxis and a search for medication overuse are needed.
| Pattern | Frequency (days of headache) | What it means in practice |
|---|---|---|
| Infrequent episodic TTH | < 1 day/month (< 12 days/year) | Usually self-managed with occasional simple analgesia. |
| Frequent episodic TTH | 1–14 days/month for > 3 months | • Focus on triggers and lifestyle • Warn about medication overuse |
| Chronic TTH | ≥ 15 days/month for > 3 months | Consider prophylaxis and actively screen for medication overuse headache. |
Source: NICE CG150 · International Classification of Headache Disorders (ICHD-3)
|
🧠 Clinical pearl – if there are any migrainous features, it is not tension-type headache • NICE is explicit: where chronic migraine and chronic TTH overlap, the presence of any migraine feature (throbbing quality, aggravation by activity, nausea, or photophobia and phonophobia together) means you diagnose migraine, not TTH. • The distinction is not academic – it changes the whole treatment pathway (triptans for acute attacks and propranolol, amitriptyline or topiramate as prophylaxis for migraine, versus acupuncture for chronic TTH). |
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