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 bilateral, pressing or tightening (“band-like”) headache of mild to moderate intensity that is not aggravated by routine physical activity and carries 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, and mild nausea may accompany chronic TTH – but anything more (moderate or severe nausea, vomiting, photophobia and phonophobia together, or throbbing pain made worse by activity) should move migraine up your differential.
Two things matter most in primary care: make the diagnosis positively so you can reassure with confidence, and 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. This is not academic – it changes the whole prophylactic pathway (propranolol, amitriptyline or topiramate, plus triptans for migraine, versus acupuncture for chronic TTH). |
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