Tension Headache

Most common primary headache disorder, bilateral, pressing/tightening quality, mild-moderate intensity, not aggravated by routine physical activity.

Classified: episodic (<15 days/month) or chronic (≥15 days/month for >3 months) : often associated with pericranial muscle tenderness, though exact pathophysiology multifactorial (myofascial, central sensitization in chronic form).

Bilateral, band-like/pressing pain, mild-moderate severity, no significant nausea/vomiting (may have mild anorexia), no more than one of photophobia OR phonophobia (distinguishes from migraine), not worsened by routine activity. Pericranial muscle tenderness on palpation common.

Duration 30 minutes to 7 days. Triggers: stress, poor posture, sleep deprivation, eye strain, dehydration, skipped meals.

Clinical, ICHD-3 criteria, exclusion of secondary causes via history/examination. No imaging needed for typical presentation with normal neurological exam.

Apply SNOOP red flags (see Migraine entry) ; same principles for any headache presentation.

Differentials: migraine (more severe, unilateral, associated nausea/photophobia/phonophobia), medication overuse headache (regular analgesic use), cervicogenic headache, secondary headaches per red flags.

• Reassurance regarding benign nature

• Acute: simple analgesics ; paracetamol 1g, or NSAIDs (ibuprofen 400mg) ; limit frequency (<2 days/week) to avoid medication overuse headache

• Avoid opioids and combination analgesics containing caffeine/codeine (higher overuse headache risk)

• Non-pharmacological: stress management, regular sleep/meals, posture correction, relaxation techniques, regular exercise

• Chronic tension headache preventive therapy: amitriptyline 10-75mg nocte ; first-line preventive; also consider addressing comorbid anxiety/depression

• Physiotherapy: for significant pericranial muscle tenderness/postural contribution

• Acupuncture: reasonable evidence for chronic form

Referral: neurology for diagnostic uncertainty, refractory chronic disease, red flag features, or suspected medication overuse headache requiring withdrawal support.