About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Most common primary headache — bilateral, pressing/tightening, mild-moderate, NOT aggravated by physical activity
- No nausea, no vomiting. At most ONE of photophobia OR phonophobia (not both)
- Duration: 30 minutes to 7 days
- Acute treatment: simple analgesia — aspirin, paracetamol, or ibuprofen. Triptans NOT effective
- Chronic tension-type headache (≥15 days/month): consider amitriptyline 10–75 mg at night for prophylaxis
Overview
Tension-type headache (TTH) is the most common primary headache disorder. It is characterised by bilateral, non-pulsating headache of mild-moderate intensity that does not worsen with routine physical activity. It lacks the autonomic features of migraine (no nausea/vomiting) and the autonomic features of cluster headache. TTH is classified into episodic infrequent (<1 day/month), episodic frequent (1–14 days/month), and chronic (≥15 days/month for ≥3 months). The pathophysiology is poorly understood but likely involves peripheral myofascial mechanisms and central sensitisation.
Epidemiology
TTH has a lifetime prevalence of approximately 80% — most adults have experienced it. Chronic TTH is less common (~3%). It affects women slightly more than men. Risk factors include stress, anxiety, depression, poor posture, musculoskeletal cervical dysfunction, and sleep disturbance.
Clinical Features
Symptoms
Bilateral headache — pressing or tightening quality ("like a band around the head")
Mild to moderate intensity — does NOT prevent daily activities
NOT aggravated by routine physical activity (contrast with migraine)
No nausea or vomiting (distinguishes from migraine)
Duration: 30 minutes to 7 days
At most one of: photophobia OR phonophobia (migraine has both)
Signs
Normal neurological examination
Pericranial muscle tenderness on palpation (temporalis, frontalis, trapezius, sternocleidomastoid)
Investigations
First-line
Clinical diagnosisNo investigations required for typical tension-type headache with normal examination and no red flags
Second-line
MRI brainOnly if atypical features, red flags, or change in headache pattern. Not routine
Specialist
Headache diaryUseful for tracking frequency, identifying triggers, and monitoring medication use (for medication-overuse headache)
1
Acute treatment
- Simple analgesia: aspirin 600–900 mg, paracetamol 1 g, or ibuprofen 400 mg
- Triptans are NOT effective for tension-type headache
- Avoid opioids and combination analgesics (risk of medication-overuse headache)
- Limit analgesic use to ≤15 days/month to prevent medication-overuse headache
2
Prophylaxis for chronic TTH (≥15 days/month)
- Amitriptyline 10 mg at night, titrated to 10–75 mg — first-line prophylaxis
- Non-pharmacological: stress management, regular exercise, sleep hygiene, cognitive behavioural therapy
- Consider physiotherapy for cervical musculoskeletal contributors
- Acupuncture: NICE CG150 recommends considering a course of up to 10 sessions for chronic TTH or migraine
Complications
- Medication-overuse headache: Frequent analgesic use (≥15 days/month) can transform episodic headache into chronic daily headache
- Chronic tension-type headache: ≥15 days/month — significant impact on quality of life, work, and mood
- Comorbid depression and anxiety: Commonly coexist — screen and treat
UKMLA Exam Tips
- 1Bilateral pressing/tightening headache, no nausea, no vomiting, not worsened by activity = TTH
- 2Migraine: unilateral, pulsating, nausea/vomiting, photo AND phonophobia, worsened by activity
- 3Triptans do NOT work for tension-type headache — only for migraine and cluster headache
- 4Amitriptyline is first-line prophylaxis for chronic TTH
- 5Medication-overuse headache: suspect if analgesics used ≥15 days/month (or triptans ≥10 days/month)
- 6The key differentiating features: TTH = bilateral, pressing, no nausea; Migraine = unilateral, pulsating, nausea
practicetest your knowledge on tension-type headacheApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — neurology and beyond.
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