# Tension-Type Headache

Diagnose tension-type headache clinically after screening for secondary-headache red flags, distinguish episodic from chronic disease by monthly headache frequency, limit acute analgesic exposure, and reserve preventive strategies for chronic burden or recurrent treatment failure.

**Clinical question:** How should clinicians diagnose and manage tension-type headache while excluding secondary causes and preventing medication-overuse headache?

Updated: 2026-08-24T16:34:51.012557+00:00

## What matters in practice
- Use a positive clinical diagnosis for a stable tension-type phenotype, but obtain urgent evaluation or neuroimaging when SNOOP features, papilledema, neck stiffness, exertional precipitation, pregnancy/postpartum status, or a major pattern change is present. [19][22]
- Classify tension-type headache as episodic when occurring fewer than 15 days per month and chronic when occurring at least 15 days per month for more than 3 months. [22]
- For short-term treatment, ibuprofen 400 mg or acetaminophen 1000 mg are guideline-supported options; choose according to comorbidity and adverse-effect risk. [6]
- Do not use opioids for acute tension-type headache. [21][22]
- Review acute-medication days at every visit: medication overuse is defined by more than 3 months of use on at least 15 days per month for simple analgesics or at least 10 days per month for triptans, ergotamines, opioids, or combination analgesics. [17]
- For chronic tension-type headache, consider a course of up to 10 acupuncture sessions over 5 to 8 weeks. [22][23]

## Exclude secondary headache before labeling a tension-type phenotype

A typical recurrent pattern without red flags supports a positive diagnosis rather than routine exclusionary testing.

Escalate beyond a primary-headache assessment when the history or examination identifies systemic symptoms or illness, fever, HIV or other immunocompromise, focal neurologic signs, sudden or thunderclap onset, onset at older age, or a substantive change in the established headache pattern. These SNOOP features warrant targeted urgent evaluation and usually neuroimaging rather than empiric treatment as uncomplicated tension-type headache. [19]

Treat papilledema, rash or neck stiffness, cough- or exertion-triggered headache, pregnancy or postpartum headache, and a patient's worst headache as red flags. Select imaging and additional emergency workup according to the suspected process; the actionable point is that these features should interrupt a routine primary-headache pathway. [19]

In the absence of red flags and with a stable compatible clinical pattern, make a positive diagnosis and explain the diagnosis and management plan; routine investigation solely to exclude alternative pathology is not required. [22][23]
- Perform and document a neurologic examination and funduscopic assessment when possible; papilledema changes the pathway to secondary-headache evaluation. [19]
- Reassess the diagnosis when headache frequency, phenotype, associated symptoms, or examination findings change rather than assuming progression of a prior tension-type disorder. [19]

*Features that should redirect evaluation from uncomplicated tension-type headache toward secondary-headache assessment. [19]*

| Clinical finding | Interpretation | Next action |
| --- | --- | --- |
| Fever, systemic illness, rash, HIV, or other systemic symptoms | SNOOP systemic red flag. [19] | Evaluate for the relevant infectious, inflammatory, or systemic cause rather than managing as isolated tension-type headache. [19] |
| Focal neurologic sign or papilledema | Neurologic red flag. [19] | Obtain urgent secondary-headache assessment and neuroimaging as clinically indicated. [19] |
| Thunderclap or sudden onset; "worst headache" | Onset-pattern red flag. [19] | Use an urgent acute-headache pathway rather than outpatient analgesic management. [19] |
| New onset at older age or marked pattern change | Age and pattern-change red flags. [19] | Investigate for secondary pathology before assigning a primary headache diagnosis. [19] |
| Pregnancy/postpartum, neck stiffness, or cough/exertion trigger | Additional concerning features. [19] | Perform condition-directed evaluation; do not presume a benign primary headache. [19] |

## Classify headache frequency and identify medication overuse

Monthly headache frequency and acute-medication exposure determine whether management should remain episodic or shift to chronic-headache care.

Document headache days per month and duration of the current frequency pattern. Tension-type headache is episodic at fewer than 15 headache days per month and chronic at 15 or more days per month for more than 3 months. This threshold identifies patients in whom recurrent acute treatment, disability assessment, and preventive options require explicit review. [22]

At every headache visit, count days of use—not simply tablets—for acetaminophen, NSAIDs, aspirin-containing products, combination analgesics, opioids, triptans, and ergot derivatives. Medication-overuse headache is defined by regular use for more than 3 months on at least 15 days per month for simple analgesics, including paracetamol or NSAIDs, or at least 10 days per month for triptans, ergotamines, opioids, or combination analgesics. [17]

A patient with escalating headache days and threshold-level acute medication use should be managed as possible medication-overuse headache superimposed on a primary headache disorder, rather than by simply increasing rescue medication. Provide explicit counseling about medication-overuse risk whenever acute treatment is used. [22][23]
- Ask specifically about nonprescription products and caffeine-containing combination analgesics; combination analgesics carry the lower, 10-days-per-month overuse threshold. [17]
- Do not infer a tension-type diagnosis solely from pain location or perceived muscle tension when the headache pattern has changed or acute-medication exposure is high. [17][19]

*Frequency and acute-medication thresholds that change management. [17][22]*

| Measure | Threshold | Clinical implication |
| --- | --- | --- |
| Episodic tension-type headache | <15 headache days/month. [22] | Use intermittent acute treatment while tracking frequency and medication days. [22] |
| Chronic tension-type headache | ≥15 headache days/month for >3 months. [22] | Assess medication overuse and discuss preventive therapy options. [22][23] |
| Simple analgesic exposure | ≥15 days/month for >3 months. [17] | Meets medication-overuse threshold for acetaminophen/paracetamol or NSAIDs. [17] |
| Triptan, ergotamine, opioid, or combination analgesic exposure | ≥10 days/month for >3 months. [17] | Meets medication-overuse threshold and requires a withdrawal-oriented strategy rather than escalating acute therapy. [17] |

## Use simple analgesics early and avoid opioids

Acute treatment selection should match comorbidities, adverse-effect risk, and the patient's monthly exposure count.

For short-term treatment of tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg as supported options. Choose ibuprofen only after considering NSAID-related risk, and choose acetaminophen with attention to the patient's total exposure from all products. [6]

Aspirin, paracetamol/acetaminophen, or an NSAID may be considered for acute tension-type headache, with selection based on patient preference, comorbidities, and risk of adverse events. Do not offer aspirin-containing preparations to patients younger than 16 years because of the association with Reye syndrome. [21][22][23]

Do not prescribe opioids for acute tension-type headache. Opioids also meet the lower medication-overuse threshold of at least 10 treatment days per month when used regularly for more than 3 months. [17][21][22]
- Before issuing a refill or recommending repeated over-the-counter treatment, record current acute-treatment days per month and compare them with medication-overuse thresholds. [17]
- If the phenotype is migrainous rather than tension-type, do not continue a tension-type pathway; migraine acute treatment recommendations include an oral triptan combined with an NSAID or paracetamol/acetaminophen. [21][23]

### When the clinical phenotype is not tension-type

Primary headache management depends on accurate phenotype assignment. For migraine with or without aura, guideline recommendations favor oral triptan plus an NSAID or oral triptan plus paracetamol/acetaminophen, rather than treating repeated attacks as tension-type headache. [21][23]

*Acute pharmacologic options for tension-type headache. [6][21][22]*

| Option | Supported use | Key restriction |
| --- | --- | --- |
| Ibuprofen 400 mg | Suggested for short-term treatment. [6] | Individualize for comorbidity and NSAID adverse-effect risk. [21][22] |
| Acetaminophen 1000 mg | Suggested for short-term treatment. [6] | Count all acetaminophen-containing products and track use days for medication-overuse risk. [17] |
| Aspirin | May be considered for acute treatment. [21][22] | Do not offer aspirin-containing preparations to patients younger than 16 years. [21][22] |
| Opioid | Not recommended. [21][22] | Avoid for acute tension-type headache; regular use reaches medication-overuse threshold at ≥10 days/month for >3 months. [17] |

## Address chronic tension-type headache with prevention and exposure reduction

Chronic frequency requires a structured review of medication use, diagnostic stability, and preventive options.

For chronic tension-type headache, consider a course of up to 10 acupuncture sessions delivered over 5 to 8 weeks as preventive treatment. This option is specifically recommended for the chronic frequency category, not merely for occasional episodic attacks. [22][23]

If chronic headache coexists with regular acute-medication use at medication-overuse thresholds, address the overuse directly. Continued use of simple analgesics on at least 15 days per month, or combination analgesics, opioids, triptans, or ergotamines on at least 10 days per month, sustains a medication-overuse diagnostic pattern after more than 3 months of exposure. [17]

Use a headache diary to capture headache days, acute-medication days by class, and change in headache phenotype. A rising frequency, a new neurologic symptom, or development of secondary-headache red flags should trigger diagnostic reassessment rather than automatic escalation of preventive care. [19][22]
- Set a follow-up interval sufficient to review a complete monthly diary and identify whether acute-treatment exposure is approaching medication-overuse thresholds. [17]
- Reevaluate patients with chronic headache for coexisting migraine or medication-overuse headache because chronic headache disorders commonly include chronic migraine, chronic tension-type headache, and medication-overuse headache. [2][3]

*Chronic tension-type headache management checkpoints. [17][22][23]*

| Checkpoint | Action | Reason to change course |
| --- | --- | --- |
| Frequency confirmation | Confirm ≥15 headache days/month for >3 months. [22] | This establishes chronic tension-type headache frequency. [22] |
| Acute medication audit | Count medication days by drug class for the preceding 3 months. [17] | Threshold exposure indicates possible medication-overuse headache. [17] |
| Preventive intervention | Consider up to 10 acupuncture sessions over 5-8 weeks. [22][23] | Use for chronic tension-type headache. [22][23] |
| Diagnostic surveillance | Recheck for SNOOP features, papilledema, and pattern change. [19] | Any red flag redirects evaluation to a secondary-headache pathway. [19] |

## References
1. Tricyclic antidepressants and headaches: systematic review and meta-analysis | The BMJ — www.bmj.com — https://www.bmj.com/content/341/bmj.c5222
2. The lived experience of chronic headache: a systematic review ... — bmjopen.bmj.com — https://bmjopen.bmj.com/content/bmjopen/7/12/e019929.full.pdf
3. The lived experience of chronic headache — bmjopen.bmj.com — https://bmjopen.bmj.com/content/7/12/e019929
4. study protocol for a randomised controlled trial — bmjopen.bmj.com — https://bmjopen.bmj.com/content/13/11/e074871
5. Practice advisory for intravenous management of ... — rapm.bmj.com — https://rapm.bmj.com/content/early/2026/01/08/rapm-2025-106718
6. 2023 U.S. Department of Veterans Affairs and ... — www.acpjournals.org — https://www.acpjournals.org/doi/10.7326/ANNALS-24-00551
7. Headache in stroke. — www.ahajournals.org — https://www.ahajournals.org/doi/10.1161/01.str.24.11.1621
8. 2024 American Heart Association and American Red ... — www.ahajournals.org — https://www.ahajournals.org/doi/10.1161/CIR.0000000000001281
9. Onset Headache Predicts Good Outcome in Patients With ... — www.ahajournals.org — https://www.ahajournals.org/doi/10.1161/strokeaha.113.677070
10. Migraine — www.acpjournals.org — https://www.acpjournals.org/doi/pdf/10.7326/0003-4819-147-9-200711060-01011
11. Slowly repeated evoked pain (SREP) as a central sensitization marker in episodic migraine patients — www.nature.com — https://www.nature.com/articles/s41598-021-84157-1
12. Paracetamol versus ibuprofen in treating episodic tension-type headache: a systematic review and network meta-analysis | Scientific Reports — www.nature.com — https://www.nature.com/articles/s41598-023-48910-y
13. Is painful temporomandibular disorder a real headache for many patients? | British Dental Journal — www.nature.com — https://www.nature.com/articles/s41415-024-7178-1
14. ARTICLE IN PRESS — www.nature.com — https://www.nature.com/articles/s41598-026-47295-y_reference.pdf
15. Abstracts - IANCON 2024 : Annals of Indian Academy ... — journals.lww.com — https://journals.lww.com/annalsofian/fulltext/2024/27001/abstracts___iancon_2024.1.aspx
16. Spinal nociceptive sensitization and plasma... : Pain — journals.lww.com — https://journals.lww.com/pain/fulltext/2021/09000/spinal_nociceptive_sensitization_and_plasma.8.aspx
17. Smoking and medication-overuse headache : Cephalalgia — journals.lww.com — https://journals.lww.com/00002881-202646060-00013
18. Medication-Overuse Headache | Continuum — journals.lww.com — https://journals.lww.com/continuum/fulltext/2012/08000/medication_overuse_headache.10.aspx
19. Headache and Neuroimaging: Why We Continue to Do It — www.ajnr.org — https://www.ajnr.org/content/41/7/1149
20. Headache Care | Pediatrics In Review — publications.aap.org — https://publications.aap.org/pediatricsinreview/article/46/3/129/201112/Headache-Care
21. NATIONAL INSTITUTE FOR HEALTH AND CLINICAL ... — www.nice.org.uk — https://www.nice.org.uk/guidance/qs42/documents/headache-in-young-people-and-adults-briefing-paper2
22. Headaches in over 12s: diagnosis and management — www.nice.org.uk — https://www.nice.org.uk/guidance/cg150/chapter/recommendations
23. Headaches in over 12s: diagnosis and management - NICE — www.nice.org.uk — https://www.nice.org.uk/guidance/cg150/resources/headaches-in-over-12s-diagnosis-and-management-pdf-35109624582853
24. 4-year surveillance (2016) — www.nice.org.uk — https://www.nice.org.uk/guidance/cg150/evidence/appendix-a-summary-of-new-evidence-pdf-2721165806

## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.