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Refer to: NICE Clinical guideline CG150: Headaches: diagnosis and management of headaches in young people and adults.
Tension headaches are generally a fairly featureless headache. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity; it does not worsen with routine physical activity. There are usually no other symptoms (and no more than one of: photophobia, phonophobia, or mild nausea; and neither moderate nor severe nausea or vomiting).
Exclusion of other causes of headache can be done clinically; a scan is not generally considered necessary.
Generally tension type headache causes little disability and treatment. Referral to neurology or headache clinic is not usually required.
Consider aspirin, paracetamol or an NSAID for the acute treatment of tension-type headache taking into account the person's preference, comorbidities and risk of adverse events.
Do not offer opioids for the acute treatment of tension-type headache.
Consider a course of up to 10 sessions of acupuncture over 5-8 weeks for the prophylactic treatment of chronic tension-type headache (not available on NHS)
Please note that it is very rare that a patient with tension type headache should require prophylactic medication, but if prophylaxis is considered necessary amitriptyline (unlicensed) may be tried in some cases: initially 10mg at night, increased if necessary to maintenance of 50-75mg at night; maximum 150mg at night (see section 4.3.1 Tricyclic and related antidepressant drugs)
Medication overuse headache may be considered if the patient has been taking simple analgesics (prescribed and/or OTC) on 15 or more days a month, or codeine-containing analgesics, ergot or triptans on 10 or more days a month. If so, these drugs should be stopped (abruptly, not gradually) and the headache re-assessed 4 weeks later. Warn the patient of temporarily exacerbating headache.
Consider anxiety/depression and lifestyle factors and treat as necessary.