Tension Headache

Definition (ICHD-3). The commonest primary headache disorder. Pain is bilateral, pressing or tightening (non-pulsating), of mild to moderate intensity, lasting 30 minutes to 7 days, and NOT aggravated by routine physical activity. There is no nausea or vomiting; photophobia or phonophobia may be present, but not both. The classic description is a “tight band” around the head.

Classification. Infrequent episodic (fewer than 1 day per month), frequent episodic (1–14 days per month) and chronic (15 or more days per month for over 3 months). Chronic tension-type headache very commonly coexists with, and is perpetuated by, medication-overuse headache.

Contributing factors. Psychological stress, anxiety and depression, sleep disturbance and obstructive sleep apnoea, pericranial muscle tenderness (the hallmark physical sign), cervical spondylosis and poor posture, eye strain, and caffeine or analgesic overuse. In older adults the dominant contributors are cervical degenerative disease, depression and analgesic overuse.

Red flags mandating investigation in an older patient. Any new or changed headache after the age of 50, thunderclap onset, progressive or positional headache, systemic features (fever, weight loss), scalp tenderness or jaw claudication — check ESR and CRP for giant cell arteritis, focal neurological signs, papilloedema, immunosuppression or malignancy, and headache in an anticoagulated patient (subdural haematoma). In their absence, no imaging is required.

Management. Non-pharmacological measures come first: reassurance, a headache diary, sleep hygiene, regular meals, stress management, relaxation training, cognitive behavioural therapy, physiotherapy, posture correction and regular exercise. Acute — paracetamol, or an NSAID used cautiously in the elderly because of gastrointestinal, renal and cardiovascular risk; limit acute analgesic use to fewer than 15 days a month to prevent medication-overuse headache; avoid opioids and butalbital combinations entirely. Preventive for frequent or chronic forms — amitriptyline is first line starting at 10 mg at night, but it is anticholinergic, sedating, orthostatic and arrhythmogenic in older people; nortriptyline, mirtazapine or venlafaxine are alternatives.

Current guidance and evidence syntheses (2023–2025) place non-pharmacological therapy at the centre of tension-type headache management, with the strongest evidence for cognitive behavioural therapy, relaxation training and supervised exercise or physiotherapy. This matters especially in older adults, because amitriptyline appears on the AGS Beers Criteria 2023 as a drug to avoid in older people (anticholinergic burden, sedation, orthostatic hypotension and falls). The second key message is the active identification and withdrawal of medication-overuse headache, which is a common, reversible and frequently missed cause of what is labelled “chronic tension headache” in this population.