Tension headache: symptoms, causes and what helps

A tension headache is usually a steady, pressing or tightening headache, often on both sides of the head, that is not made much worse by ordinary movement. It is common, but it should not be dismissed if it is frequent, new, worsening, linked to painkiller overuse, or mixed with migraine features. The useful first step is to identify the pattern, rule out red flags, then build a plan that reduces headache days rather than only chasing each attack.

What a tension headache feels like

The classic tension-type headache is a pressing, tightening, band-like or helmet-like pain. It is usually mild to moderate, often on both sides, and can last from 30 minutes to several days. It does not normally cause vomiting, and it is not usually made much worse by walking around or climbing stairs. Some people have tenderness in the scalp, jaw, neck or shoulders at the same time.

That pattern matters because many people use "tension headache" as a casual label for any headache during stress. Medically, it is a primary headache disorder with recognised features. The diagnosis is made from the story, examination and absence of warning signs. A scan is not automatically helpful when the pattern is typical and the neurological examination is normal, but that judgement depends on the whole clinical picture.²

Tension-type headache can be infrequent, frequent episodic or chronic. The chronic form is the one that most changes quality of life: headache on 15 or more days a month for more than 3 months, with tension-type features and no better explanation.³ If headaches are this frequent, the plan should move beyond "take paracetamol when it happens".

Why it happens

Tension-type headache is not simply "stress in your head". The current model includes sensitivity in pain-processing pathways, tenderness in the muscles around the head and neck, sleep disruption, stress load, jaw clenching, visual strain, low physical activity, and repeated use of acute pain medicines in some people. In chronic cases, the nervous system can become easier to trigger, so the same neck tension or poor night of sleep causes more pain than it used to.

Common triggers include long screen sessions, skipped meals, dehydration, caffeine swings, poor sleep, bruxism, anxiety, sustained neck and shoulder load, abrupt changes in exercise, and recovery after illness. These triggers are not always the root cause. They are clues about a system that is running close to its threshold.

The neck and jaw are worth assessing, but with proportion. Many people with tension-type headache have neck tenderness. That does not prove that the neck is the only cause. A useful physiotherapy or dental assessment asks what movements, clenching patterns, work positions and sleep behaviours change symptoms. It should then give you a plan you can test over weeks, not just a passive treatment that wears off by the next day.

Tension headache, migraine or medication overuse

Migraine and tension-type headache can overlap. Some people have both. A migraine can feel tight rather than dramatic, and a tension-type headache can become disabling when it is chronic. The distinction still matters because migraine-specific treatment, medication-overuse advice and prevention choices differ.

Medication-overuse headache deserves special attention because it can turn a treatable pattern into a daily one. NICE advises suspecting it when headache develops or worsens during regular use for 3 months or more: triptans, opioids, ergots or combination painkillers on 10 or more days a month, or paracetamol, aspirin or an NSAID on 15 or more days a month.² A simple rule for self-audit is to write down every day you take acute pain relief, whatever the reason.

Red flags that change the plan

Most tension-type headaches are not emergencies. The job is to know when the pattern is no longer routine. Seek urgent help for a thunderclap headache that peaks within minutes, headache with weakness, confusion, fainting, seizure, new speech or vision problems, fever with neck stiffness, headache after a significant head injury, or a new severe headache during pregnancy or soon after birth.

Book prompt medical assessment for a new headache after age 50, cancer or immune suppression, unexplained weight loss, scalp tenderness or jaw pain when chewing, a steadily worsening headache, headache triggered by coughing, sex or exertion, or a pattern that is very different from your usual headache. NICE lists these kinds of features because they can point to secondary causes that need a different pathway.²

If the headache is frequent but not urgent, a GP appointment is still worthwhile. You are not asking for reassurance only. You are asking for a named diagnosis, a medication-overuse check, a red-flag screen, and a plan that reduces headache days.

What actually helps

For occasional tension-type headache, NHS advice includes rest, hydration, simple pain relief when suitable, and reducing stress where possible.¹ The important caveat is frequency. Acute painkillers can be reasonable for occasional headaches, but they become part of the problem if they are used too often.

A headache diary is the highest-return first intervention. Track headache days, severity, sleep, meals, hydration, caffeine, alcohol, menstrual cycle if relevant, screen load, exercise, stress, jaw clenching, neck symptoms and every pain-relief day. Four weeks of data can show whether the label is really tension-type headache, migraine, medication overuse or a mixture.

Movement helps some people, especially when the headache pattern is tied to long sitting, low activity, neck sensitivity or stress physiology. A 2021 systematic review by Kroll and colleagues included 13 randomised trials of non-drug treatments for tension-type headache. It found low or very low certainty evidence that supervised physical activity, manual mobilisation, psychological treatment and acupuncture may help some outcomes, with few serious adverse events reported.⁷ That is not proof that every treatment works for everyone. It is a reason to test a structured plan rather than rely only on tablets.

Acupuncture has a separate Cochrane review. Linde and colleagues reviewed trials for prevention of tension-type headache and concluded that acupuncture is probably helpful for frequent episodic or chronic tension-type headache, although effects and trial quality vary.⁵ In the UK this is often a self-funded option unless offered locally, so it should be judged by headache-day change, not by how convincing it feels during treatment.

For chronic or frequent episodic tension-type headache, preventive medication may be discussed. BASH lists amitriptyline as a first-line preventive option for frequent episodic or chronic tension-type headache.⁴ A 2017 systematic review and meta-analysis by Jackson and colleagues included 22 randomised trials and found tricyclic antidepressants reduced headache frequency versus placebo by about 4.8 headaches per month, while also increasing side effects such as dry mouth, drowsiness and weight gain risk.⁶ This is not the same as treating the headache as "depression". It is using a nervous-system pain-modulating medicine at a dose and schedule your clinician judges appropriate.

Supplements are less central. Magnesium, riboflavin and coenzyme Q10 are discussed more often for migraine than for tension-type headache. If your pattern is mixed, read more widely in the health library, but avoid stacking supplements before the diagnosis is clear. The stack builder is useful for listing medicines, supplements and painkiller days before a GP or pharmacist review.

How to use a GP appointment well

A short appointment can still work if you bring the right information. Start with the number of headache days per month, the number of painkiller days per month, whether you have nausea, light sensitivity or aura, whether activity worsens pain, whether there are red flags, and what has changed recently. That is more useful than a long description of every painful episode.

Use the Start Here approach to build a timeline: when the headache pattern began, what it replaced, what you take, what helps, what worsens it, and which symptoms are new. Use insights to stay sceptical of over-simple claims. A tension-type headache plan is usually boring on purpose: diagnosis, diary, red flags, medicine limits, sleep, movement, jaw and neck assessment, then prevention if the pattern is frequent.

This article is educational and does not constitute medical advice, diagnosis, or a treatment recommendation. Medication uses described as “off-label” are not licensed for that purpose in the UK and should only be considered under qualified clinical supervision. Always speak to your GP, pharmacist, or a registered specialist before starting, stopping, or changing any treatment. If you have severe or alarm symptoms - unintentional weight loss, blood in your stool, difficulty swallowing, persistent vomiting, a fever, or severe pain - seek urgent medical care.