How should I approach the management of a patient with chronic tension-type headaches in primary care?

Management of chronic tension-type headaches in primary care should begin with a thorough assessment to exclude secondary causes and identify any red flags that require urgent referral or investigation.

Use a headache diary for at least 8 weeks to record frequency, duration, severity, associated symptoms, medication use, and possible triggers to aid diagnosis and monitor treatment response.

Provide a positive diagnosis with clear explanation and reassurance that other serious pathology has been excluded.

Offer information and support, including written materials and details of support organisations, to help the patient understand their condition.

Advise on lifestyle modifications and non-pharmacological approaches such as stress management, regular sleep, hydration, and physical activity, as these can help reduce headache frequency and severity.

For acute treatment, simple analgesics like paracetamol or NSAIDs can be used, but caution is needed to avoid medication overuse headache by limiting use to fewer than 15 days per month.

Consider prophylactic treatment if headaches are frequent and disabling, but specific pharmacological prophylaxis recommendations for chronic tension-type headache are less well defined than for migraine; treatment should be individualized and may include tricyclic antidepressants.

Regularly review the patient’s headache pattern and medication use to identify and manage medication overuse headache if it develops.

Refer to specialist care if there are atypical features, diagnostic uncertainty, or failure to respond to treatment.

Do not routinely perform neuroimaging solely for reassurance in patients with a clear diagnosis of tension-type headache without red flags.

This approach aligns with NICE CG150 recommendations on headache management in people over 12 years old.