What are the physical findings of a tension headache?

From the Guidelines

Physical findings in tension headaches typically include tenderness or tightness in the neck, shoulder, and scalp muscles, with palpable muscle knots or trigger points, particularly in the suboccipital, temporal, or trapezius muscles, as noted in the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1.

Key Physical Findings

• Tenderness or tightness in the neck, shoulder, and scalp muscles
• Palpable muscle knots or trigger points, particularly in the suboccipital, temporal, or trapezius muscles
• Bilateral, non-pulsating pain described as a "band-like" pressure or tightness around the head
• Normal neurological findings, including intact cranial nerves, normal pupillary responses, and no papilledema on fundoscopic examination
• Limited range of motion in the neck due to muscle tightness

Distinguishing Features

• Absence of significant neurological findings, photophobia, phonophobia, or nausea, which are more commonly associated with migraine headaches
• Diagnosis is primarily clinical and based on the patient's history and description of symptoms, as many physical examination findings can be subtle or absent in tension headaches

Management

• The guideline suggests physical therapy for the management of tension-type headache 1, which may help alleviate symptoms and improve quality of life
• Other management options, such as pharmacotherapy with ibuprofen or acetaminophen, may also be considered, as suggested in the guideline 1

From the Research

Tension Headache Physical Findings

• Tension-type headache (TTH) is characterized by recurrent headaches of mild to moderate intensity, bilateral location, pressing or tightening quality, and no aggravation by routine physical activity 2
• Patients typically describe headache pain as pressing, dull, and with the sensation of a tight band around the head 3
• Physical findings may include:
  • Tightness or tenderness in the neck and scalp muscles
  • Limited range of motion in the neck
  • Trigger points in the neck and scalp muscles

Diagnosis and Treatment

• Diagnosis is based on headache history and the exclusion of alternative diagnoses, with clinical criteria provided by the International Classification of Headache Disorders, third edition 2
• Treatment options include:
  • Simple analgesics such as ibuprofen, aspirin, and acetaminophen 4, 5, 6
  • Preventive medications such as amitriptyline, venlafaxine, and mirtazapine 3, 2
  • Non-pharmacological therapies such as electromyography biofeedback, cognitive behavioral therapy, exercise, massage, and trigger point injection 3

Comparison of Treatment Options

• Ibuprofen and paracetamol are both effective for short-term pain relief in patients with TTH, with ibuprofen showing better efficacy than paracetamol for pain-free status at 2 hours 6
• Paracetamol may be considered as a preferred option for individuals at a higher risk, such as those with renal insufficiency or risk of GI bleeding 6