From the Research
For a hospital progress note on tension headache, I recommend a structured approach that includes subjective findings, objective data, assessment, and plan, with first-line pharmacological treatment including acetaminophen 650-1000mg every 6 hours as needed or NSAIDs such as ibuprofen 400-600mg every 6-8 hours with food, as supported by the most recent study 1. When documenting the patient's headache characteristics, it is essential to include location, intensity, duration, frequency, and associated symptoms like photophobia or phonophobia. Note any triggers such as stress, poor sleep, or prolonged screen time. Some key points to consider in the assessment and plan include:
- Documenting objective findings including vital signs, neurological examination results, and any tenderness of pericranial muscles
- Starting with non-pharmacological approaches including stress management techniques, adequate hydration, regular sleep patterns, and ergonomic adjustments
- Considering muscle relaxants like cyclobenzaprine 5-10mg at bedtime for 7-10 days for persistent symptoms
- Preventive therapy with amitriptyline 10-25mg nightly (titrating up as needed) for recurrent headaches, as suggested by 2
- Including patient education about tension headache triggers and lifestyle modifications
- Documenting follow-up plans including when to return if symptoms worsen or don't improve within 48-72 hours The most recent study 1 compared paracetamol and ibuprofen in treating episodic tension-type headache and found that both medications showed better efficacy than placebo, with no statistically significant difference in efficacy between the two drugs. However, paracetamol was associated with the lowest likelihood of rescue medication use, and ibuprofen was associated with a lower likelihood of the occurrence of any events and gastrointestinal adverse events. It is crucial to prioritize the patient's safety and consider potential contraindications, such as renal insufficiency or risk of GI bleeding, when choosing between paracetamol and ibuprofen, as noted in 1.