Tension Headache Discharge Instructions from the Emergency Department
Patients with tension headache should be followed up until headache resolution, with appropriate medication management and referrals to specialists if symptoms worsen or change in character. 1
Follow-up Recommendations
- Follow-up should continue until the headache completely resolves, with arrangements made before discharge from the emergency department 1
- Primary care physician should continue follow-up after discharge, with appropriate information about the headache diagnosis communicated to them 1
- Referral to pain specialist or neurologist is indicated if symptoms persist or worsen despite treatment 1
- Urgent neuroimaging and specialist referral should be performed if the patient develops worsening symptoms, new focal neurologic symptoms, or a change in headache character 1
Treatment Options
- First-line acute treatment includes NSAIDs (ibuprofen 400-800mg, naproxen 550-825mg, ketoprofen 50-75mg), which are more effective than aspirin or acetaminophen 2
- Avoid caffeine-containing preparations for frequent use as they may lead to headache chronification 2
- For chronic tension headaches, consider tricyclic antidepressants (particularly amitriptyline) which have documented efficacy in multiple studies 3
- Non-pharmacological treatments with evidence of efficacy include relaxation therapy with EMG biofeedback, which has approximately 40-50% efficacy rate 2, 3
Patient Education
- Provide written discharge instructions, as patients rarely remember verbal instructions 1
- Inform patients about the possibility of headache recurrence within 24 hours (occurs in 19-31% of headache patients discharged from the ED) 4
- Warn about the potential for developing chronic headaches, which occur in 26-38% of patients during the 3 months following ED discharge 4
- Advise patients to avoid unnecessary imaging studies for isolated headache without neurological deficits, as diagnostic yield is low 5
Warning Signs Requiring Urgent Medical Attention
- Worsening headache despite appropriate treatment 1
- Development of new focal neurological symptoms 1
- Change in the character or location of the headache 1
- Severe neck pain or stiffness 1
- Fever, confusion, or altered mental status 6
Pitfalls to Avoid
- Do not discharge patients without any follow-up recommendations (occurs in 9% of mild TBI cases) 1
- Avoid prescribing opioids for chronic non-cancer pain, as nonopioid analgesics should be used preferentially 1
- If opioids are deemed appropriate in specific cases, prescribe the lowest indicated dose of a short-acting opioid for the shortest feasible time 1
- Do not attribute persistent symptoms solely to tension or anxiety without ruling out serious conditions 6
- Avoid caffeine-containing medications for frequent use as they may contribute to medication overuse headache 2