What is the most likely diagnosis for a patient presenting with a 4-day bilateral squeezing headache exacerbated by loud noise, without associated nausea, vomiting, or visual changes, and a history of similar episodes over the past year?

Tension-Type Headache

This patient's presentation is most consistent with tension-type headache based on the bilateral, pressing/squeezing quality of pain, absence of migraine features (no nausea, vomiting, or visual changes), and phonophobia without photophobia. 1

Clinical Reasoning

The diagnostic criteria from the International Headache Society clearly distinguish between primary headache types, and this patient meets the specific criteria for tension-type headache rather than the alternatives:

Why Tension-Type Headache Fits

• Bilateral location with pressing/tightening character - The "squeezing sensation across the top of her head" is the classic description of tension-type headache, which causes pain that radiates in a band-like fashion bilaterally 1, 2

• Mild to moderate intensity - The patient is able to present for evaluation after 4 days, suggesting the pain is not severe enough to be incapacitating 1

• No nausea or vomiting - Tension-type headache diagnostic criteria specifically require the absence of both nausea and vomiting (though anorexia may be present) 1

• Phonophobia without photophobia - Tension-type headache may have one or the other sensory sensitivity, but not both together 1

• Recurrent pattern - The history of similar headaches over the past year is consistent with episodic tension-type headache 3, 4

Why NOT Migraine

• Migraine requires BOTH photophobia AND phonophobia together as associated symptoms, not just one 1

• Migraine typically presents with unilateral, throbbing/pulsating pain that worsens with routine activity 1

• Migraine commonly includes nausea and/or vomiting, which are absent in this patient 1

• The bilateral, non-throbbing nature and lack of typical migraine-associated symptoms make this diagnosis unlikely 1

Why NOT Cluster Headache

• Cluster headache causes severe unilateral pain lasting only 15-180 minutes, not 4 days 1

• Cluster headache requires autonomic features such as lacrimation, nasal congestion, ptosis, or miosis on the same side as the pain 1

• Cluster attacks occur with high frequency (one to eight attacks per day), which does not match this patient's presentation 1

Why NOT Trigeminal Neuralgia

• Trigeminal neuralgia presents with brief, shock-like, lancinating facial pain in the distribution of the trigeminal nerve, not a prolonged bilateral squeezing headache 5

• The 4-day duration and bilateral distribution are incompatible with trigeminal neuralgia 5

Important Clinical Pitfalls

• Tension-type headache is the most common primary headache disorder, with a worldwide lifetime prevalence of 46-78%, yet it remains underrecognized and undertreated 3, 4

• Do not assume all bilateral headaches are tension-type - migraine can occasionally be bilateral, but the absence of nausea/vomiting and the presence of only phonophobia (not both photophobia and phonophobia) are key distinguishing features 1

• The normal neurologic examination supports a primary headache diagnosis and does not require neuroimaging in the absence of red flags 1