Tension-Type Headache
The most likely diagnosis is tension-type headache, given the bilateral, band-like pressure from forehead to neck without migrainous features (no nausea, photophobia, or aura) and absence of cervicogenic reproduction on examination. 1, 2
Clinical Reasoning
This patient's presentation is classic for tension-type headache based on several key features:
Characteristic Features Present
Bilateral distribution: The pain affects both sides of the head in a band-like pattern, which is typical for tension-type headache rather than the unilateral presentation more common in migraine 1, 3
Quality of pain: The "vice-like" pressure and tightening sensation is the hallmark pressing or tightening quality of tension-type headache, not the pulsating/throbbing character seen in migraine 1, 2
Absence of migrainous features: The lack of nausea, photophobia, phonophobia, and prodromal symptoms effectively rules out migraine without aura, which requires at least one of these associated symptoms 4, 2
Severity: The description suggests mild to moderate intensity, consistent with tension-type headache rather than the moderate to severe pain typical of migraine 1, 3
Why Other Diagnoses Are Excluded
Migraine without aura is unlikely because migraine requires at least one associated symptom (nausea/vomiting, photophobia, or phonophobia), and this patient explicitly lacks all of these features 4, 2
Cluster headache is definitively excluded by the bilateral nature of the pain—cluster headaches are strictly unilateral with severe to very severe intensity, last only 15-180 minutes, and are accompanied by ipsilateral autonomic symptoms like lacrimation or nasal congestion 5, 2
Cervicogenic headache is ruled out by the negative cervical spine range-of-motion testing and inability to reproduce the headache with skull palpation 1
Occipital headache is not a distinct diagnostic entity in the International Headache Society classification and would not explain the band-like distribution from forehead to neck 2
Clinical Pitfalls to Avoid
Do not assume bilateral headaches cannot be migraine—approximately 40% of migraines are bilateral, but they still require associated symptoms for diagnosis 4
The absence of muscle tenderness on palpation does not exclude tension-type headache, as the pathophysiology involves both peripheral and central mechanisms 6
Always screen for red flags (thunderclap onset, focal neurologic signs, fever, rapidly increasing frequency, awakening from sleep, cancer history) before settling on a primary headache diagnosis, though none are present in this case 2
Neuroimaging is not indicated for this typical presentation without concerning features on history or examination 1, 2