From the Guidelines
For initial evaluation of tension headaches, no specific laboratory tests or imaging studies are routinely recommended as first-line assessments. Tension headaches are primarily diagnosed clinically based on history and physical examination 1. According to the US guidelines on neuroimaging in patients with non-acute headache, the proportion of individuals with a serious abnormality on brain imaging (CT or MRI) is very low in patients with tension-type headache and normal neurological examination, similar to that found in asymptomatic volunteers 1.
Key Points to Consider
- The guidelines recommend that neuroimaging is not usually warranted for patients with migraine and normal neurological examination, and it can be inferred that a similar approach may be applied to tension-type headache 1.
- Basic blood work such as complete blood count (CBC), comprehensive metabolic panel, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may be considered if there are concerning features suggesting a secondary cause, to rule out inflammatory or systemic conditions.
- Neuroimaging such as CT or MRI is generally reserved for patients with abnormal neurological findings, sudden onset of severe headache, change in headache pattern, or headaches that worsen with Valsalva maneuvers 1.
- The diagnosis of tension headaches remains primarily clinical, focusing on the pattern of headaches, triggers, and response to treatment, with testing primarily serving to rule out other conditions when red flags are present.
Clinical Approach
- A thorough history and physical examination are essential for the diagnosis of tension headaches.
- The presence of red flags such as abnormal neurological findings, sudden onset of severe headache, or change in headache pattern should prompt further investigation with imaging or laboratory tests.
- The clinical characteristics of tension headaches, including bilateral, non-pulsating pain of mild to moderate intensity without significant associated symptoms, should guide the diagnosis and management.
From the Research
Initial Tension HA Labs/Tests
The following labs/tests are considered for initial tension HA:
- A complete neurological examination 2, 3, 4, 5
- Serum/spinal fluid analysis if indicated 2, 5
- Neuroimaging (e.g. CT scan, MRI) if red flags are present or if secondary causes are suspected 2, 3, 4, 5
- Lumbar puncture to rule out subarachnoid hemorrhage if CT scan is normal 4, 5
Red Flags for Secondary Headaches
Red flags that may indicate secondary headaches and warrant further evaluation include:
- Focal neurologic signs 3, 4, 5
- Papilledema 3, 4, 5
- Neck stiffness 3
- Immunocompromised state 3
- Sudden onset of the worst headache in the patient's life 3, 4, 5
- Personality changes 3
- Headache after trauma 3, 5
- Headache that is worse with exercise 3
- Acute thunderclap headache 4
- Fever 4
- Meningeal irritation on physical examination 4
- Impaired consciousness 4
- Concern for acute glaucoma 4