What is the assessment and plan for a patient presenting with tension headache, considering demographic information, medical history, and symptoms?

Tension-Type Headache Assessment & Plan Template

Tension-type headache is diagnosed clinically based on bilateral, pressing/tightening quality pain of mild-to-moderate intensity without autonomic features, and management focuses on acute treatment with NSAIDs while limiting use to prevent medication overuse headache. 1, 2

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ASSESSMENT

Clinical Diagnosis Criteria

At least two of the following pain characteristics are required: 1

• Bilateral location
• Pressing or tightening (non-pulsatile) character
• Mild to moderate intensity
• No aggravation with routine physical activity

Both of the following must be present: 1

• No nausea or vomiting (anorexia may be present)
• No photophobia AND phonophobia (may have one or the other, but not both)

Classification

• Episodic tension-type headache: <15 headache days per month 3
• Chronic tension-type headache: ≥15 headache days per month for >3 months 3

Red Flags Assessment (Must Rule Out Secondary Causes)

Any of the following warrant urgent neuroimaging and/or specialist referral: 2, 4

• Thunderclap onset (peaking within 1 second to 1 minute)
• New headache after age 50
• Headache worsened by Valsalva maneuver (coughing, straining, bending)
• Headache awakening patient from sleep
• Progressively worsening pattern over days to weeks
• Fever or signs of infection
• Abnormal neurological examination findings
• Focal neurological deficits or motor weakness

Medication Overuse Assessment

Screen for medication overuse headache if: 1

• Non-opioid analgesics used ≥15 days/month for ≥3 months, OR
• Any other acute medication used ≥10 days/month for ≥3 months

Differential Considerations

• Migraine without aura (unilateral, pulsating, moderate-to-severe, worsened by activity, with nausea/vomiting or photophobia AND phonophobia) 1
• Chronic migraine (≥15 headache days/month with migraine features on ≥8 days) 2
• Secondary headache from systemic medical disorders (hypothyroidism, sleep disorders, hypertensive crisis) 5

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PLAN

Acute Treatment

First-line pharmacologic therapy: 6

• Naproxen sodium 500-825 mg at onset, may repeat every 2-6 hours (maximum 1.5 g/day), OR
• Combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks

Critical medication overuse prevention: 6

• Limit acute treatment to no more than 2 days per week to prevent medication overuse headache

Preventive Therapy Indications

Consider preventive therapy if: 6

• Headaches occur ≥2 times per month causing significant disability, OR
• Continuous headache of prolonged duration is present

First-line preventive options: 6

• Propranolol 80-160 mg daily (long-acting formulation)
• Alternative options: topiramate, antidepressants, CGRP monoclonal antibodies

Non-Pharmacologic Management

Address contributing factors: 7, 8

• Evaluate for pericranial muscle tenderness and trigger points
• Assess lifestyle factors (stress, sleep hygiene, posture)
• Consider physical therapy for muscular component

Neuroimaging Indications

MRI brain (preferred modality) is indicated if: 1, 2

• Any red flags are present
• Unexplained abnormal findings on neurologic examination
• Atypical features that don't fit established primary headache patterns

Neuroimaging is NOT routinely warranted for: 1

• Typical tension-type headache with normal neurological examination
• Long history of similar headaches without change in pattern

Specialist Referral Indications

Refer to neurology if: 4, 9

• Diagnosis remains uncertain after thorough evaluation
• Poor response to preventive strategies after adequate trials
• Motor weakness or persistent aura develops
• Chronic daily headache pattern emerges

Emergency department referral if: 4

• Any red flag features present (see above)

Follow-Up Strategy

Re-evaluate within 2-3 months to assess: 6

• Attack frequency and severity
• Disability level
• Adverse medication events
• Treatment adherence

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COMMON PITFALLS TO AVOID

Do not dismiss new headache in patients over 50 as "just tension headache" without thorough evaluation for secondary causes including temporal arteritis and mass lesions. 4

Recognize that most headaches presenting in the context of medical disorders have clinical features overlapping with tension-type headache - medical history and specific features of the systemic disorder are the clues to correct diagnosis. 5

Do not allow patients to develop medication overuse headache - this creates a vicious cycle of increasing headache frequency leading to daily headaches. 6

Distinguish chronic tension-type headache from chronic daily headache syndrome - the latter includes transformed migraine, new daily persistent headache, and hemicrania continua, which require different management approaches. 3