What is the most likely diagnosis and initial management for a patient with frontal pressure involving the ears that radiates to the neck and worsens at night?

Tension-Type Headache with Cervical Component

This presentation is most consistent with tension-type headache (TTH) with a significant cervical musculoskeletal component, and initial management should focus on over-the-counter analgesics (acetaminophen or NSAIDs) combined with physical therapy targeting the posterior neck muscles and postural correction.

Clinical Reasoning for Diagnosis

The symptom pattern strongly suggests TTH rather than a vascular or structural emergency:

• Bilateral frontal pressure radiating to the neck matches the classic band-like distribution of TTH, which typically causes pain described as tightness or pressure (not throbbing) that radiates bilaterally from forehead to occiput and down to neck muscles 1

• Worsening at night is characteristic of postural muscle strain, as prolonged neck flexion (looking down, poor sleeping position) increases EMG activity in posterior neck muscles and decreases muscle blood flow, triggering referred pain from occipital tender points that spreads to frontal and temporal regions 2

• Absence of migraine features (no unilateral throbbing, nausea, photophobia, or phonophobia) effectively rules out migraine 1

• Cervical musculoskeletal dysfunction is well-documented in TTH patients, who exhibit neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, and trigger points that reproduce their headache pattern 3

Red Flags to Exclude First

Before proceeding with TTH management, rapidly assess for conditions requiring urgent imaging:

• Pulsatile quality synchronous with heartbeat would indicate vascular pathology (dural arteriovenous fistula, arterial dissection, sigmoid sinus abnormalities) requiring immediate CT angiography 4

• Unilateral ear involvement with hearing loss, vertigo, or visible retrotympanic mass on otoscopy would necessitate high-resolution CT temporal bone or MRI internal auditory canals 5, 4

• Focal neurological deficits (weakness, numbness, gait disturbance, visual changes) mandate emergent neuroimaging per stroke protocols, not tinnitus protocols 4

• Severe positional vertigo triggered by head movements lasting seconds to minutes would suggest BPPV requiring Dix-Hallpike testing and canalith repositioning procedures 5

Initial Management Algorithm

First-Line Pharmacologic Treatment

• Over-the-counter analgesics (acetaminophen 1000 mg or ibuprofen 400-600 mg) are the mainstay of acute TTH treatment 1

• Critical warning: Limit analgesic use to less than twice weekly to prevent progression to chronic daily headache (medication overuse headache) 1

• Avoid butalbital-containing compounds or opiates initially despite their effectiveness, as they carry significantly higher risk of chronic daily headache 1

Physical Therapy and Postural Interventions

• Upper cervical spine mobilization or manipulation targeting C1-C2 joints can provide significant relief when cervical dysfunction is present 3, 6

• Soft tissue interventions including trigger point therapy or dry needling of posterior neck muscles (upper trapezius, levator scapulae, suboccipital muscles) address the muscular component 3

• Postural correction is essential: patients with forward head posture and prolonged neck flexion (desk work, phone use) develop static overstrain in posterior neck muscles and compensatory hyperextension at the craniocervical junction 7, 2

• Ergonomic modifications: Adjust workstation to maintain orbitomeatal line horizontal rather than flexed downward, as 30-degree neck flexion triggers occipital muscle ischemia and referred frontal headache within 2 minutes 2

Prophylactic Treatment for Frequent Headaches

• Amitriptyline (starting 10-25 mg at bedtime, titrating to 50-75 mg) is the most extensively studied prophylactic agent for frequent TTH and should be initiated if headaches occur more than twice weekly 1

• Non-pharmacologic prophylaxis including biofeedback, relaxation training, and cognitive therapy can be offered, though large rigorous trials are lacking 1

Common Pitfalls to Avoid

• Do not order neuroimaging for bilateral, symmetric, non-pulsatile headache without focal neurological findings, as this represents low-value care with no diagnostic yield 4

• Do not dismiss cervical involvement as irrelevant to "primary" headache—current evidence demonstrates that cervical musculoskeletal dysfunction is a significant component (though not the primary cause) in TTH 3, 6

• Do not overlook psychological stress, which decreases muscle blood flow and aggravates ischemic muscle contraction in the neck, perpetuating the pain cycle 2

• Do not confuse with cervicogenic headache: In TTH the neck is a contributing component, whereas in cervicogenic headache the neck is the primary source, and pain must be reproduced by provocative maneuvers of cervical structures 3, 6

When to Escalate Care

Refer for specialist evaluation if:

• Headaches persist despite 4-6 weeks of appropriate treatment 1
• Atypical features develop (sudden severe onset, progressive worsening, awakening from sleep, associated fever) 1
• Medication overuse headache develops from excessive analgesic use 1
• Severe anxiety or depression emerges requiring psychiatric intervention 8