Tension headache

Background

Definition

1. Headache lasting from 30 min to 7 d (but typically 4-6 hours)
2. Headache has at least two of the following characteristics:
   • Bilateral location
   • Pressure or tightening (nonpulsating quality)
   • Mild or moderate intensity
   • Not aggravated by routine physical activity such as walking
3. Both of the following:
   • No nausea or vomiting (anorexia may occur)
   • No more than one of photophobia or phonophobia
4. Not attributed to another disorder
5. Classified as infrequent episodic (<1 day per month), frequent episodic (1-14 days per month) or chronic (>15 days per month)

Clinical Features

• Bilateral non-pulsating pain in a band-like or vice-like distribution around the head.

Differential Diagnosis

Headache

Common

• Migraine headache
• Tension headache
• Cluster headache

Killers

• Meningitis/encephalitis
  • Neoplastic meningitis
• Myocardial ischemia
• Retropharyngeal abscess
• Intracranial Hemorrhage (ICH)
  • SAH / sentinel bleed
• Acute obstructive hydrocephalus
• Space occupying lesions
• CVA
• Carbon monoxide poisoning
• Basilar artery dissection
• Preeclampsia
• Cerebral venous thrombosis
• Hypertensive emergency
• Depression

Maimers

• Giant cell arteritis of temporal artery (temporal arteritis)
• Idiopathic intracranial hypertension (Pseudotumor Cerebri)
• Acute Glaucoma
• Acute sinusitis
• Cavernous sinus thrombosis or cerebral sinus thrombosis
• Carotid artery dissection

Others

• Mild traumatic brain injury
• Trigeminal neuralgia
• TMJ pain
• Post-lumbar puncture headache
• Dehydration
• Analgesia abuse
• Various ocular and dental problems
• Herpes zoster ophthalmicus
• Herpes zoster oticus
• Cryptococcosis
• Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
• Ophthalmoplegic migraine
• Superior Vena Cava Syndrome

Aseptic Meningitis

• Viral
  • Varicella
  • Herpes
  • Enterovirus
  • West Nile
• Tuberculosis
• Lyme disease
• Syphilis
• Leptospirosis
• Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
• Noninfectious
  • Sarcoidosis
  • Vasculitis
  • Connective tissue disease
  • Drug induced aseptic meningitis

Evaluation

Workup

• Typically does not require tests/studies

Diagnosis

• Typically a clinical diagnosis
• After checking for all other causes of headache, palpate the temporalis, occipitalis and other muscles of the calvarium and neck to look for areas of tenderness and spasm that sometimes accompany tension headaches

Management

• NSAIDs
• Consider treating severe tension headache like a migraine headache (can be difficult to distinguish)

Disposition

• Outpatient

See Also

• Headache

Videos

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