1.07 Tension Headache
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agk's Library of Common Simple Emergencies

Presentation
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The patient complains of a dull, steady pain, 
described as an ache, pressure, throb, or 
constricting band, located anywhere from eyes 
to occiput, perhaps including the neck or 
shoulders. Most commonly, the headache develops 
near the end of the day, or after some partic- 
ular stress. The pain may improve with rest, 
aspirin, acetaminophen, or other medications. 
The physical exam will be unremarkable except 
for cranial or posterior muscle spasm or 
tenderness.

What to do:
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- Perform a complete general history (including 
   environmental factors and foods which 
   precede the headaches) and physical 
   examination (including a neurological 
   examination).
- If the patient complains of sudden onset of 
   the "worst headache of my life," accompanied 
   by any change in mental status, weakness, 
   vomiting, seizures, stiff neck, or persist- 
   ent neurologic abnormalities, suspect a 
   cerebrovascular cause, especially a sub- 
   arachnoid hemorrhage, intracranial 
   hemorrhage, or arteriovenous malformation. 
   The best initial diagnostic test for these 
   is computed tomography, but when CT is not 
   available and the patient does not have 
   papilledema or other signs of increased 
   intracranial pressure, rule out these 
   problems with a lumbar puncture.
- If the headache is accompanied by fever and 
   stiff neck, or change in mental status, you 
   need to rule out bacterial meningitis as 
   soon as possible, again with lumbar 
   puncture.
- If the headache was preceded by ophthalmic or 
   neurologic symptoms, now resolving, suggest- 
   ive of a migraine headache, you may want to 
   try sumatriptan or ergotamine therapy. If 
   vasospastic symptoms persist into the 
   headache phase, the etiology may still be a 
   migraine, but it becomes more important to 
   rule out other cerebrovascular causes.
- If the headache follows prolonged reading, 
   driving, or television watching, and 
   decreased visual acuity is improved by 
   viewing through a pinhole, the headache may 
   be due to a defect in optical refraction, 
   curable with new eyeglass lenses.
- If the temples are tender, check for visual 
   defects and myalgias that accompany temporal 
   arteritis.
- If there is a history of recent dental work 
   or grinding of teeth, tenderness anterior to 
   the tragus, or crepitus on motion of the 
   jaw, suspect arthritis of the temporo- 
   mandibular joint.
- If there is fever, tenderness to percussion 
   over the frontal or maxillary sinuses, 
   purulent drainage visible in the nose, or 
   facial pain exacerbated by lowering the 
   head, consider sinusitis.
- If pain radiates to the ear, be sure to 
   inspect and palpate the teeth, which are a 
   common site of referred pain.
- Finally, after checking for all these other 
   causes of headache, palpate the temporalis, 
   occipitalis, and other muscles of the 
   calvarium and neck, looking for areas of 
   tenderness and spasm which usually accompany 
   muscle tension headaches. Keep an eye out 
   for especially tender trigger points which 
   may resolve with gentle pressure or massage.
- Prescribe anti-inflammatory analgesics 
   (ibuprofen, naproxen), recommend rest, and 
   have the patient try cool compresses and 
   massage of any trigger points.
- Explain the etiology and treatment of muscle 
   spasm of the head and neck. Volunteer the 
   information that you see no evidence of 
   other serious disease (if this is true); 
   especially that a brain tumor is unlikely. 
   (Often this is a fear which is never 
   voiced.)
- Arrange for followup. Instruct the patient to 
   return to the ED or contact his own 
   physician if symptoms change or worsen.

What not to do:
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- Do not discharge without followup instruct- 
   ions. Many serious illnesses begin with a 
   minor cephalgia, and patients may postpone 
   urgent; care in the belief that they have 
   been definitively diagnosed on the first 
   visit.
- Do not miss subarachnoid hemorrhage and 
   meningitis. (If you are not obtaining a 
   majority of negative CTs and LPs, you may 
   not be looking hard enough.)

Discussion
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Headaches are common and most are benign, but 
any headache brought to medical attention 
deserves a thorough evaluation. Screening tests 
are of little value--a laborious history and 
physical examination are required. Other causes 
of headache include carbon monoxide exposure 
from wood heaters, fevers and viral myalgias, 
caffeine withdrawal, hypertension, glaucoma, 
tic douloureux (trigeminal neuralgia) and 
intolerance of foods containing nitrite, 
tyramine, xanthine. 

Tension headache is not a wastebasket diagnosis 
of exclusion but a specific diagnosis, 
confirmed by palpating tenderness in cranio- 
cervical muscles. ("Tension" refers to muscle 
spasm more than life stress.) Tension headache 
is often dignified with the diagnosis of 
"migraine" without any evidence of a vascular 
etiology, and is often treated with minor 
tranquilizers, which may or may not help. 

Focal tenderness over the greater occipital 
nerves (C2, 3) can be associated with an 
occipital neuralgia or occipital headache, and 
be secondary to cervical radiculopathy from 
cervical spondylosis. These tend to occur in 
older patients and should not be confused with 
tension headache. 

Remember to probe for the patient's hidden 
agenda. "Headache" may often be the 
justification for seeing a physician when some 
other physical, emotional, or social concern is 
actually the patient's major problem.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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