FFS: Tension Headache

Diagnosis is clinical, and the major ED priority is to exclude more serious causes of headache requiring urgent intervention.

Treatment involves simple oral analgesics (avoiding opioids) and addressing underlying triggers where possible.

Tension headache is ultimately a diagnosis of exclusion — presentations to hospital warrant a high index of suspicion for serious pathology.

Pathology

Cause

• Previously attributed to muscle tension and ischaemia, though studies have not confirmed increased contraction or ischaemia in affected individuals.
• More recent theories implicate central CNS processing mechanisms.

Classification

• Episodic: Infrequent attacks.
• Chronic: Often daily, associated with muscle tightness in the neck, scalp, and upper back.

Precipitating Factors

Type	Examples
Mental stress	Most common trigger
Physical stress	Exhaustion
Other	Insomnia, depression, jet lag

Clinical Assessment

Typical Features

Feature	Description
Frequency	Recurrent attacks
Location	Bilateral, band-like occipitofrontal
Nature	Pressure, heaviness, or tightness
Severity	Mild; usually doesn’t impair basic activity
Onset	Gradual and vague
Associated Symptoms	May include mild photophobia; nausea, vomiting or aura suggest alternate diagnoses (e.g. migraine)

ED Red Flags to Consider

Category	Indicators
Abnormal exam	GCS changes, neuro signs, fever, meningism, petechial rash
Symptoms	Recurrent vomiting, myalgia
Severity	Severe headache may suggest alternate diagnosis
Time course	Sudden onset (e.g. SAH), chronicity, morning headaches
Infection risk	Recent travel (e.g. malaria)
Comorbidities	Malignancy, coagulopathy, shunts, immunosuppression
Demographics	New headache in patient >50 years
Atypical migraine	Consider further assessment
Pregnancy	Includes puerperium
Medications	Anticoagulants, OCPs
Family history	SAH in relatives
Trauma	Recent or remote, not always volunteered
Communication barriers	Language, cognitive impairment, intoxication
Representations	Raises suspicion for underlying pathology

Investigations

• None required if classic features and no red flags.
• Investigations are aimed at excluding secondary causes (see “Headache” document in Clinical Presentations folder).

Management

General Principles

• Avoid opioid analgesics
• Identify and manage underlying triggers

Episodic Tension Headache

1. Simple Oral Analgesics

Agent	Adult Dose	Notes
Aspirin	600–900 mg PO, repeat in 4 hrs	Avoid in peptic ulcer disease
Ibuprofen	400 mg PO, repeat in 6 hrs	Caution in elderly, renal impairment
Paracetamol	1 g PO q4h (max 4 g/day)	IV option: 1 g q6h if needed

Triptans are not effective and should be avoided.

• Limit analgesics to <3 days/week to avoid medication-overuse headache.

2. Psychotherapy
   • Counselling, reassurance, placebo effect
   • Anxiety symptoms may be prominent
3. Physical Therapies
   • Massage, heat application, posture correction
4. Stress Management
   • Identify and address sources of tension
   • Patient insight may aid coping strategies

Chronic Tension Headache

1. Preventive Medication
   • Amitriptyline is first-line
   • Avoid chronic analgesic use
2. Psychotherapy
   • Cognitive behavioural therapy (CBT)
   • Relaxation and stress management training
3. Headache Diary
   • Track frequency, severity, triggers, treatment
   • Useful for both patient and clinician

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References

Publications

• Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. 8e 2021
• Fuller G. Neurological Examination Made Easy. 6e 2019

FOAMed

• Coni R. Tension headache. LITFL
• Coni R. Headache classification. LITFL
• Coni R. Headache Essentials. LITFL