History
Pain onset in tension-type headache can have a throbbing quality and is usually more gradual than onset in migraines. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.
IHS diagnostic criteria for tension-type headaches states that two of the following characteristics must be present: [1]
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Pressing or tightening (nonpulsatile quality)
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Frontal-occipital location
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Bilateral - Mild/moderate intensity
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Not aggravated by physical activity
Tension-type headache history is as follows:
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Duration of 30 minutes to 7 days
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No nausea or vomiting (anorexia may occur) [11]
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Photophobia and/or phonophobia [11]
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Minimum of 10 previous headache episodes; [11] fewer than 180 days per year with headache to be considered "infrequent"
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Bilateral and occipitonuchal or bifrontal pain
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Pain described as "fullness, tightness/squeezing, pressure," or "bandlike/viselike"
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May occur acutely under emotional distress or intense worry
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Insomnia
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Often present upon rising or shortly thereafter
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Muscular tightness or stiffness in neck, occipital, and frontal regions
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Duration of more than 5 years in 75% of patients with chronic headaches
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Difficulty concentrating
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No prodrome
New headache onset in elderly patients should suggest etiologies other than tension headache.
Physical Examination
The physical examination serves mainly to exclude the possibility of other headache causes.
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Vital signs should be normal.
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Normal neurologic examination
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Tenderness may be elicited in the scalp or neck, but no other positive physical exam findings should be noted.
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Pain should not be elicited over temporal arteries or positive trigger zones.
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Some patients with occipital tension headaches may be very tender when upper cervical muscles are palpated.
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Pain associated with neck flexion and stretching of paracervical muscles must be distinguished from nuchal rigidity associated with meningeal irritation.
Complications
Complications of headache may include the following:
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Overreliance on nonprescription caffeine-containing analgesics
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Dependence on/addiction to narcotic analgesics
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GI bleed from use of NSAIDs
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Risk of epilepsy 4 times greater than that of the general population
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Medication overuse headache
