Tension Headache

History Taking

• Chief complaint:

  • Recurrent headaches

  • Pain described as a constant, dull ache

  • Band-like pain around the forehead or back of the head and neck

  • Pain lasting several hours or even days

• History of presenting complaint:

  • Onset: Gradual and non-sudden

  • Duration: Often long-lasting, often persisting for more than 30 minutes and can last several days

  • Character: Described as a tightness, pressure, or dull ache

  • Exacerbating or relieving factors: Stress, anxiety, eye strain, poor posture may exacerbate the pain; rest, relaxation techniques, massage may relieve it

  • Severity: Generally mild to moderate, not severe

  • Timing: Can occur at any time but often worse in the afternoon or evening

  • Associated symptoms: Fatigue, sleep disturbances, difficulty in concentrating, irritability, sensitivity to light or sound, general muscle aches

• System review:

  • Neurological: No focal neurological deficits such as weakness or numbness

  • Musculoskeletal: Tension in neck and shoulder muscles

  • Psychological: Increased stress, anxiety, or depression

• Past medical history:

  • History of stress or anxiety

  • History of depression

  • Previous episodes of tension-type headaches

• Drug history:

  • Overuse of pain medications, leading to rebound headaches

  • Antidepressants for associated mood disorders

  • Regular intake of caffeine

• Family history:

  • Other members of the family with a history of tension headaches

• Personal history:

  • Work stress

  • Poor sleep quality

  • Lack of physical exercise

  • Poor posture while working, especially at a computer

• Social history:

  • Job that involves high levels of stress or long hours

  • Sedentary lifestyle

  • History of traumatic events or significant life changes

Physical Examination

• General examination:

  • Appears stressed or anxious

  • No signs of dehydration or pallor

  • No signs of acute distress

• Examination of hands and arms:

  • No tremors or signs of overuse of caffeine or medications

  • No cyanosis or clubbing

• Face examination:

  • Eyes: No signs of redness or irritation, no conjunctival pallor

  • Nose: No signs of sinus tenderness

  • Mouth: No signs of jaw clenching or dental problems

• Neck examination:

  • Tenderness and muscle tightness in the neck area may be palpable

  • No lymphadenopathy or thyroid enlargement

• Neurological examination:

  • Normal cranial nerve examination

  • No signs of meningism

  • Normal motor and sensory examination in all four limbs

  • Tenderness over scalp muscles may be present

Investigations

• Laboratory tests:

  • Complete blood count: to rule out infection or anemia which can cause headaches

  • Thyroid function tests: hyperthyroidism can present with headaches

  • Erythrocyte sedimentation rate (ESR): to rule out temporal arteritis in older patients

  • Blood glucose level: to exclude hypoglycemia or hyperglycemia

  • Serum electrolyte levels: to rule out electrolyte imbalances that can cause headaches

  • Liver and kidney function tests: to rule out metabolic causes of headache

• Imaging tests:

  • MRI brain: if the headache is unusual, severe, or associated with neurological signs or risk factors for brain lesions

  • CT head: if MRI is contraindicated or unavailable and there are similar indications as for MRI

• Other tests:

  • Eye examination: to rule out visual problems or glaucoma as the cause of headache

  • Sleep study: if sleep apnea or insomnia is suspected, as they can contribute to tension-type headaches

Management

• General management:

  • Education: Reassurance about the benign nature of the condition

  • Lifestyle modifications: Improve sleep hygiene, regular exercise, balanced diet

  • Stress management: Encourage techniques such as yoga, meditation, relaxation exercises

  • Ergonomics: Advise on correct posture, especially during desk jobs

• Medical management:

  • Symptomatic treatment: Paracetamol, NSAIDs, or combination analgesics for acute relief

  • Prophylactic treatment: Amitriptyline can be used in chronic cases

  • Review and manage overuse of over-the-counter analgesics: Could be contributing to rebound headaches

• Surgical management:

  • Generally not indicated for tension-type headaches

• Other:

  • Physical therapy: Can help with posture correction, muscle tension relief

  • Cognitive-behavioral therapy: Can help manage associated stress or anxiety

  • Biofeedback: Can help patients to identify and control muscle tension

  • Acupuncture: Some patients find relief from acupuncture or other complementary therapies