Tension headaches present with dull, steady pain in the head that worsens near the end of the day or after stress. The pain may be relieved by rest, aspirin, or acetaminophen. A physical exam is usually normal except for muscle spasm or tenderness. Evaluation of tension headaches should include a thorough history, physical exam, and ruling out other potential causes through tests like CT scans or lumbar punctures depending on symptoms. Treatment involves anti-inflammatory drugs, rest, massage, and follow up care.

1. Tension Headache
Presentation
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 particular 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:
• 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 persistent neurologic abnormalities,
suspect a cerebrovascular cause, especially a subarachnoid
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, suggestive of a migrain 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 temperomandibular 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, considers sinusitis.

2. • 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:
• Do not discharge without followup instructions. 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
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
craniocervical 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

3. other physical, emotional, or social concern is actually the patient's major
problem.