Table of contents

Tension-type headache

What's new

Updated 2023 ACR and 2022 AAFP guidelines for the diagnosis and management of tension-type headache.


Key sources

The following summarized guidelines for the evaluation and management of tension-type headache are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2023), the American Academy of Family Physicians (AAFP 2022,2020,2018,2014), the European Federation of Neurological Societies (EFNS 2010), and the The Scottish Intercollegiate Guidelines Network (SIGN 2008). ...
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Diagnostic investigations

History and physical examination
As per AAFP 2020 guidelines:
Obtain a complete clinical assessment in patients with frequent or increasing headaches, even in patients with long-standing headaches, as a new headache type may have developed or the current diagnosis may be inaccurate.
Assess for medication overuse in all patients with frequent or increasing headaches.
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  • Diagnostic imaging

Diagnostic procedures

Lumbar puncture: as per AAFP 2022 guidelines, perform a lumbar puncture to exclude subarachnoid hemorrhage in patients with acute headache after a normal CT.

Medical management

Acute therapy: as per EFNS 2010 guidelines, offer the following agents for acute therapy in patients with tension-type headache:
ibuprofen 200-800 mg
ketoprofen 25 mg
aspirin 500-1,000 mg
naproxen 375-550 mg
diclofenac 12.5-100 mg
acetaminophen PO 1,000 mg
caffeine combination 65-200 mg.
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  • Prophylactic therapy (indications)

  • Prophylactic therapy (antidepressants)

  • Prophylactic therapy (other agents)

Nonpharmacologic interventions

Nonpharmacological therapies: as per AAFP 2020 guidelines, offer nonpharmacological therapies, such as relaxation with or without biofeedback, CBT, acupuncture, and physical therapy, incorporated into the management strategies for frequent headaches.

Specific circumstances

Pregnant patients, evaluation
As per ACR 2023 guidelines:
Obtain MRI or CT in patients with new-onset or a new pattern of headache during pregnancy or the peripartum period.
Consider obtaining MRV without IV contrast or CTV with IV contrast given the specific clinical scenario.

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  • Pregnant patients (management)

Patient education

General counseling: as per AAFP 2014 guidelines, counsel all patients with chronic daily headaches about medication overuse, which can complicate the course of the headache.

Follow-up and surveillance

Indications for referral: as per AAFP 2022 guidelines, refer patients with acute thunderclap headache to the emergency department.