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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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Guidelines

1.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.
B
Assess for medication overuse in all patients with frequent or increasing headaches.
B
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  • Diagnostic imaging

2.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.
B

3.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
A
ketoprofen 25 mg
A
aspirin 500-1,000 mg
A
naproxen 375-550 mg
A
diclofenac 12.5-100 mg
A
acetaminophen PO 1,000 mg
A
caffeine combination 65-200 mg.
B
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  • Prophylactic therapy (indications)

  • Prophylactic therapy (antidepressants)

  • Prophylactic therapy (other agents)

4.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.
B

5.Specific circumstances

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

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  • Pregnant patients (management)

6.Patient education

General counseling: counsel all patients with chronic daily headaches about medication overuse, which can complicate the course of the headache.
B

7.Follow-up and surveillance

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