Clinical Features
Tension-type headache produces a bilateral, dull, pressing or tightening pain often described as a band or vice around the head, of mild to moderate intensity. It is not pulsating, is not aggravated by routine activity, and lacks the prominent nausea, vomiting, and photophobia or phonophobia that characterize migraine. Episodes can be episodic or chronic, and stress, poor sleep, and muscle tension are common contributors.
Distinguishing the Primary Headaches
Contrasting the primary headaches is a classic exam task. Migraine is typically unilateral, pulsating, moderate to severe, worsened by activity, and accompanied by nausea and light and sound sensitivity, sometimes with aura. Cluster headache causes severe unilateral periorbital pain in clusters with autonomic features such as tearing and nasal congestion. Tension headache is the featureless, band-like, bilateral type.
Red Flags
Most headaches are benign, but certain features suggest a dangerous secondary cause and warrant urgent evaluation, often recalled with SNOOP: systemic symptoms (fever, weight loss), neurologic deficits, sudden thunderclap onset, older age at new onset, and a change from the prior pattern. A sudden worst-ever headache in particular raises concern for subarachnoid hemorrhage.
Treatment
Acute tension headaches respond well to simple analgesics such as NSAIDs or acetaminophen. Because overuse of acute medications can cause medication-overuse (rebound) headache, frequent use should be limited. For frequent or chronic tension-type headache, preventive strategies include stress management, regular sleep and exercise, addressing muscle tension, and sometimes a low-dose tricyclic antidepressant such as amitriptyline.