Nervous System & Special Senses

Tension-type headache: management

Clinical Overview and When to Suspect Tension-Type Headache

— Lifetime prevalence ~30–78% globally; peaks in 30s–40s; slight female predominance (~5:4).

— Leading cause of lost productivity among primary headache disorders given its sheer prevalence.

— Infrequent episodic TTH: <1 day/month (<12 days/year).

— Frequent episodic TTH: 1–14 days/month for >3 months.

— Chronic TTH: ≥15 days/month for >3 months — this is the threshold that changes management from abortive-only to prophylactic.

— Patient describes a "band-like," "vise," or "hatband" sensation across the forehead or occiput, often worse late in the day.

— Triggered or exacerbated by stress, poor sleep, sustained postures (computer/desk work), eye strain, dehydration, caffeine withdrawal, and bruxism.

— Pain does not worsen with routine physical activity (key feature distinguishing from migraine).

— Exam may show pericranial muscle tenderness on manual palpation.

Board pearl: Bilateral, pressing, non-disabling pain that improves with activity or distraction and lacks autonomic/migrainous features is TTH until proven otherwise — but ≥15 headache days/month with analgesic use ≥10–15 days/month should prompt screening for medication-overuse headache masquerading as chronic TTH.

Definition: Tension-type headache (TTH) is the most common primary headache, characterized by bilateral, pressing/tightening (non-pulsatile) pain of mild-to-moderate intensity, lasting 30 minutes to 7 days, without nausea/vomiting and without both photophobia and phonophobia (one may be present in some subtypes).

Epidemiology:

ICHD-3 subtypes (know these for Step 3 outpatient management decisions):

When to suspect TTH in clinic:

Red flags that argue against benign TTH (SNNOOP10 mnemonic): Systemic symptoms/fever, Neoplasm history, Neurologic deficit, sudden Onset (thunderclap), Older age >50 at onset, Pattern change, Positional, Precipitated by Valsalva, Papilledema, Pregnancy, Painful eye, Post-traumatic, Pathology of immune system (HIV), Painkiller overuse.

Presentation Patterns and Key History

— Quality: pressing/tightening, dull, non-throbbing.

— Location: bilateral — frontal, occipital, or holocephalic; often radiates to neck/trapezius.

— Severity: mild to moderate (typically 3–6/10); patient can usually continue working.

— Duration: 30 minutes to 7 days per episode.

— No aggravation with stairs/walking — contrast with migraine.

— No nausea/vomiting in pure TTH (mild anorexia OK).

— Photophobia or phonophobia may be present (not both) in episodic TTH; chronic TTH may have one plus mild nausea.

— No autonomic features (no lacrimation, ptosis, rhinorrhea — those suggest trigeminal autonomic cephalalgias).

— Sleep deprivation or irregular schedule, skipped meals, dehydration.

— Psychosocial stress, anxiety, depression (comorbid in up to 50% of chronic TTH).

— Sustained neck/shoulder posture, prolonged screen time, uncorrected refractive error.

— Caffeine intake pattern — both excess and withdrawal precipitate TTH.

— Bruxism, TMJ dysfunction.

— Quantify days/month of analgesic use. Simple analgesics ≥15 days/month or triptans/opioids/combination ≥10 days/month for >3 months defines medication-overuse headache.

— Ask specifically about OTC combination products (acetaminophen-aspirin-caffeine), butalbital, and opioids — patients often underreport these.

Step 3 management: Have the patient keep a headache diary for 4–8 weeks (frequency, duration, severity, triggers, abortive use) before committing to prophylaxis. The diary doubles as both a diagnostic tool and a baseline to measure treatment response on follow-up.

Classic patient script: A 35-year-old office worker reports a 6-month history of near-daily bilateral "pressure" headaches that build through the workday, are relieved by going home or by a short nap, and are not accompanied by nausea, aura, or pulsation.

Pain characteristics to elicit (POUNDing helps rule OUT migraine):

Associated features (or lack thereof):

Trigger and lifestyle history (high-yield for counseling-based Step 3 questions):

Medication history is mandatory:

Physical Exam Findings

— BP and HR should be normal. Markedly elevated BP (>180/120) with new headache warrants evaluation for hypertensive emergency or PRES.

— Fever points away from TTH — consider meningitis, sinusitis, GCA, or systemic illness.

— Manual palpation of pericranial muscles (frontalis, temporalis, masseter, sternocleidomastoid, splenius, trapezius) — increased tenderness on palpation is the defining physical finding and subclassifies TTH as "with pericranial tenderness."

— Inspect for temporal artery tenderness or beading (GCA in age >50).

— Assess TMJ for click, crepitus, deviation; check dental occlusion and signs of bruxism.

— Cervical ROM and trigger points in trapezius/levator scapulae.

— Cranial nerves intact, including funduscopy (no papilledema).

— Normal strength, sensation, coordination, gait, reflexes.

— No meningismus (Kernig/Brudzinski negative).

— Any focal deficit, papilledema, or meningismus mandates urgent neuroimaging before labeling as TTH.

— Visual acuity and external eye exam (refractive error, acute angle-closure glaucoma — red painful eye, mid-dilated pupil).

— Sinus percussion tenderness (acute bacterial sinusitis).

— Skin/scalp for zoster vesicles in V1 distribution.

— Brief PHQ-2/GAD-2 in chronic TTH — depression and anxiety are major modifiable contributors and predict prophylaxis response.

Key distinction: A normal neurologic exam plus pericranial muscle tenderness in a patient without red flags is the classic TTH exam profile — and is sufficient to defer neuroimaging, which is not indicated for typical TTH per ACR Appropriateness Criteria and AAN Choosing Wisely.

General principle: TTH is a clinical diagnosis; the role of the exam is to exclude secondary causes and document pericranial tenderness, which supports the diagnosis and guides non-pharmacologic therapy.

Vital signs:

Head and neck exam:

Neurologic exam — must be normal in TTH:

Targeted secondary screens:

Mental status and mood screen:

Diagnostic Workup — Initial Labs / Imaging / ECG / Biomarkers

— Patients meeting ICHD-3 criteria for primary headache with normal neuro exam and no red flags.

— Stable, recurrent headache pattern present for >6 months without change.

— Imaging in this setting yields significant findings in <1–2%, mostly incidental.

— Thunderclap onset → noncontrast CT head immediately, followed by LP if CT negative and SAH still suspected.

— New headache >50 years old → MRI brain; check ESR/CRP for GCA.

— Progressive worsening, positional, Valsalva-triggered, or wake-from-sleep headaches → MRI brain with and without contrast.

— Focal neurologic deficit, papilledema, seizure, altered mental status → urgent MRI (or CT if MRI not immediately available).

— Immunocompromised (HIV, transplant) or cancer history → MRI with contrast.

— Headache with fever and meningismus → CT then LP; do not delay empiric antibiotics.

— MRI brain is more sensitive than CT for tumor, demyelination, venous sinus thrombosis, posterior fossa lesions, and Chiari.

— CT is appropriate for acute thunderclap (SAH) or when MRI is contraindicated/unavailable.

— ESR/CRP if GCA suspected (age ≥50, jaw claudication, scalp tenderness, visual symptoms).

— CBC, BMP, TSH if systemic features or to screen for contributors before prophylaxis.

— CO level if cluster of household members with headaches in winter (carbon monoxide).

— Pregnancy test before initiating prophylactic agents in reproductive-age women.

Board pearl: Ordering MRI for typical TTH is a distractor answer on Step 3. The correct stem-ending is usually "reassurance, headache diary, lifestyle modification, and trial of acetaminophen or NSAID." Imaging is only correct when a red flag is embedded in the vignette.

Core principle: TTH is diagnosed clinically using ICHD-3 criteria. Routine labs, imaging, and EEG are not indicated when history and exam are typical and red flags are absent — this is a recurring Step 3 testing-stewardship theme.

When NOT to image (Choosing Wisely / AAN / ACR):

When TO image (red flags — SNNOOP10):

Preferred modality:

Targeted labs by clinical suspicion:

Diagnostic Workup — Advanced or Confirmatory Studies

— At least 10 episodes meeting B–D criteria.

— B: Duration 30 min to 7 days.

— C: At least 2 of 4: bilateral location, pressing/tightening (non-pulsatile) quality, mild-to-moderate intensity, not aggravated by routine activity.

— D: Both of: no nausea/vomiting; no more than one of photophobia or phonophobia.

— E: Not better accounted for by another ICHD-3 diagnosis.

— Subtype frequency thresholds: <12/yr (infrequent), 12–180/yr (frequent), ≥180/yr or ≥15/month for >3 months (chronic).

— Lumbar puncture: indicated when SAH is suspected with negative CT (sensitivity of CT falls after 6 hours), or for suspected meningitis, idiopathic intracranial hypertension (IIH — measure opening pressure with patient in lateral decubitus), or CNS infection.

— MR venography (MRV): suspected cerebral venous sinus thrombosis — postpartum, OCP use, hypercoagulable, papilledema.

— MR angiography (MRA) / CTA: suspected aneurysm, dissection (post-trauma, neck pain, Horner), or reversible cerebral vasoconstriction syndrome (RCVS — recurrent thunderclap).

— Tonometry: suspected acute angle-closure glaucoma.

— Polysomnography: morning headaches with snoring/witnessed apnea (OSA-related headache improves with CPAP).

— Temporal artery biopsy: elevated ESR/CRP with GCA features in patient ≥50.

— PHQ-9 and GAD-7 — depression and anxiety drive chronification.

— Sleep questionnaire (STOP-BANG) for OSA.

— Medication-overuse screen — quantify all OTC and prescription analgesic days/month.

Key distinction: Chronic TTH vs chronic migraine — chronic migraine requires ≥8 days/month with migrainous features (throbbing, unilateral, nausea, photo+phonophobia, or triptan response) over ≥15 total headache days/month. The distinction matters because chronic migraine has FDA-approved therapies (onabotulinumtoxinA, CGRP antagonists) that are not first-line for TTH.

ICHD-3 criteria (memorize structure, not minutiae):

Differentiating studies when diagnosis is unclear:

Comorbidity screening in chronic TTH:

Risk Stratification or First-Line Management Logic

— Infrequent episodic TTH (<1 day/month): Reassurance + as-needed simple analgesic + trigger modification. No prophylaxis.

— Frequent episodic TTH (1–14 days/month): Abortive therapy + structured non-pharmacologic program (sleep, stress, posture, hydration, caffeine moderation). Consider prophylaxis if analgesic use trending toward overuse thresholds or quality of life impaired.

— Chronic TTH (≥15 days/month for >3 months): Prophylactic pharmacotherapy + behavioral therapy (CBT, biofeedback, relaxation training) + strict abortive limits to prevent medication-overuse headache.

— Confirm ICHD-3 criteria; exclude red flags.

— Initiate headache diary (paper or app).

— Counsel on lifestyle pillars: regular sleep 7–8 h, hydration, scheduled meals, ergonomic workstation, 20-20-20 rule for screen breaks, regular aerobic exercise 30 min ≥3x/week, stress management.

— Address modifiable contributors: refractive error correction, dental/TMJ evaluation if bruxism, CPAP if OSA, treatment of comorbid depression/anxiety.

— Set abortive limits: simple analgesics ≤2 days/week to avoid MOH.

— Cognitive behavioral therapy (CBT) — strong evidence in chronic TTH.

— Biofeedback (EMG) and relaxation training — Grade A evidence.

— Physical therapy with postural correction and trigger-point work — moderate benefit.

— Acupuncture — moderate evidence for prevention of frequent TTH.

— Aerobic exercise — modest preventive effect.

— Predictors: baseline frequency >1/week, analgesic overuse, comorbid depression/anxiety, poor sleep, female sex, obesity, low socioeconomic status.

Step 3 management: At the first visit for episodic TTH, the highest-yield interventions are a headache diary, abortive prescription with explicit day-limits, and a written non-pharmacologic plan — not prophylaxis and not imaging. Reserve prophylaxis for ≥2 disabling days/week or chronic TTH.

Decision algorithm by frequency (this is the Step 3 framework):

Stepwise plan in clinic visit 1:

Non-pharmacologic therapies with evidence:

Risk stratification for chronification:

Pharmacotherapy — First-Line Drug Regimen

— First line: simple analgesics

— Ibuprofen 400 mg PO (most evidence) — NNT ~2 for meaningful relief at 2 h.

— Naproxen 500–550 mg PO.

— Acetaminophen 1000 mg PO — preferred in pregnancy, peptic ulcer disease, anticoagulated patients.

— Aspirin 500–1000 mg PO.

— Ketorolac 10 mg PO or 30–60 mg IM for severe episodes in clinic/ED.

— Avoid or use sparingly:

— Opioids and butalbital-containing combinations — high MOH risk, no role in routine TTH; AAN explicitly recommends against.

— Triptans — not first-line; reserve for patients with comorbid migraine where attacks cannot be distinguished.

— Caffeine-containing combination analgesics — effective but high MOH potential.

— Hard day-limit: ≤2 days/week of any acute analgesic to prevent MOH.

— First line: amitriptyline (TCA)

— Start 10–25 mg PO qhs; titrate by 10–25 mg every 1–2 weeks to 30–75 mg qhs as tolerated.

— Onset of benefit: 4–6 weeks; full trial 8–12 weeks before declaring failure.

— Counsel on anticholinergic effects (dry mouth, constipation, urinary retention, blurred vision), sedation (dose at night), weight gain, and orthostasis.

— Baseline ECG if age >40 or cardiac risk — TCAs prolong QT and slow conduction.

— Second line / TCA-intolerant:

— Nortriptyline 10–75 mg qhs — fewer anticholinergic side effects, useful in elderly.

— Mirtazapine 15–30 mg qhs — good for comorbid insomnia/depression, weight gain caveat.

— Venlafaxine XR 75–150 mg/day — SNRI, useful with comorbid anxiety.

— Limited evidence: gabapentin, topiramate, tizanidine — consider when TCAs and SNRIs fail or are contraindicated.

Board pearl: Amitriptyline is the single most evidence-supported prophylactic for chronic TTH. Onabotulinumtoxin A and CGRP monoclonal antibodies (erenumab, fremanezumab) are not FDA-approved for TTH and are a wrong answer if the stem is pure TTH without migrainous features.

Abortive (acute) therapy — episodic TTH:

Prophylactic therapy — chronic TTH or frequent disabling episodic TTH:

Duration of prophylaxis: continue 6–12 months after adequate control, then taper.

Procedures and Expanded Pharmacologic Management

— CBT for headache — addresses catastrophizing, pain coping, stress reactivity; 6–12 sessions.

— EMG biofeedback — patient learns to relax frontalis/temporalis/trapezius via real-time feedback; durable benefit.

— Progressive muscle relaxation and mindfulness-based stress reduction.

— Physical therapy: postural retraining, suboccipital and trapezius release, cervical mobilization, ergonomic workstation evaluation. Combine with home exercise.

— Acupuncture: 6–10 sessions reduce headache days in frequent episodic and chronic TTH (Cochrane evidence).

— Aerobic exercise ≥30 min, 3x/week.

— Trigger point injections with lidocaine into pericranial/trapezius bands — modest evidence, useful when palpable taut bands reproduce pain.

— Greater occipital nerve block — typically studied for migraine and cluster but can help in selected TTH with prominent occipital component.

— OnabotulinumtoxinA — evidence is inconsistent for chronic TTH and it is not FDA-approved for this indication; do not select on exams.

— CPAP if OSA is identified.

— Dental occlusal splint for nocturnal bruxism.

— Refractive correction for uncorrected hyperopia/astigmatism causing eye strain.

— SSRI/SNRI titration for comorbid depression and anxiety with shared improvement in headache.

— Abrupt withdrawal of overused simple analgesics/triptans (taper for opioids, butalbital, benzodiazepines).

— Expect transient worsening for 2–10 days; bridge with naproxen 500 mg BID x 2–4 weeks or a steroid taper in selected cases.

— Initiate prophylaxis concurrently; counsel on 2-days-per-week acute-treatment ceiling going forward.

CCS pearl: For a chronic TTH CCS case, the high-yield order set is: headache diary, PHQ-9/GAD-7, sleep history, amitriptyline 25 mg qhs, CBT referral, PT referral, smoking cessation if applicable, and return visit in 4–6 weeks to titrate and reassess — not MRI, not triptans, not opioids.

Why this slot is non-procedural for TTH: TTH has no first-line procedural therapy. The "procedures" relevant to Step 3 are behavioral/physical interventions and select injection therapies for refractory cases.

Behavioral and physical interventions (high-yield first-line adjuncts):

Trigger point and nerve interventions (refractory cases, specialist referral):

Treat contributory conditions (often the highest-yield "procedure"):

Detoxification protocol for medication-overuse headache (MOH):

Special Populations — Elderly and Renal/Hepatic Impairment

— New-onset headache after age 50 is a red flag. Before labeling as TTH, exclude giant cell arteritis (ESR, CRP, temporal artery exam, jaw claudication, visual symptoms), subdural hematoma (falls, anticoagulation), brain tumor, cervical spondylosis, and medication side effects (nitrates, PDE5 inhibitors, CCBs).

— Imaging threshold is lower in the elderly — MRI is reasonable for any new or changed pattern.

— NSAIDs: increased risk of GI bleed, AKI, hypertension, heart failure exacerbation, and interactions with anticoagulants/antiplatelets. Use the lowest effective dose for shortest duration; consider PPI co-prescription if needed.

— Acetaminophen is the preferred abortive (max 3 g/day in elderly or with hepatic risk).

— Amitriptyline is on the Beers Criteria — strongly avoid in adults ≥65 due to anticholinergic burden, falls, orthostasis, cognitive impairment, and cardiac conduction risk.

— Prefer nortriptyline (less anticholinergic) at low doses (10–25 mg qhs) or mirtazapine with caution.

— Avoid opioids, butalbital, and benzodiazepines (Beers).

— Avoid NSAIDs when eGFR <30 mL/min/1.73 m²; use cautiously at 30–60 with monitoring and avoid in volume-depleted or HF patients.

— Acetaminophen is renally safe.

— Gabapentin requires dose reduction by CrCl (e.g., 300 mg qhs at CrCl 30–59, lower at <30).

— TCAs: no specific renal dose adjustment, but anticholinergic effects (urinary retention) worsen with comorbid BPH.

— Cap acetaminophen at 2 g/day in chronic liver disease; avoid in active alcohol use disorder.

— NSAIDs increase variceal bleeding and hepatorenal syndrome risk in cirrhosis — avoid in decompensated disease.

— TCAs are hepatically metabolized — start low, titrate slowly; avoid in severe hepatic dysfunction.

Step 3 management: In a 72-year-old with chronic TTH, the correct prophylactic choice is typically nortriptyline 10 mg qhs with a screening ECG and orthostatic check — not amitriptyline, which fails Beers, and not NSAIDs for prophylaxis at any age.

Elderly (≥65 years) — new headache demands workup:

Pharmacologic cautions in the elderly:

Renal impairment:

Hepatic impairment:

Special Populations — Pregnancy, Pediatrics, and Other Subgroups

— Reassurance first: TTH often improves in pregnancy; new severe headache warrants evaluation for preeclampsia (BP, urine protein, reflexes), cerebral venous sinus thrombosis, pituitary apoplexy, and PRES.

— Abortive options:

— Acetaminophen is first-line throughout pregnancy and lactation.

— NSAIDs: avoid in third trimester (premature ductus closure, oligohydramnios) and after 20 weeks per FDA 2020 advisory; cautious limited use 1st/2nd trimester if needed.

— Avoid opioids, butalbital, ergots, and aspirin near term.

— Prophylaxis:

— Prioritize non-pharmacologic therapy (CBT, biofeedback, PT, sleep optimization).

— If essential, low-dose amitriptyline or nortriptyline has the most pregnancy data; SSRIs (paroxetine avoided) and venlafaxine considered for comorbid mood disorders. Counsel about risk/benefit; involve maternal-fetal medicine in chronic TTH with severe disability.

— Avoid topiramate (cleft lip/palate) and valproate (neural tube defects, neurodevelopmental).

— Lactation: acetaminophen, ibuprofen, and low-dose TCAs are generally compatible; check LactMed before prescribing.

— TTH is the most common headache in school-age children; often related to sleep deficit, dehydration, skipped meals, screen time, refractive error, and school stress/anxiety.

— Evaluate growth, BP, vision, posture, mood, and bullying/academic stressors.

— Acute: ibuprofen 10 mg/kg or acetaminophen 15 mg/kg; limit to ≤2 days/week.

— Prophylaxis: non-pharmacologic measures dominate; CBT has strong pediatric evidence. Pharmacologic prophylaxis is rarely indicated and should involve pediatric neurology.

— Avoid aspirin (Reye syndrome) in children with viral illness.

— Dual treatment with amitriptyline, nortriptyline, mirtazapine, or venlafaxine treats both headache and mood — efficient, single-agent strategy.

— Refer to behavioral health for CBT — synergistic with pharmacotherapy.

Key distinction: A pregnant patient at 32 weeks with new severe headache, BP 165/105, and brisk reflexes does not have TTH — order urgent preeclampsia workup (CBC, LFTs, creatinine, urine protein/creatinine) and arrange OB evaluation, regardless of prior TTH history.

Pregnancy and lactation:

Pediatrics and adolescents:

Patients with comorbid mood disorders:

Complications and Adverse Outcomes

— Defined as headache ≥15 days/month for >3 months in a person with a pre-existing headache disorder using:

— Simple analgesics (acetaminophen, NSAIDs, aspirin) ≥15 days/month, or

— Combination analgesics, triptans, ergots, opioids, or butalbital ≥10 days/month.

— Clinical clue: headache "transformation" from episodic to near-daily; relief that is shorter and shorter; patient escalates dosing.

— Management = withdrawal of overused agent + initiation of preventive therapy + bridging strategy + patient education with written abortive day-limits.

— Episodic → chronic TTH driven by analgesic overuse, untreated mood disorders, OSA, poor sleep hygiene, persistent stressors, and central sensitization.

— Reduced quality of life, presenteeism, work disability.

— NSAIDs: GI ulceration/bleeding, AKI, hypertension worsening, heart failure decompensation, MI/stroke risk with chronic use.

— Acetaminophen: hepatotoxicity if >3–4 g/day or with alcohol/hepatic disease; check OTC combination products for hidden acetaminophen.

— TCAs (amitriptyline/nortriptyline): anticholinergic burden, orthostasis, weight gain, sedation, urinary retention, QT prolongation, lowered seizure threshold, serotonin syndrome if combined with serotonergic agents (SSRIs, tramadol, linezolid, MAOIs), overdose lethality (cardiac sodium channel blockade).

— Venlafaxine: hypertension at higher doses — monitor BP.

— Mirtazapine: weight gain, sedation, rare agranulocytosis.

— Opioids/butalbital: dependence, MOH, sedation — avoid.

— Comorbid depression and anxiety, sleep disorders, work absenteeism, family/relationship strain, healthcare overutilization.

— Anchoring bias — labeling new or changed headache as TTH and missing GCA, SAH, CVST, tumor, or IIH.

Board pearl: A patient with a long-standing TTH history who now takes ibuprofen "every day for the past 6 months" and reports worsening daily headache almost certainly has MOH. The intervention is to stop the overused analgesic and start prophylaxis — not to increase the dose or add a second NSAID.

Medication-overuse headache (MOH) — the dominant complication:

Chronification of TTH:

Drug-specific adverse effects to anticipate and counsel on:

Psychosocial complications:

Diagnostic complications:

When to Escalate Care — Consult, Imaging, or Inpatient Triage

— Thunderclap headache (max intensity <1 minute) → rule out SAH, RCVS, dissection, CVST, pituitary apoplexy. Order noncontrast CT, then LP if CT negative.

— Headache with fever, neck stiffness, altered mental status → suspected meningitis/encephalitis; do not delay empiric antibiotics ± acyclovir.

— Focal neurologic deficit, seizure, papilledema, or new cognitive change → urgent neuroimaging.

— Severe hypertension with headache (>180/120) with end-organ signs → hypertensive emergency workup.

— Headache in pregnancy/postpartum with BP elevation, vision change, or seizure → preeclampsia/eclampsia or CVST evaluation.

— Headache in immunocompromised patient (HIV CD4 <200, transplant) → MRI with contrast, consider LP for opportunistic infection.

— Failure of two adequately dosed prophylactic agents over 8–12 weeks each.

— Diagnostic uncertainty between chronic TTH, chronic migraine, NDPH (new daily persistent headache), hemicrania continua (responds to indomethacin), or trigeminal autonomic cephalalgia.

— Suspected MOH requiring structured withdrawal.

— Pediatric chronic headache requiring prophylaxis.

— Behavioral health/psychiatry for refractory comorbid depression, anxiety, PTSD, or for initiation of CBT for headache.

— Sleep medicine for suspected OSA or chronic insomnia.

— Ophthalmology for visual changes, suspected IIH, or refractive evaluation.

— Dentistry/oromaxillofacial for bruxism, TMD, or occlusal splint.

— Physical therapy for cervicogenic contribution and postural correction.

— Rheumatology for suspected GCA.

— Intractable headache failing outpatient therapy with dehydration or inability to function.

— Need for structured MOH withdrawal with IV bridging in selected patients.

— Diagnostic uncertainty requiring expedited workup.

CCS pearl: On a CCS case, a sudden change in headache character (new pulsation, unilateral focal pain, thunderclap component, or focal deficit) should trigger MRI brain (or CT for thunderclap) and neurology consult — not an escalation of TTH prophylaxis. Pattern change is itself the red flag.

Immediate ED referral / inpatient triage:

Urgent outpatient neurology referral:

Other specialists to consider:

Hospital admission criteria (rare in pure TTH):

Key Differentials — Same-Category Primary Headaches

— Unilateral (60%), pulsating, moderate-to-severe, worsened by routine activity, with nausea/vomiting and/or both photophobia and phonophobia.

— Duration 4–72 hours.

— Responds to triptans; TTH does not require triptans.

— Distinguishing: migraine is disabling and activity-limiting; TTH is mild-moderate and patients continue function.

— ≥15 headache days/month for >3 months, with ≥8 days meeting migraine criteria or responding to triptan.

— Approved therapies: topiramate, propranolol, onabotulinumtoxinA, CGRP mAbs (erenumab, fremanezumab, galcanezumab) — none first-line for chronic TTH.

— Strictly unilateral, periorbital/temporal, excruciating ("suicide headache"), 15–180 minutes, occurring in bouts.

— Autonomic features: ipsilateral lacrimation, conjunctival injection, ptosis, miosis, rhinorrhea, nasal congestion, restlessness/agitation.

— Acute: 100% O₂ 12–15 L/min via non-rebreather + subcutaneous sumatriptan.

— Prevention: verapamil.

— Unilateral, autonomic features, shorter attacks (2–30 min), more frequent (>5/day).

— Absolutely responsive to indomethacin — diagnostic.

— Continuous unilateral headache with autonomic features, indomethacin-responsive.

— Daily and unremitting headache from a clearly remembered onset day, lasting >3 months. Can phenotype as TTH-like or migraine-like; often refractory.

— Very brief (seconds), unilateral, with prominent autonomic features; high frequency.

Key distinction: The triad bilateral + pressing + not worsened by activity + no nausea/no photo-AND-phono = TTH. Any unilateral, throbbing, activity-aggravated, or autonomic-feature-laden headache should push you off the TTH diagnosis to migraine or TAC.

Migraine without aura:

Chronic migraine:

Cluster headache (trigeminal autonomic cephalalgia):

Paroxysmal hemicrania:

Hemicrania continua:

New daily persistent headache (NDPH):

SUNCT/SUNA:

Key Differentials — Secondary and Other-Category Causes

— Subarachnoid hemorrhage — thunderclap, "worst headache of life," meningismus; CT then LP.

— Cerebral venous sinus thrombosis — postpartum, OCP, hypercoagulable, dehydration; MRV diagnostic.

— Carotid/vertebral artery dissection — neck pain, Horner, post-trauma or chiropractic manipulation; CTA/MRA.

— Reversible cerebral vasoconstriction syndrome (RCVS) — recurrent thunderclaps over days–weeks, often postpartum or with vasoactive drugs; CTA with "string of beads."

— Giant cell arteritis — age ≥50, scalp tenderness, jaw claudication, vision change, elevated ESR/CRP; start prednisone 40–60 mg before biopsy if suspected.

— Hypertensive emergency / PRES.

— Bacterial/viral/fungal meningitis, encephalitis, brain abscess, sinusitis (frontal, sphenoid), dental abscess, herpes zoster ophthalmicus.

— Brain tumor — progressive, worse in morning, worse with Valsalva, focal deficit, seizure.

— Idiopathic intracranial hypertension — young obese woman, papilledema, vision changes, pulsatile tinnitus; LP opening pressure >25 cm H₂O.

— Chiari malformation — occipital headache worsened by cough/Valsalva.

— Low-pressure headache — post-LP or spontaneous CSF leak; postural (worse upright, relieved supine).

— Acute angle-closure glaucoma — red eye, mid-dilated fixed pupil, halos.

— Acute sinusitis — facial pressure with purulent rhinorrhea, fever.

— TMJ dysfunction.

— Carbon monoxide poisoning — cluster of household members, winter, gas appliances; check CO level.

— Hypoglycemia, hypoxia, sleep apnea, dialysis disequilibrium, hypothyroidism.

— Nitrates, PDE5 inhibitors, CCBs, dipyridamole, oral contraceptives, hormone therapy, immunosuppressants, and stimulant withdrawal.

— Medication-overuse headache itself.

Board pearl: The trio age >50 + new headache + elevated ESR mandates empiric high-dose prednisone immediately and temporal artery biopsy within 1–2 weeks — never wait for biopsy if GCA is suspected, because vision loss is irreversible.

Vascular:

Infectious:

Mass effect and intracranial pressure:

Ophthalmologic / ENT:

Toxic-metabolic:

Medication-induced:

Secondary Prevention / Long-Term Plan

— Trigger avoidance and lifestyle structure: consistent sleep, hydration, regular meals, aerobic exercise, ergonomic workstation, stress management, caffeine moderation (≤200 mg/day, consistent timing).

— Treat comorbidities: depression, anxiety, OSA, bruxism, refractive error, TMD, neck pathology — each contributes to chronification.

— Adhere to abortive day-limits: simple analgesics ≤2 days/week; opioids/butalbital avoided entirely.

— Continue prophylaxis ≥6–12 months after sustained reduction in headache days, then attempt slow taper while continuing behavioral therapy.

— Amitriptyline 25–50 mg qhs (or nortriptyline in elderly).

— Acetaminophen 1000 mg PRN or ibuprofen 400–600 mg PRN with explicit "≤2 days/week" written instruction.

— Concurrent PPI if NSAIDs used regularly in high-risk patient.

— Vitamin D / magnesium repletion if deficient (supportive evidence).

— Concept of MOH and the 2-days/week rule.

— Realistic prophylaxis expectations: goal is 50% reduction in headache days, not zero; benefit takes 4–8 weeks.

— Headache diary remains the central self-monitoring tool.

— When to call: new neurologic symptoms, thunderclap onset, fever with headache, headache in pregnancy, vision change.

— Use the headache visit to ensure age-appropriate USPSTF screening (BP, lipid, diabetes, depression, cancer screening) — many chronic TTH patients are anchored to the headache and miss preventive care.

— Reinforce smoking cessation, alcohol moderation, weight management — all reduce headache burden and cardiovascular risk.

— Discuss reasonable accommodations: ergonomic chair, monitor adjustment, scheduled breaks; coordinate FMLA forms only when functionally warranted to avoid reinforcing illness behavior.

Step 3 management: The long-term plan is multimodal: prophylactic medication + behavioral therapy + lifestyle structure + strict abortive limits + treatment of comorbidities. Single-modality treatment is the wrong answer for chronic TTH on Step 3.

Pillars of long-term TTH management:

Discharge or visit-end medication list (typical chronic TTH patient):

Patient education essentials:

Vaccination and preventive care alignment (Step 3 longitudinal lens):

Workplace and value-based considerations:

Follow-Up, Monitoring Parameters, and Counseling

— 2–4 weeks after starting prophylaxis: tolerability, side effects, adherence; titrate dose. Brief telehealth visit acceptable.

— 8–12 weeks: assess response with headache diary — target ≥50% reduction in headache days/severity. Reassess at adequate dose before declaring failure.

— Every 3 months thereafter for stable patients; sooner if change in pattern.

— Annual review of headache diagnosis, medication necessity, attempt at taper if 6–12 months of good control.

— Amitriptyline/nortriptyline: baseline ECG if ≥40 years or cardiac risk; recheck if dose escalates >75 mg/day. Monitor weight, BP (orthostatic), anticholinergic symptoms, mood, suicidal ideation (black-box warning in <25 years).

— Venlafaxine: BP at each titration step (dose-dependent hypertension).

— Topiramate (if used): weight, cognitive side effects, bicarbonate (metabolic acidosis), nephrolithiasis history, contraception (teratogen).

— Chronic NSAID use: annual CMP for renal function, CBC for occult blood, BP, GI symptoms.

— Chronic acetaminophen use: LFTs annually if >2 g/day chronically or alcohol use; cap dose.

— Headache diary remains essential — frequency, intensity, duration, triggers, medications, days/week of analgesic.

— Discuss MOH risk explicitly at every visit; reinforce 2-days/week rule.

— Sleep hygiene, hydration, exercise, ergonomic, and stress-management plans should be re-evaluated and updated.

— Address adherence barriers: cost, side effects, fear of dependence, expectations.

— Reinforce when to seek emergent care.

— Headache days/month, HIT-6 (Headache Impact Test), MIDAS, PHQ-9/GAD-7, sleep score, work/school days lost.

CCS pearl: When advancing the clock in a chronic TTH case, schedule the return visit at 6–8 weeks after starting amitriptyline, repeat the headache diary review, titrate to effect, and order/repeat PHQ-9 — a visit too soon (1–2 weeks) misses the response window and a visit too late (6 months) lets MOH or adverse effects develop unchecked.

Follow-up cadence:

Monitoring parameters by agent:

Counseling specifics:

Outcome measures:

Ethical, Legal, and Patient Safety Considerations

— Amitriptyline is off-label for TTH; document discussion of benefits, side effects (anticholinergic, cardiac, sedation, weight gain), expected onset (4–8 weeks), and alternatives.

— SSRIs/TCAs carry a black-box warning for suicidality in patients <25 years — explicit counseling and documented safety planning required, with closer follow-up in adolescents and young adults.

— Prescribing opioids or butalbital for routine TTH violates current best practice and AAN Choosing Wisely. Document refusal rationale clearly if a patient requests these; offer evidence-based alternatives. Check the PDMP before any controlled-substance prescription.

— Counsel patients starting sedating medications (amitriptyline, mirtazapine, tizanidine) about driving, machinery operation, and fall risk, especially in older adults.

— Document the warning.

— Patients discharged from ED with new prescriptions for opioids or butalbital are at high risk of MOH and dependence — ensure primary care follow-up within 1–2 weeks and medication reconciliation at every handoff.

— Avoid duplicative analgesics across prescriptions; OTC combination products often contain hidden acetaminophen.

— Screen for intimate partner violence in patients with chronic headache and inconsistent injury patterns — IPV is associated with chronic pain syndromes. Follow state-specific mandated reporting (e.g., reporting of suspected child or elder abuse is mandatory in all US jurisdictions).

— Screen for substance use disorders, especially with concurrent opioid or sedative requests.

— CBT, biofeedback, PT, and acupuncture may be limited by insurance coverage and geography — identify low-cost options (digital CBT apps, group classes, telehealth) to avoid widening disparities.

— Document shared decision-making when patients decline behavioral therapy or prefer alternative approaches.

— Topiramate and valproate are teratogens; verify pregnancy status and contraception plan before initiating in reproductive-age patients, and document the conversation.

Board pearl: A patient repeatedly returning to the ED for headache and requesting opioids should prompt PDMP check, screening for MOH and substance use disorder, behavioral health referral, and a clear PCP-based care plan — not refilling the opioid. The ethical response is non-abandonment with redirection to evidence-based care.

Informed consent for off-label and long-term therapy:

Opioid and butalbital stewardship:

Driving and occupational safety:

Transition-of-care risks (high-yield Step 3 theme):

Mandatory reporting and screening considerations:

Health-systems and equity issues:

Pregnancy disclosure and teratogenicity:

High-Yield Associations and Rapid-Fire Clinical Facts

Key distinction: TTH is bilateral, pressing, non-disabling; migraine is unilateral (often), pulsating, disabling with nausea/photophobia/phonophobia. Memorize this dichotomy — it generates dozens of Step 3 stems.

TTH is the most prevalent primary headache disorder worldwide — far more common than migraine.

Bilateral, pressing, mild-moderate, non-pulsatile, no nausea, not aggravated by activity = TTH phenotype.

Pericranial muscle tenderness on palpation is the defining physical finding and supports the diagnosis.

Chronic TTH = ≥15 days/month for >3 months — triggers prophylactic therapy.

Amitriptyline is the most evidence-based prophylactic for chronic TTH; start 10–25 mg qhs, target 30–75 mg.

Nortriptyline is preferred over amitriptyline in elderly (Beers Criteria flags amitriptyline).

Triptans, opioids, butalbital, and onabotulinumtoxinA are NOT first-line in TTH — common Step 3 distractors.

Medication-overuse headache thresholds: simple analgesics ≥15 days/month, or triptans/opioids/combination/butalbital ≥10 days/month, for >3 months.

Acute treatment day-limit: ≤2 days/week of any analgesic to prevent MOH.

First-line acute therapy: ibuprofen 400 mg or naproxen 500–550 mg; acetaminophen 1000 mg as alternative.

Imaging is NOT indicated for typical TTH with normal exam and no red flags (Choosing Wisely).

Red flags (SNNOOP10): Systemic, Neoplasm, Neurologic deficit, sudden Onset, Older age, Pattern change, Positional, Precipitated by Valsalva, Papilledema, Pregnancy/Postpartum, Painful eye, Post-traumatic, Pathology of immune system, Painkiller overuse.

Cluster headache acute treatment: 100% O₂ 12–15 L/min + subcutaneous sumatriptan; verapamil for prevention.

Indomethacin-responsive headaches: paroxysmal hemicrania and hemicrania continua.

GCA workup: ESR, CRP, temporal artery biopsy — start prednisone empirically before biopsy if suspected.

CBT and EMG biofeedback have Grade A evidence for chronic TTH prevention.

Comorbid depression/anxiety present in up to 50% of chronic TTH and predict chronification.

OSA, bruxism, and refractive error are commonly missed contributors — screen routinely.

Pregnancy abortive of choice: acetaminophen; avoid NSAIDs after 20 weeks.

Childhood TTH: sleep, hydration, meals, screen time, school stress, refractive error — non-pharmacologic first.

Board Question Stem Patterns

— 32-year-old accountant with 6 months of bilateral, band-like, end-of-day headaches relieved by going home. Normal neuro exam, mild trapezius tenderness. Next step?

— Answer: Reassurance, headache diary, ergonomic/sleep counseling, ibuprofen PRN with day-limit. Not MRI, not triptan.

— 45-year-old with daily bilateral pressure headaches for 6 months, taking ibuprofen 3–4 times weekly. PHQ-9 = 12. Normal exam. Best next step?

— Answer: Start amitriptyline 25 mg qhs; refer for CBT; reinforce abortive limits.

— Long-standing TTH now reports daily headache after taking acetaminophen-aspirin-caffeine "every day for months." Best next step?

— Answer: Withdraw the overused analgesic and initiate prophylaxis (amitriptyline). Not increase the dose, not add a triptan.

— 68-year-old with new bilateral headache and jaw pain when chewing. ESR 92.

— Answer: Empiric prednisone 60 mg + temporal artery biopsy — GCA, not TTH.

— G2P1 at 30 weeks with worsening daily headaches, BP 168/108, brisk reflexes.

— Answer: Evaluate for preeclampsia (urine protein, labs); not TTH treatment.

— 74-year-old with chronic TTH; PCP considering amitriptyline.

— Answer: Nortriptyline instead (Beers Criteria) or non-pharmacologic therapy.

— Unilateral throbbing headache with nausea and photophobia, worsened by climbing stairs.

— Answer: Migraine — triptan abortive; not TTH treatment.

— Patient with 5-year history of typical TTH requests MRI.

— Answer: Reassurance and decline imaging; explain low yield and risks of incidental findings.

— 14-year-old with frequent headaches, screen time 6 hours/day, irregular sleep.

— Answer: Sleep hygiene, screen limits, regular meals, hydration, CBT — non-pharmacologic first.

— Chronic TTH case: correct order set = headache diary, PHQ-9, sleep history, amitriptyline, CBT referral, return visit 6–8 weeks.

Step 3 management: When in doubt on a TTH stem, the answer is usually a conservative, evidence-based, longitudinal action — diary, lifestyle, abortive with limits, prophylaxis if chronic, behavioral therapy, scheduled follow-up — and almost never imaging, triptans, opioids, or onabotulinumtoxinA.

Stem 1 — Classic episodic TTH:

Stem 2 — Chronic TTH requiring prophylaxis:

Stem 3 — Medication-overuse headache:

Stem 4 — Red flag hidden in vignette:

Stem 5 — Pregnancy:

Stem 6 — Elderly patient:

Stem 7 — Distinguishing migraine:

Stem 8 — Imaging stewardship:

Stem 9 — Pediatric:

Stem 10 — CCS flow:

One-Line Recap

Tension-type headache is a bilateral, pressing, non-disabling primary headache diagnosed clinically by ICHD-3 criteria and managed with a frequency-stratified plan: lifestyle and abortive analgesics for episodic disease, and amitriptyline plus CBT/biofeedback for chronic disease — while imaging is reserved for red flags and triptans, opioids, and butalbital are avoided to prevent medication-overuse headache.

Board pearl: If a Step 3 stem describes a bilateral, pressing, near-daily headache in a stressed patient who takes OTC analgesics most days of the week, the answer is almost always stop the overused analgesic, start amitriptyline, refer for CBT, and follow up in 6–8 weeks — not imaging, not opioids, not triptans, and not onabotulinumtoxinA.

Diagnosis is clinical: bilateral, pressing, mild-moderate, non-pulsatile, not aggravated by activity, no nausea, ≤1 of photo/phonophobia. Pericranial tenderness supports the diagnosis. Image only for red flags (SNNOOP10) — never for typical TTH.

Acute (abortive) therapy: ibuprofen 400 mg, naproxen 500–550 mg, or acetaminophen 1000 mg, capped at ≤2 days/week to prevent medication-overuse headache. Avoid opioids, butalbital, and combination caffeine analgesics. Triptans are not first-line in TTH.

Preventive therapy is reserved for chronic TTH (≥15 days/month for >3 months) or frequent disabling episodic disease: amitriptyline 10–75 mg qhs is the best-evidence agent (nortriptyline in elderly per Beers; venlafaxine or mirtazapine with comorbid mood disorder). Trial 8–12 weeks at adequate dose before declaring failure; continue 6–12 months after control, then taper.

Multimodal long-term care wins on Step 3: CBT, EMG biofeedback, relaxation, physical therapy, aerobic exercise, sleep hygiene, ergonomic correction, and treatment of comorbid depression/anxiety, OSA, bruxism, and refractive error — combined with headache diary monitoring, scheduled follow-up at 6–8 weeks, and explicit MOH counseling — define guideline-aligned management.