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1.07 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:

What not to do:

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

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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
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