Tension-Type Headache¶

DIAGNOSIS: Tension-Type Headache ICD-10: G44.209 (Tension-type headache, unspecified, not intractable); G44.219 (Episodic tension-type headache, not intractable); G44.221 (Chronic tension-type headache, not intractable) SYNONYMS: TTH; Tension headache; Muscle contraction headache; Stress headache; Chronic tension-type headache; Episodic tension-type headache SCOPE: Episodic and chronic tension-type headache diagnosis, acute treatment, and preventive therapy. Excludes secondary headaches, medication overuse headache (separate protocol), and trigeminal autonomic cephalalgias.

VERSION: 1.1 CREATED: January 27, 2026 REVISED: January 30, 2026

STATUS: Draft - Pending Review

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

SECTION A: ACTION ITEMS¶

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC (85025)	STAT	ROUTINE	ROUTINE	-	Rule out anemia or infection as headache trigger	Normal
BMP (80048)	STAT	ROUTINE	ROUTINE	-	Electrolyte abnormalities can trigger headaches	Normal
TSH (84443)	-	ROUTINE	ROUTINE	-	Hypothyroidism associated with chronic headache	Normal (0.4-4.0 mIU/L)

1B. Extended Workup (Second-line)¶

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
ESR, CRP (85652/86140)	URGENT	ROUTINE	ROUTINE	-	Rule out giant cell arteritis if age >50 with new headache	Normal
Vitamin D (82306)	-	ROUTINE	ROUTINE	-	Deficiency associated with chronic pain and headache	>30 ng/mL
Ferritin (82728)	-	ROUTINE	ROUTINE	-	Iron deficiency associated with headache	>50 ng/mL
Magnesium, RBC (83735)	-	ROUTINE	ROUTINE	-	Low magnesium linked to headache disorders	>4.2 mg/dL

1C. Rare/Specialized (Refractory or Atypical)¶

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
ANA (86038)	-	EXT	EXT	-	Rule out autoimmune disorder in atypical presentations	Negative
Sleep study (95811)	-	-	EXT	-	Evaluate for sleep apnea contributing to chronic headache	AHI <5
Lyme serology (86618)	-	EXT	EXT	-	Consider in endemic areas with refractory symptoms	Negative

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain without contrast (70551)	URGENT	ROUTINE	ROUTINE	-	Only if red flags present (see SNNOOP10 below)	Normal	MRI-incompatible devices
CT Head non-contrast (70450)	STAT	STAT	-	-	Acute severe headache or new neurological deficits	No hemorrhage, mass, or hydrocephalus	Pregnancy (relative)

2B. Extended¶

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain with contrast (70553)	URGENT	ROUTINE	ROUTINE	-	Atypical features, focal deficits, suspected secondary cause	No enhancement or mass lesion	Gadolinium allergy, severe renal impairment
MRA Head/Neck (70544/70547)	URGENT	ROUTINE	EXT	-	Suspected vascular etiology or cervical artery dissection	Patent vessels; no dissection	MRI contraindications
C-spine X-ray or MRI (72050/72141)	-	ROUTINE	ROUTINE	-	Cervicogenic component suspected	Normal alignment; no disc disease	None

2C. Rare/Specialized¶

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRV Brain (70546)	URGENT	ROUTINE	EXT	-	Suspected cerebral venous thrombosis	Patent venous sinuses	MRI contraindications
LP with opening pressure (62270)	-	ROUTINE	EXT	-	Suspected idiopathic intracranial hypertension	Normal (10-20 cm H2O)	Coagulopathy; mass lesion

IMAGING RED FLAGS (SNNOOP10): Imaging indicated if any of the following: - Systemic symptoms (fever, weight loss) or systemic disease (HIV, cancer) - Neurological symptoms or abnormal signs - New onset or sudden onset (thunderclap) - Onset after age 50 - Other associated conditions (pregnancy, postpartum, immunosuppression) - Pattern change from previous headaches - Positional (worse lying down or standing) - Precipitated by Valsalva (cough, sneeze, exertion) - Papilledema - Progressive headache or atypical features - Painful eye with autonomic features

3. TREATMENT¶

ICHD-3 Diagnostic Criteria for Tension-Type Headache¶

Episodic TTH (<15 days/month): A. At least 10 episodes fulfilling criteria B-D B. Lasting 30 minutes to 7 days C. At least 2 of: bilateral location; pressing/tightening (non-pulsating) quality; mild-moderate intensity; not aggravated by routine physical activity D. Both: no nausea or vomiting; no more than one of photophobia or phonophobia E. Not better accounted for by another ICHD-3 diagnosis

Chronic TTH (≥15 days/month for >3 months): Same as above but occurring ≥15 days/month on average for >3 months

3A. Acute/Emergent¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Ketorolac	IV/IM	Severe acute TTH in ED; NSAID-responsive headache	30 mg :: IV :: x1 :: 30 mg IV x1 (15 mg if >65y, renal impairment, or <50 kg); do not exceed 5 days total NSAIDs	Renal impairment; GI bleed history; aspirin allergy; third trimester pregnancy	Renal function if repeated dosing	STAT	URGENT	-	-
Metoclopramide	IV	Acute headache with nausea; has anti-headache properties	10 mg :: IV :: x1 :: 10 mg IV over 15 min; pretreat with diphenhydramine 25 mg to prevent akathisia	Parkinson's disease; tardive dyskinesia history; bowel obstruction	Akathisia, dystonic reaction	URGENT	URGENT	-	-
Diphenhydramine	IV	Adjunct to prevent akathisia from dopamine antagonists	25 mg :: IV :: x1 :: 25 mg IV prior to metoclopramide	Narrow-angle glaucoma; urinary retention	Sedation	URGENT	URGENT	-	-

3B. Symptomatic Treatments¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Ibuprofen	PO	First-line acute treatment for episodic TTH	400 mg :: PO :: PRN :: 400-800 mg PO at onset; may repeat q6-8h; max 2400 mg/day; limit to <10 days/month	Renal impairment; GI bleed history; aspirin allergy; third trimester	GI symptoms; renal function if prolonged use	URGENT	ROUTINE	ROUTINE	-
Naproxen	PO	First-line acute treatment; longer duration than ibuprofen	500 mg :: PO :: PRN :: 500-550 mg PO at onset; may repeat 250 mg in 12 hr; max 1250 mg/day; limit to <10 days/month	Renal impairment; GI bleed history; aspirin allergy; third trimester	GI symptoms; renal function if prolonged use	URGENT	ROUTINE	ROUTINE	-
Acetaminophen	PO	First-line if NSAID contraindicated; mild-moderate TTH	1000 mg :: PO :: PRN :: 1000 mg PO at onset; may repeat q6h; max 3000 mg/day (2000 mg if liver disease); limit to <10 days/month	Severe hepatic impairment; avoid if >3 alcoholic drinks/day	LFTs if chronic use; total daily dose from all sources	URGENT	ROUTINE	ROUTINE	-
Aspirin	PO	First-line acute treatment; anti-inflammatory	650 mg :: PO :: PRN :: 650-1000 mg PO at onset; max 4000 mg/day; limit to <10 days/month	Bleeding disorders; GI ulcer; aspirin allergy; children/teens (Reye syndrome); third trimester	GI symptoms; bleeding	URGENT	ROUTINE	ROUTINE	-
Caffeine/Analgesic combination	PO	Enhanced efficacy with caffeine adjunct	2 tablets :: PO :: PRN :: Acetaminophen 250 mg/aspirin 250 mg/caffeine 65 mg: 2 tablets at onset; max 2 doses/24hr	Aspirin or acetaminophen contraindications	Limit use to prevent caffeine dependence and MOH	-	ROUTINE	ROUTINE	-

3C. Second-line/Refractory¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Trigger point injection	IM	Pericranial muscle tenderness; refractory to oral therapy	1-2 mL :: IM :: q2-4wk :: Inject 1-2 mL 1% lidocaine into tender points in trapezius, temporalis, or cervical paraspinals; may repeat q2-4wk	Local anesthetic allergy; infection at site	Local bruising; vasovagal response	-	EXT	ROUTINE	-
Greater occipital nerve block	SC	Occipital-predominant pain; refractory cases	2-3 mL :: SC :: PRN :: 2-3 mL 2% lidocaine with or without 40 mg triamcinolone at greater occipital nerve bilaterally	Local anesthetic allergy; infection at site	Immediate pain relief; monitor for vasovagal	-	EXT	ROUTINE	-
Physical therapy	N/A	Musculoskeletal dysfunction; postural abnormalities	N/A :: N/A :: N/A :: 1-2 sessions/week for 6-8 weeks focusing on cervical/shoulder mobility, posture, and relaxation techniques	None	Symptom improvement over 6-8 weeks	-	ROUTINE	ROUTINE	-
Biofeedback/Relaxation therapy	N/A	Stress-related TTH; patient preference for non-pharmacologic	N/A :: N/A :: N/A :: Weekly sessions for 8-12 weeks; EMG biofeedback targeting frontalis/temporalis; may combine with CBT	None	Symptom diary; headache frequency reduction	-	-	ROUTINE	-
Cognitive behavioral therapy (CBT)	N/A	Stress, anxiety, or depression contributing to headache	N/A :: N/A :: N/A :: Weekly sessions for 8-12 weeks; focus on pain coping, stress management, and cognitive restructuring	None	Symptom diary; validated headache disability measures	-	-	ROUTINE	-

3D. Disease-Modifying or Chronic Therapies (Preventive Medications)¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Amitriptyline	PO	First-line prevention for chronic TTH; ≥15 days/month	10 mg :: PO :: qHS :: Start 10 mg qHS; titrate by 10-25 mg every 1-2 weeks; target 25-75 mg qHS; max 150 mg qHS	ECG if age >50 or cardiac history	Cardiac conduction abnormality (QTc >450 ms); recent MI; narrow-angle glaucoma; urinary retention; concurrent MAOIs	Sedation, dry mouth, weight gain, constipation; ECG if dose >100 mg/day	-	ROUTINE	ROUTINE	-
Nortriptyline	PO	Prevention if amitriptyline not tolerated (less sedating); chronic TTH	10 mg :: PO :: qHS :: Start 10 mg qHS; titrate by 10-25 mg every 1-2 weeks; target 25-75 mg qHS; max 150 mg qHS	ECG if age >50 or cardiac history	Cardiac conduction abnormality (QTc >450 ms); recent MI; narrow-angle glaucoma; urinary retention; concurrent MAOIs	Sedation (less than amitriptyline), dry mouth, weight gain, constipation; ECG if dose >100 mg/day	-	ROUTINE	ROUTINE	-
Venlafaxine XR	PO	Prevention; comorbid depression or anxiety; TCA intolerant	37.5 mg :: PO :: daily :: Start 37.5 mg daily; increase by 37.5-75 mg every 1 week; target 75-150 mg daily	None	Uncontrolled hypertension; concurrent MAOIs; abrupt discontinuation (taper required)	Blood pressure at higher doses (>150 mg); serotonin syndrome signs	-	ROUTINE	ROUTINE	-
Mirtazapine	PO	Prevention; comorbid insomnia, depression, or poor appetite	7.5 mg :: PO :: qHS :: Start 7.5-15 mg qHS; may increase to 30 mg qHS; more sedating at lower doses	None	Concurrent MAOIs; severe hepatic impairment	Sedation, increased appetite, weight gain	-	ROUTINE	ROUTINE	-
Tizanidine	PO	Prevention; prominent pericranial muscle tension	2 mg :: PO :: qHS :: Start 2 mg qHS; may increase by 2-4 mg every 3-7 days; max 36 mg/day in 3 divided doses	LFTs at baseline	Concurrent ciprofloxacin or fluvoxamine (CYP1A2 inhibitors); hepatic impairment	LFTs monthly for first 6 months then periodically; sedation, hypotension, dry mouth	-	ROUTINE	ROUTINE	-
Topiramate	PO	Prevention; comorbid migraine or obesity	25 mg :: PO :: qHS :: Start 25 mg qHS; increase by 25 mg/week; target 50-100 mg BID	None	Narrow-angle glaucoma; kidney stones; pregnancy (teratogen); metabolic acidosis	Cognitive effects (word-finding), paresthesias, weight loss, kidney stones, bicarbonate	-	ROUTINE	ROUTINE	-
Gabapentin	PO	Prevention; comorbid neuropathic pain or anxiety	300 mg :: PO :: qHS :: Start 300 mg qHS; titrate by 300 mg every 3-5 days; target 900-1800 mg/day in 3 divided doses	None	Severe renal impairment (dose adjust for CrCl)	Sedation, dizziness, peripheral edema	-	ROUTINE	ROUTINE	-

MEDICATION OVERUSE HEADACHE WARNING: Limit acute analgesic use to <10 days/month for combination analgesics, opioids, or triptans, and <15 days/month for simple analgesics (NSAIDs, acetaminophen). Exceeding these thresholds risks transformation to medication overuse headache (MOH). If MOH suspected, refer to medication overuse headache protocol.

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Neurology/Headache specialist referral for chronic TTH (≥15 days/month) not responding to first-line preventives	-	ROUTINE	ROUTINE	-
Physical therapy for cervicogenic component, postural dysfunction, and pericranial muscle tension	-	ROUTINE	ROUTINE	-
Behavioral medicine/Psychology for stress management, biofeedback, and cognitive behavioral therapy	-	-	ROUTINE	-
Sleep medicine evaluation if underlying sleep disorder (insomnia, apnea) contributing to chronic headache	-	-	ROUTINE	-
Ophthalmology evaluation to rule out refractive error or eye strain as contributing factor	-	-	ROUTINE	-
Dentistry/TMJ specialist if temporomandibular joint dysfunction contributing to headache	-	-	ROUTINE	-
Psychiatry referral for comorbid depression or anxiety requiring pharmacologic management beyond preventive therapy	-	-	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Return immediately for sudden severe headache ("worst headache of life") which may indicate hemorrhage or other serious cause	STAT	-	ROUTINE
Return immediately for headache with fever, stiff neck, or altered mental status which may indicate infection	STAT	-	ROUTINE
Return if new neurological symptoms develop (weakness, numbness, vision changes, speech difficulty)	STAT	ROUTINE	ROUTINE
Maintain headache diary tracking frequency, triggers, medication use, and response to guide treatment optimization	-	ROUTINE	ROUTINE
Limit acute pain medication use to no more than 10 days per month to prevent medication overuse headache	URGENT	ROUTINE	ROUTINE
Take acute medications early at headache onset for best efficacy rather than waiting for severe pain	-	ROUTINE	ROUTINE
Identify and modify personal triggers (stress, poor posture, inadequate sleep, screen time, skipped meals)	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Regular sleep schedule (7-8 hours, consistent bedtime and wake time) as sleep disturbance is a common trigger	-	ROUTINE	ROUTINE
Stress management through relaxation techniques, mindfulness meditation, or progressive muscle relaxation	-	ROUTINE	ROUTINE
Regular aerobic exercise (30 minutes moderate activity 5 times/week) shown to reduce chronic headache frequency	-	ROUTINE	ROUTINE
Ergonomic workplace assessment to optimize posture and reduce neck/shoulder strain during computer work	-	-	ROUTINE
Limit screen time and take regular breaks (20-20-20 rule: every 20 minutes, look 20 feet away for 20 seconds)	-	ROUTINE	ROUTINE
Adequate hydration (at least 64 oz water daily) as dehydration can trigger headache	-	ROUTINE	ROUTINE
Regular meals to avoid fasting-triggered headache; do not skip meals	-	ROUTINE	ROUTINE
Limit caffeine to moderate consistent intake (≤200 mg/day or ~2 cups coffee) to prevent withdrawal headaches	-	ROUTINE	ROUTINE
Stretching exercises for neck and shoulders daily, especially if sedentary work	-	ROUTINE	ROUTINE

SECTION B: REFERENCE¶

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Migraine	Unilateral, pulsating, moderate-severe intensity; nausea/vomiting; photo AND phonophobia; aggravated by physical activity	Clinical criteria (ICHD-3); normal imaging
Medication overuse headache	Daily or near-daily headache; acute medication use ≥10-15 days/month for ≥3 months	Headache diary documenting medication use; improves with withdrawal
Cervicogenic headache	Unilateral, starts in neck, radiates frontally; triggered by neck movement or sustained posture; reduced ROM	Physical exam (decreased ROM, tenderness); C-spine imaging; diagnostic block
Temporomandibular joint dysfunction	Pain in jaw, temple, or preauricular area; worse with chewing; clicking/popping of jaw; bruxism history	TMJ exam; panoramic dental X-ray; may need MRI TMJ
Giant cell arteritis	Age >50; new headache type; scalp tenderness; jaw claudication; visual changes; elevated ESR/CRP	ESR, CRP; temporal artery biopsy (gold standard)
Idiopathic intracranial hypertension	Positional headache (worse lying flat); papilledema; pulsatile tinnitus; visual obscurations; obesity	LP with opening pressure >25 cm H2O; MRI/MRV normal
Intracranial mass lesion	Progressive headache; worse in morning or with Valsalva; focal neurological signs	MRI brain with contrast
Cervical artery dissection	Sudden severe headache or neck pain; may have Horner syndrome; history of trauma or neck manipulation	MRA or CTA neck
Trigeminal neuralgia	Brief (seconds) electric shock-like pain; unilateral V2/V3 distribution; triggered by touch, chewing, or talking	MRI for vascular loop; clinical criteria
Cluster headache	Unilateral, periorbital, severe; autonomic features (lacrimation, rhinorrhea, ptosis, miosis); 15-180 min duration	Clinical history; attacks occur in clusters

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Headache diary (frequency, severity, duration, medication use)	Continuous at home; review each visit	<4 headache days/month on preventive; 50% reduction	Optimize preventive therapy; consider referral	-	ROUTINE	ROUTINE	-
Acute medication use days per month	Monthly	≤10 days/month (simple analgesics ≤15 days)	Counsel on MOH risk; consider prevention; detox if MOH	-	ROUTINE	ROUTINE	-
HIT-6 disability score	Every 3 months	Score reduction; target <50 (mild impact)	Escalate preventive therapy if disability persists	-	-	ROUTINE	-
LFTs (if on tizanidine)	Baseline, monthly x 6 months, then q6mo	Normal transaminases	Hold or discontinue if >3x ULN	-	ROUTINE	ROUTINE	-
ECG (if on TCA)	Baseline if age >50 or cardiac history; if dose >100 mg	QTc <450 ms; no heart block	Reduce dose or switch agent if QTc prolonged	-	ROUTINE	ROUTINE	-
Blood pressure (if on venlafaxine or SNRI)	Each visit	<140/90 mmHg	Reduce dose or add antihypertensive	-	ROUTINE	ROUTINE	-
Weight (if on TCA or mirtazapine)	Each visit	Stable; <5% gain	Dietary counseling; consider switching agent	-	ROUTINE	ROUTINE	-
Cognitive function (if on topiramate)	Each visit	No word-finding difficulty or slowed thinking	Reduce dose or switch agent	-	ROUTINE	ROUTINE	-
Bicarbonate (if on topiramate)	Baseline, 3 months	>18 mEq/L	Consider dose reduction or discontinuation if acidosis	-	ROUTINE	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Pain controlled with oral medications; able to tolerate PO; no red flags; follow-up arranged; MOH counseling provided
Admit to floor	Rare; consider if: intractable headache requiring IV therapy; need for medication overuse headache detoxification protocol
Outpatient neurology follow-up	Within 4-8 weeks for chronic TTH not responding to first-line treatment; sooner if diagnostic uncertainty
Primary care follow-up	Within 2-4 weeks for new episodic TTH to assess response to acute treatment and need for prevention

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
ICHD-3 diagnostic criteria for tension-type headache	Expert Consensus	Headache Classification Committee. Cephalalgia 2018
Amitriptyline effective for chronic TTH prevention	Class I, Level A	Bendtsen et al. Neurology 1996
Simple analgesics (acetaminophen, NSAIDs, aspirin) for acute TTH	Class I, Level A	Stephens et al. Cochrane 2016
Tricyclic antidepressants for chronic TTH prevention	Class I, Level A	Jackson et al. Neurology 2017
Biofeedback and relaxation training reduce headache frequency	Class II, Level B	Nestoriuc et al. Pain 2008
Physical therapy for tension-type headache	Class II, Level B	Espi-Lopez et al. Phys Ther 2014
Cognitive behavioral therapy reduces headache disability	Class I, Level B	Holroyd et al. JAMA 2001
Medication overuse headache prevalence and management	Expert Consensus	Diener et al. Nat Rev Neurol 2016
Ibuprofen 400-800 mg effective for acute TTH	Class I, Level A	Steiner et al. Headache 2003
Combination analgesics (aspirin/acetaminophen/caffeine) effective	Class I, Level A	Diener et al. Cephalalgia 2006
Venlafaxine for chronic TTH prevention	Class II, Level B	Zissis et al. Headache 2007
Topiramate for chronic TTH (limited evidence)	Class III, Level C	Lampl et al. J Neurol 2006
Greater occipital nerve block for refractory headache	Class II, Level B	Afridi et al. Brain 2006
SNNOOP10 red flags for secondary headache	Expert Consensus	Do et al. Neurology 2019

CHANGE LOG¶

v1.1 (January 30, 2026) - Standardized lab tables: reordered columns to Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding - Added CPT codes to all lab tests (1A: 3 rows, 1B: 4 rows, 1C: 3 rows) - Standardized imaging tables: reordered columns to Study (CPT) | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications - Added CPT codes to all imaging studies (2A: 2 rows, 2B: 3 rows, 2C: 2 rows) - Fixed structured dosing first fields across all treatment sections (3A-3D): starting dose only in first field - Added ICD-10 codes G44.219 and G44.221 - Added SYNONYMS line - Added VERSION/CREATED/REVISED header block

v1.0 (January 27, 2026) - Initial template creation - ICHD-3 diagnostic criteria included - Comprehensive acute and preventive treatment coverage - Non-pharmacologic approaches emphasized (PT, biofeedback, CBT) - Medication overuse headache warning prominently featured - SNNOOP10 red flags for imaging decisions - Structured dosing format for order sentence generation - Real PubMed citations with verified PMIDs