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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Bilateral pressing/tightening mild-to-moderate headache
- Not worsened by routine activity
- No vomiting and no more than one of photophobia or phonophobia
- Neurological exam should be normal
- Chronic prevention: amitriptyline
Overview
Tension-type headache is the most common primary headache disorder. It is usually bilateral, band-like, pressing or tightening, and less disabling than migraine. Diagnosis is clinical when there are no red flags.
Epidemiology
Associated factors include stress, sleep deprivation, anxiety, depression, poor posture, jaw clenching, and pericranial muscle tenderness. Chronic tension-type headache occurs on at least 15 days per month for more than 3 months.
Clinical Features
Symptoms
Bilateral frontal, temporal, or occipital pressure
Mild-to-moderate pain not aggravated by activity
No nausea or vomiting
May have photophobia or phonophobia but not both prominently
Thunderclap, fever, papilledema, or focal deficit is a red flag
Signs
Normal neurological examination
Pericranial muscle tenderness may be present
No cranial autonomic symptoms
No meningismus or papilledema
Near-daily headache may indicate medication overuse
Investigations
First-line
Clinical diagnosisICHD pattern with bilateral pressing pain and no migraine features
Medication historyAssess analgesic, triptan, caffeine, opioid, and butalbital frequency
Second-line
MRI/CT headOnly with red flags, abnormal exam, cancer, immunosuppression, trauma, or changed pattern
ESR/CRPNew headache after age 50 or GCA symptoms
Headache diaryFrequency, triggers, medication use, response
Specialist
Psychological assessmentAnxiety, depression, sleep disorder, or stress drivers
Physical therapy reviewNeck and shoulder contributors in chronic cases
Management
International Headache Society ICHD-31
Acute therapy
- Acetaminophen, ibuprofen, or naproxen as needed
- Avoid opioids and butalbital
- Limit analgesic days to prevent medication overuse
- Address sleep and hydration
2
Prevention
- Amitriptyline low dose nightly for chronic tension headache
- Nortriptyline if anticholinergic effects problematic
- Treat anxiety/depression and insomnia
- Use headache diary
3
Nonpharmacologic
- Exercise, posture, ergonomics, relaxation training
- CBT or mindfulness for chronic stress association
- Physical therapy for neck/shoulder tension
- Avoid prolonged bed rest
4
Medication overuse
- Educate on rebound cycle
- Withdraw overused medication
- Start prevention if chronic pattern
- Avoid opioids/barbiturates
Complications
- Chronic daily headache: >=15 days/month
- Medication overuse: Frequent analgesics perpetuate pain
- Functional impairment: Reduced productivity and sleep
USMLE Step 2 CK Exam Tips
- 1Band-like bilateral pressure + normal exam = tension-type headache
- 2Migraine has nausea and photophobia/phonophobia and worsens with activity
- 3Cluster headache is unilateral orbital pain with autonomic symptoms
- 4Chronic prevention = amitriptyline
- 5Do not use opioids/butalbital
- 6Abnormal exam or papilledema requires imaging
- 7Frequent analgesics cause medication overuse headache
practicetest your knowledge on tension-type headacheApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — neurology and beyond.
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