Review Question - QID 106897

This patient's presentation is most consistent with a tension headache, which should be treated with NSAIDS in the acute setting.

Tension headaches usually present as dull, bilateral headaches that can last several days. They are rarely found in patients under 10 years old, and are often associated with stress. They can be differentiated from migraines due to its bilateral localization and by a lack of aura, photophobia, and phonophobia. They can be differentiated from cluster headaches based on the continuous nature of the headache, and the lack of hemifacial symptoms. NSAIDS are recommended for acute treatment, and antidepressants and beta blockers are recommended for prophylaxis.

Maizels describes the differential diagnosis of patients with chronic daily headaches. He notes that 50-80% of such headaches are likely due to medication overuse. He lists the mnemonic "SNOOP" to remember red flags in headaches: Systemic symptoms, Neurological symptoms, Onset is recent or sudden, Onset after 40 years of age, or Previous headaches are different in character.

Holroyd et al. performed a randomized, controlled trial to compare antidepressants with stress management sessions (relaxation, cognitive coping), for treatment of tension headaches. They found that both interventions alone showed improved outcomes over a placebo, and that combined antidepressants and stress management was more effective than single-mode treatment.

Illustration A is a chart showing the diagnostic criteria for tension headaches. Illustration B is a chart depicting symptoms of different types of headaches.

Incorrect Answers:
Answers 1 and 3: These are used for prophylaxis (verapamil) or treatment (oxygen) of cluster headaches.
Answer 2: This is used for treatment of migraine headaches.
Answer 4: There is no clear indication for an MRI in this patient given the lack of alarm symptoms (see Maizels et al above).