Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Stabilization and immediate exclusion of secondary headache
Airway compromise
Vomiting with decreased level of consciousness
Inability to protect airway
Breathing compromise
Hypoxia as alternate cause of altered mental status
Hypercapnia as alternate cause of headache with confusion
Circulatory compromise
Shock physiology
Hypertensive emergency features
Immediate escalation triggers
Thunderclap onset
New focal neurologic deficit
New seizure
Fever with meningismus
Altered mental status
Papilledema
Pregnancy or postpartum headache with severe features
Immunocompromised state with new headache
Secondary headache red flags
Red flag framework
SNNOOP10 features
Systemic symptoms
Systemic disease
Neurologic deficit or altered mental status
Sudden onset
Older age at onset
Pattern change or progressive course
Positional component
Precipitated by exertion, cough, Valsalva
Papilledema
Pregnancy or postpartum
Painful eye with autonomic features
Post traumatic onset
Pathology of immune system
Painkiller overuse or new medication
Working diagnosis decision points
Tension-type headache likelihood
Bilateral location
Band-like or pressure quality
Occipital or frontal predominance
Mild to moderate intensity
Not worsened by routine activity
No need to stop activity
Nonpulsating quality
Tightness
Dull ache
Associated features
No nausea or vomiting
Photophobia or phonophobia absent or only one present
Key concepts
High-risk headache exclusions before benign labeling
Subarachnoid hemorrhage
Thunderclap onset
Worst headache of life
Meningitis or encephalitis
Fever
Neck stiffness
Giant cell arteritis
Age 50 years or older
Jaw claudication
Intracranial mass or elevated ICP
Progressive pattern
Morning predominance with vomiting
Cerebral venous thrombosis
Pregnancy or postpartum
Prothrombotic risk
History
Symptom characterization
Headache phenotype
Onset
Gradual
Sudden or thunderclap
Time course
Minutes to hours
Recurrent episodic
Chronic daily pattern
Location
Bilateral
Occipital
Pericranial
Quality
Pressure
Tightness
Nonpulsating
Severity
Mild
Moderate
Severe or disabling
Modifiers
Worse with activity
Worse with cough or Valsalva
Positional component
Associated symptoms and red flags
Associated features
Nausea or vomiting
Absent favors tension-type
Present favors migraine or secondary causes
Photophobia
None or mild
Marked with phonophobia favors migraine
Phonophobia
None or mild
Marked with photophobia favors migraine
Autonomic features
Lacrimation
Nasal congestion
Ptosis or miosis
Visual symptoms
Aura features
Vision loss
Infection features
Fever
Recent sinusitis or otitis
Neurologic symptoms
Weakness
Speech change
Confusion
Triggers, context, and exposures
Context and triggers
Stress
Acute psychosocial stressor
Anxiety symptoms
Sleep
Sleep deprivation
Irregular schedule
Musculoskeletal triggers
Prolonged screen time
Poor ergonomics
Dehydration
Low fluid intake
Recent gastrointestinal illness
Caffeine pattern
Withdrawal
High intake
Medication exposure
New medication associated with headache
Vasodilators
Nitrates
Headache history and risk
Prior headache history
Similar prior episodes
Prior response to NSAIDs or acetaminophen
Prior benign evaluation
Change from baseline
New type
Increasing frequency
Medication overuse risk
Analgesic use on many days per month
Triptan use on many days per month
Medical risk factors
Anticoagulation
Cancer history
Immunosuppression
Pregnancy or postpartum
Recent head trauma
Functional impact
Missed school or work
Reduced activity
Physical Exam
General and vital signs
Systemic evaluation
Temperature
Fever
Afebrile
Blood pressure
Severe elevation with end-organ signs
Normal range
Heart rate
Tachycardia with systemic illness
Normal range
General appearance
Toxic appearance
Comfortable appearance
Head, neck, and musculoskeletal exam
Pericranial and cervical exam
Scalp tenderness
Temporal artery tenderness
Diffuse scalp tenderness
Pericranial muscle tenderness
Temporalis
Masseter
Occipitalis
Cervical paraspinal tenderness
Trigger points
Range of motion limitation
Jaw exam
Jaw claudication concern
Bruxism signs
Neurologic exam
Neurologic screen
Mental status
Normal orientation and attention
Altered mental status
Cranial nerves
Pupillary size and reactivity
Extraocular movements
Facial symmetry
Motor and sensory
Strength symmetry
Sensory asymmetry
Coordination and gait
Ataxia
Normal gait
Meningeal signs
Neck stiffness
Photophobia with neck flexion pain
Eye and fundoscopic exam
Ocular assessment
Visual acuity gross screen
Reduced acuity
Normal acuity
Fundoscopy
Papilledema
Normal optic discs
Painful red eye features
Corneal haze
Mid-dilated pupil
Differential Diagnosis
Life-threatening and high-risk causes
Dangerous headache causes
Subarachnoid hemorrhage
Thunderclap onset
Meningismus
Intracerebral hemorrhage
Focal deficit
Severe hypertension
Ischemic stroke
Focal deficit
Speech change
Meningitis or encephalitis
Fever
Altered mental status
Giant cell arteritis
Age 50 years or older
Jaw claudication
Cerebral venous thrombosis
Pregnancy or postpartum
Hypercoagulability
Acute angle-closure glaucoma
Painful red eye
Vision change
Carbon monoxide toxicity
Multiple symptomatic contacts
Exposure to combustion sources
Primary headache disorders
Primary headache mimics
Migraine
Unilateral predominance
Pulsating quality
Cluster headache
Severe unilateral orbital pain
Autonomic features
Medication overuse headache
Frequent analgesic use
Chronic daily headache
New daily persistent headache
Abrupt onset to daily pattern
Persistent over months
Secondary benign mimics
Common secondary causes
Cervicogenic headache
Neck movement provocation
Reduced cervical range of motion
Sinusitis
Purulent nasal discharge
Facial pain with bending forward
Temporomandibular disorder
Jaw pain
Clicking
Eyestrain
Prolonged near work
Uncorrected vision
Coding alignment
ICD-10-CM considerations
Tension-type headache G44.2
Episodic tension-type headache G44.21
Chronic tension-type headache G44.22
Headache unspecified R51.9
Use when phenotype unclear
Laboratory Tests
When labs are not needed
Typical tension-type presentation
Normal neurologic exam
No laboratory testing indicated
Focus on symptom relief
No red flags
No screening labs needed
Reassessment after therapy
Targeted labs for red flags
Inflammatory and vascular concern
ESR
Age 50 years or older with new headache
Giant cell arteritis risk
CRP
Giant cell arteritis risk
Supportive with ESR
CBC
Infection concern
Anemia concern
Infection concern
CBC
Leukocytosis support
Normal does not exclude meningitis
Blood cultures
Sepsis concern
Prior to antibiotics when feasible
Pregnancy and postpartum
Urine pregnancy test
Reproductive age with unknown status
Imaging and medication planning
Urinalysis and protein assessment
Preeclampsia concern
Hypertension with headache
Metabolic and toxin concern
Capillary glucose
Altered mental status
Hypoglycemia exclusion
Carboxyhemoglobin
Carbon monoxide exposure concern
Consider venous sample
Pitfalls and interpretation
Lab limitations
Normal ESR or CRP
Giant cell arteritis not excluded
Specialist input for persistent concern
Leukocytosis absence
Meningitis not excluded
Lumbar puncture decision based on clinical features
Diagnostic Tests
Scoring Systems
Decision support for secondary headache
Ottawa subarachnoid hemorrhage rule use case
Acute nontraumatic headache peaking within 1 hour
Normal neurologic exam required for rule application
SNNOOP10 red flags use case
Structured secondary headache screen
Triggers imaging or lumbar puncture pathways
Tension-type clinical diagnosis
No validated scoring system required
Diagnosis of exclusion after red flag screen
MRI
MRI brain indications
Subacute or chronic progressive headache pattern
New daily persistent headache concern
Concern for mass lesion
Abnormal neurologic exam
Focal deficit
Cognitive change
Suspected secondary causes better seen on MRI
Posterior fossa lesions
Demyelination
Contraindications and limitations
Implanted device incompatibility
Limited availability in urgent setting
CT
CT head indications
Thunderclap onset
Subarachnoid hemorrhage evaluation
Time-sensitive pathway
New focal neurologic deficit
Stroke or hemorrhage evaluation
Mass effect concern
Head trauma
Intracranial hemorrhage evaluation
Anticoagulation increases risk
Immunocompromised with new headache
Mass lesion concern
Opportunistic infection concern
Typical tension-type presentation
Imaging not indicated
Reassurance after exam
Ultrasound (or US)
Ultrasound applications
Temporal artery ultrasound
Giant cell arteritis concern
Halo sign consideration
Ocular ultrasound
Papilledema surrogate via optic nerve sheath diameter
Elevated ICP concern
POCUS limitations
Operator dependence
Adjunct only without definitive exclusion
Disposition
ED course and reassessment
Response-based disposition
Symptom improvement after therapy
Stable vital signs
Normal neurologic exam
Persistent severe pain
Reconsider diagnosis
Escalation to imaging or specialist input
New symptoms during ED stay
Repeat neurologic exam change
Secondary headache workup trigger
Discharge criteria
Safe discharge features
No red flags
Negative secondary screen
No concerning exam findings
Adequate pain control
Functional improvement
Oral medication tolerance
Clear follow-up plan
Primary care or headache clinic
Return precautions understood
Admission or consultation criteria
Higher level of care triggers
Concern for secondary headache
Abnormal imaging
Need for lumbar puncture
Uncontrolled symptoms
Refractory pain despite appropriate therapy
Frequent returns
Medication safety concerns
High-risk comorbidities
Significant dehydration requiring ongoing IV fluids
Treatment
Nonpharmacologic
Supportive measures
Environment modification
Quiet area
Low light if photophobia present
Hydration
Oral fluids if tolerated
IV crystalloids if dehydration suspected
Musculoskeletal interventions
Heat or cold packs to neck or shoulders
Gentle stretching guidance
Trigger management
Sleep optimization plan
Ergonomic adjustments
First-line analgesics
Oral options
Acetaminophen
1000 mg PO once
Maximum 4000 mg per 24 hours
Lower maximum with liver disease or heavy alcohol use
Ibuprofen
400 to 600 mg PO once
Maximum 2400 mg per 24 hours
Avoid with significant renal disease or active GI bleed
Naproxen
500 mg PO once
Maximum 1000 mg per 24 hours
Avoid with significant renal disease or active GI bleed
Parenteral options
Ketorolac
15 mg IV once
30 mg IV once
Avoid with significant renal disease or active GI bleed
Acetaminophen IV
1000 mg IV over 15 minutes once
Consider when unable to tolerate PO
Same daily maximum as PO
Adjuncts for muscle component
Skeletal muscle relaxants
Cyclobenzaprine
5 mg PO once
10 mg PO once
Sedation risk
Methocarbamol
500 mg PO once
750 mg PO once
Sedation risk
Antiemetics when nausea present
Metoclopramide
10 mg IV once
Akathisia risk
Consider diphenhydramine for akathisia
Prochlorperazine
10 mg IV once
Akathisia risk
QT prolongation risk
Avoided or limited therapies
Opioid avoidance
Poor efficacy for primary headache
Recurrence risk
Medication overuse headache risk
Use only when alternative diagnosis requires opioid or contraindications limit options
Clear documentation of rationale
Lowest effective dose
Butalbital combinations avoidance
Medication overuse headache risk
Dependence risk
Rebound headache risk
Avoid as first-line therapy
Use only with specialist plan
Refractory pathway
If inadequate response after first-line
Reconsider phenotype
Migraine features emerging
Secondary headache features emerging
Additional NSAID strategy
Avoid stacking multiple NSAIDs
Switch route if vomiting
Occipital nerve block consideration
Occipital tenderness pattern
Clinician skill dependent
Evidence notes
Practice recommendations overview
Primary tension-type acute treatment
NSAIDs and acetaminophen as first-line
Avoid routine opioids
Imaging strategy
No routine neuroimaging without red flags
Use structured red flag assessment
Special Populations
Pregnancy
Pregnancy and postpartum considerations
Secondary headache risk higher
Preeclampsia or eclampsia
Cerebral venous thrombosis
Medication safety
Acetaminophen preferred first-line
NSAID avoidance in third trimester
Workup modifications
Blood pressure assessment emphasis
Proteinuria assessment when hypertensive
Geriatric
Older adult considerations
Higher secondary headache risk
Giant cell arteritis
Mass lesion
Medication safety
NSAID GI and renal risks
Polypharmacy interactions
Diagnostic threshold
Lower threshold for ESR and CRP with new headache
Lower threshold for imaging with new pattern
Pediatrics
Pediatric considerations
Primary headache common but secondary causes must be screened
Head trauma
Infection
Medication dosing principles
Weight-based dosing required
Avoid aspirin
Red flags
Morning vomiting
Growth or development concerns
Background
Epidemiology
Population patterns
Tension-type headache prevalence high
Common in adolescents and adults
Often underreported
Chronic daily headache subset
Risk with frequent analgesic use
Comorbidity with anxiety and depression
Pathophysiology
Mechanisms
Peripheral myofascial nociception
Pericranial muscle tenderness association
Trigger points
Central sensitization in chronic forms
Lower pain threshold
Amplified nociceptive processing
Psychophysiologic contributors
Stress response association
Sleep disruption association
Therapeutic Considerations
Treatment principles
Acute symptom control
NSAIDs and acetaminophen efficacy
Route selection based on nausea and vomiting
Prevention of medication overuse
Limit frequent analgesic days
Follow-up for frequent headaches
Nonpharmacologic prevention
Sleep regularity
Hydration and nutrition regularity
Patient Discharge Instructions
copy discharge instructions
Discharge instructions set
Diagnosis explanation
Tension-type headache pattern
Not dangerous based on current evaluation
Home treatment plan
Acetaminophen within daily maximum
NSAID option if safe for kidneys and stomach
Lifestyle measures
Regular sleep schedule
Hydration
Screen breaks and neck stretching
Avoidance guidance
Avoid frequent use of pain medicines on many days per month
Avoid combining multiple NSAIDs
Follow-up plan
Primary care within 1 to 2 weeks if recurring
Headache diary for triggers and frequency
Return to ED now
Sudden severe headache reaching peak within 1 minute
Fever with stiff neck
Fainting or confusion
New weakness, numbness, trouble speaking, or trouble walking
New seizure
Vision loss or severe eye pain
Headache after head injury
Pregnancy or within 6 weeks postpartum with severe headache
Headache that is worsening quickly or different from usual
References
Clinical guidelines and evidence sources
Reference set
International Classification of Headache Disorders criteria for tension-type headache
Diagnostic phenotype definitions
Chronic versus episodic definitions
Emergency headache evaluation guidance
Red flag frameworks including SNNOOP10
Imaging guidance for secondary headache concern
Primary headache acute treatment summaries
NSAIDs and acetaminophen first-line for tension-type headache
Opioid avoidance to reduce recurrence and medication overuse
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.