Care Pathway for the Management of Chronic Tension-type Headaches

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Conduct an appropriate clinical evaluation to rule out major structural or other pathologies as the cause of the symptoms.

Risk factors/red flags may include:​

  • worsening headache with fever

  • sudden-onset headache (thunderclap) reaching maximum intensity within 5 minutes

  • new onset neurological deficit 

  • new onset cognitive dysfunction

  • change in personality 

  • impaired level of consciousness 

  • recent (within the last 3 months) head trauma

  • headache triggered by exertion (e.g. cough, valsalva maneuver, sneeze, exercise)

  • headache that changes with posture 

  • symptoms suggestive of giant cell arteritis

  • symptoms and signs of acute narrow-angle glaucoma 

  • a substantial change in the characteristics of the patient's headache 

  • new onset or change in headache of patients who are over 40 years of age and older 

  • headache wakening the patient up (migraine is the most frequent cause of morning headache)

  • patients with risk factors for cerebral venous sinus thrombosis

  • jaw claudication or visual disturbance

  • neck pain or stiffness

  • limited neck flexion upon examination

  • new onset headache in patients with a history of human immunodeficiency virus (HIV) infection

  • new onset headache in patients with a history of cancer 

 

Are risk factors present?

 

No

No

No

Yes

Management of Symptoms

 

Based on shared decision making between the patient and provider, any one of the following therapeutic interventions is recommended:

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Yes

Yes

No

Discharge

Yes

Yes

Discharge

No