Care Pathway for the Management of Chronic Tension-type Headaches


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?