MDM - Tension Headache

[##-year-old male/female] with headache with history and exam consistent with likely tension headache.

Initial consideration in this patient included tension headache, migraine, cluster headache, meningitis, encephalitis, subarachnoid hemorrhage (SAH), venous sinus thrombosis, and intracranial hemorrhage or tumor among others.

Patient presented with headache and a normal neurologic exam without report of preceding trauma.  Headache described as [tightness/pressure] in the [right/left/bilateral temporal/frontal/parietal] head without report of associated [nausea/blurred vision/photophobia], or other features suggestive of migraine headache.  Patient reports recent [decreased caffeine intake/insomnia/stress] suggestive of tension-type headache.  Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time [in patient meeting none of the Ottawa SAH rules as noted above].  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.  No indication for neuroimaging at this time based on normal neurologic exam in patient with headache with features suggestive of tension-type headache.  Patient reported significant improvement with [treatment] prior to discharge from ED.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement.

https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation
https://rebelem.com/the-ottawa-sah-clinical-decision-rule/