Pain in Primary Care

Tension Headaches: What Can We Offer?

Charles P. Vega, MD


December 15, 2021

To focus on issues of pain management in primary care, this month I'm presenting a clinical scenario drawn from my own practice. I'll tell you what I plan to do, but I'm most interested in crowdsourcing a response from all of you to collectively determine best practice. So please answer the polling question and contribute your thoughts in the comments, whether you agree or disagree.

Alejandra is a 38-year-old woman who presents with increasing headaches over the past 4 months. She says that she used to get headaches a couple times per month, but now they occur nearly every day.

The headaches begin in her frontotemporal areas bilaterally and feel like her head is in a vise. There is no pulsating pain. They began when she experienced more stress in her job, and exercise does not affect the headache. She denies photophobia, phonophobia, nausea/vomiting, visual symptoms, or other neurologic symptoms.

The patient has been using a combination of different over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) daily and takes a total of six to eight pills per day. They relieve the headache for about an hour, but then the headache returns quickly.

The patient has no significant chronic illnesses. Her only medications are the NSAIDs.

The patient completed a Patient Health Questionnaire-2, and the results do not indicate that she has depression. She was promoted to an executive position 6 months ago and is now putting many more hours in at work. She has carved out time to spend with her children in the evenings, but this means that she usually works until 1:00 AM after they go to bed. She estimates that she gets about 5 hours of sleep per night. She has two cups of tea during the day and is not consuming alcohol or using other drugs.

Her vital signs and physical examination are entirely normal.


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