Tension headaches. Relieving pain without creating dependence.

Almost half of headaches that are treated in a primary care practice are of the tension type. The diagnosis is made primarily on the basis of a history of bilateral mild or moderate headache with a pressing or tightening quality, often located in the hatband region and sometimes extending down the back of the neck. Laboratory tests and imaging studies are indicated only for selected patients to rule out other causes. A stepwise approach to treatment, starting with reduction of precipitating factors and use of over-the-counter analgesic medications, is often helpful. Prophylaxis should be considered if tension headaches occur more than twice a week or last more than 2 days. A tricyclic antidepressant is the drug of choice for prophylaxis.