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Assessment: The patient presents with bilateral, pressing or tightening pain of mild to moderate intensity, lasting from 30 minutes to several days, without associated nausea, vomiting, or aura. Differential diagnosis includes tension-type headache, migraine (without aura), cluster headache, medication overuse headache, cervicogenic headache, and sinus headache.
Plan: Educate the patient about tension headaches and common triggers such as stress and poor posture, recommending stress management techniques and regular physical activity. For treatment, prescribe NSAIDs: ibuprofen 400-600 mg orally every 6-8 hours as needed (max 2400 mg/day) or naproxen 250-500 mg orally every 12 hours as needed (max 1000 mg/day), with acetaminophen as an alternative if NSAIDs are contraindicated. Schedule a follow-up in 4-6 weeks to reassess if symptoms persist or worsen, and monitor for medication overuse headache. For persistent cases, consider further evaluation and potential preventative treatments, such as amitriptyline. Instruct the patient to maintain a headache diary to track frequency, duration, triggers, and response to treatment, and to contact the office if headaches worsen or if new symptoms develop.
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