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2025 ICD-10-CM code G44.21

Episodic tension-type headache. This refers to head pain due to muscle tension in the neck or scalp, occurring less than 15 times a month for three or more months.

The diagnosis of episodic tension-type headache is made based on the International Classification of Headache Disorders (ICHD) criteria. It's important to distinguish episodic tension-type headache from other headache disorders, such as migraine, and to document the specific characteristics of the headache to support the diagnosis.

Medical necessity for treatment of episodic tension-type headache is established by the presence of headache symptoms impacting the patient's quality of life.Treatment is aimed at relieving pain and reducing the frequency and severity of headaches.

Providers diagnose episodic tension-type headache based on medical history, symptoms, and a physical exam.Although there are no specific tests to confirm the diagnosis, trigger points in the neck and shoulder muscles are often present.

In simple words: Episodic tension-type headache is a common type of headache caused by tense muscles in the head, neck, and shoulders. It occurs less than 15 times a month. The pain can feel like a tight band around your head or a dull ache in your neck and shoulders, lasting from 30 minutes up to a week. Stress, tiredness, and noise can make it worse.

Episodic tension-type headache is characterized by head pain due to muscle tension or contraction in the neck or scalp. This pain occurs fewer than 15 times per month for a duration of three or more months.It can range from infrequent (one or fewer episodes per month) to frequent (less than 15 episodes per month for 3-4 months). The pain can be unilateral or bilateral, described as a band-like or vise-like tightness, or a dull ache in the back of the neck and shoulders.Episodes can last from 30 minutes to 7 days and may worsen with stress, fatigue, or noise.

Example 1: A 35-year-old patient presents with a bilateral, pressing headache that they describe as feeling like a tight band around their head. The headache has been present for several hours and is mild in intensity. They report similar headaches occurring a few times a month, typically lasting a few hours and resolving with over-the-counter pain medication. They deny any nausea, vomiting, or sensitivity to light or sound. The patient is diagnosed with episodic tension-type headache., A 50-year-old patient reports experiencing frequent headaches, occurring 10-12 days per month, for the past six months. The headaches are characterized by a dull, aching pain in the back of the neck and shoulders, sometimes spreading to the head.The pain is typically mild to moderate in intensity and lasts for several hours.The patient reports increased stress at work as a potential trigger. They deny any neurological symptoms or other associated symptoms.The diagnosis is frequent episodic tension-type headache., A 25-year-old patient presents with a unilateral, pressing headache on the right side of their head.They report that the headache has been present for two days, and describe the pain as a constant pressure. The headache is moderate in intensity and is not aggravated by routine physical activity. They report experiencing similar headaches a few times a year. They deny any other symptoms. The patient is diagnosed with infrequent episodic tension-type headache.

Documentation should include the frequency, duration, location, and quality of the headache, as well as the presence or absence of associated symptoms such as nausea, vomiting, photophobia, and phonophobia.Any triggers or aggravating factors should also be noted. Physical examination findings, particularly regarding tenderness in the neck and shoulder muscles, are also important.

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