Learn about tension headache diagnosis, including clinical documentation tips, ICD-10 code G44.2, medical coding guidelines, and differential diagnosis considerations for healthcare professionals. Find information on tension headache symptoms, treatment, and best practices for accurate medical record keeping. Explore resources for proper coding and billing related to tension-type headaches in a clinical setting. This resource helps ensure accurate and efficient healthcare documentation for tension headaches.
Also known as
Tension-type headache
Headache caused by muscle tension in the head and neck.
Headache
General category for headaches not otherwise specified.
Persistent somatoform pain disorder
Chronic pain without a clear physical cause, sometimes including tension headaches.
Other headache syndromes
Catch-all for headache conditions not fitting other categories, may include tension headaches.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the headache episodic?
Yes
Less than 15 days/month?
No
Is the headache chronic?
When to use each related code
| Description |
|---|
| Headache from muscle tension |
| Migraine headache |
| Medication overuse headache |
Using unspecified codes like R51 when sufficient documentation supports a more specific tension headache diagnosis (G44.2).
Insufficient documentation of headache characteristics (frequency, duration, location, quality) to support G44.2, impacting accurate coding and reimbursement.
Missing or incorrect coding of comorbidities associated with tension headache, such as migraine (G43) or anxiety (F41), affecting risk adjustment and quality reporting.
Patient presents with a complaint of tension headache, characterized by bilateral, pressing or tightening pain of mild to moderate intensity. The headache is described as a band-like pressure or tightness across the forehead, temples, or back of the head. Onset is gradual and the headache is typically episodic, lasting from 30 minutes to several days. Associated symptoms may include scalp tenderness, neck pain, or muscle tension in the shoulders and neck, but no nausea, vomiting, photophobia, or phonophobia are reported. Physical examination reveals no neurological deficits. The patient denies any recent head trauma, fever, or other symptoms suggestive of a more serious underlying condition. Diagnosis of tension-type headache is based on clinical presentation and history, consistent with International Classification of Headache Disorders (ICHD-3) criteria. Differential diagnoses considered include migraine without aura, cervicogenic headache, and medication overuse headache. Treatment plan includes over-the-counter analgesics such as ibuprofen or acetaminophen, stress management techniques including relaxation exercises and good sleep hygiene, and education regarding headache triggers and preventative measures. Patient advised to follow up if symptoms worsen or do not improve with conservative management. ICD-10 code G44.21 (Tension-type headache) is assigned. CPT codes for evaluation and management services will be determined based on the complexity of the encounter.