Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
simple analgesics
For mild to moderate pain.
Episodic attacks generally respond well to simple analgesics such as paracetamol, and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or aspirin.[6][17][21][22][23]
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[Evidence B] Treatment should be implemented early in an attack and must be of adequate dose.
Paracetamol is the recommended treatment for pregnant and breastfeeding women if medication is needed, although non-pharmacological treatment is preferred if possible.[24] NSAIDs inhibit prostaglandin synthesis and may lead to premature closure of the ductus arteriosus or oligohydramnios; they should therefore be avoided where possible during the third trimester.[27] They can be used judiciously as a second-line therapy in the second trimester.[24][28] However, it should be noted that US and UK guidelines now recommend avoiding them at 20 weeks or later in pregnancy. If deemed necessary by a healthcare professional, use of NSAIDs between 20 and 30 weeks of pregnancy should be limited to the lowest effective dose for the shortest duration.[29][30] Observational data of NSAID use during the first trimester regarding embryo-fetal and miscarriage risks are inconclusive and it is recommended that NSAIDs should be avoided.[24][30] Naproxen and ibuprofen are compatible with breastfeeding; ibuprofen is preferred because of its short elimination half-life and low excretion in human milk.[28] Aspirin at analgesic doses, opioids, and barbiturates (including butalbital, which is available in combination products for the treatment of TTH in some countries), are not recommended for the management of headache in pregnancy.[24]
Primary options
aspirin: 300-900 mg orally every 4-6 hours when required, maximum 4000 mg/day; 450-900 mg rectally every 4 hours when required, maximum 3600 mg/day
OR
paracetamol: 500-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: 400-800 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day
antidepressants
Doses used are generally low and not in the range used to treat depression, even when it is comorbid with tension-type headache (TTH).
Low-dose tricyclic antidepressants may reduce the frequency and intensity of attacks; there is evidence to support the use of amitriptyline in chronic TTH.[6] If one tricyclic antidepressant does not provide symptom relief or is not tolerated, others should be considered (e.g., doxepin).
Small studies suggested that venlafaxine or mirtazapine may be of some value, and they are recommended as second choice options, although one Cochrane review concluded that the use of venlafaxine is not supported by evidence.[6][33]
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There is little evidence for effectiveness of selective serotonin-reuptake inhibitors.[33]
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Dose should start low and be gradually increased until clinical improvement.
The optimal length of treatment with preventative agents in the treatment of TTH has not been established.[31]
Comorbidity, response to treatment, patient characteristics, previous headache history, patient preferences, and lifestyle choices should be taken into account when deciding how long to continue treatment. In patients with an excellent response (such as a 50% to 75% reduction in monthly headache days), pausing the treatment after 3 or 6 months and monitoring for recurrence of headache is a widely used approach.[3] Need for prophylaxis should be reviewed every 6 months.
There is limited evidence regarding both the efficacy and safety of medicines for use in the prevention of headaches during pregnancy and, if possible, medicine should be avoided and non-pharmacological interventions should be considered first-line.
For women with frequent or disruptive headaches who require initiation or continuation of preventive treatment in pregnancy; however, the risks and benefits of tricyclic antidepressants should be weighed up. Potential associated risks of amitriptyline include small for gestational age, congenital abnormalities, cardiovascular abnormalities, neonatal convulsions, and neonatal respiratory distress.[24] Amitriptyline and nortriptyline are considered to be relatively safe during breastfeeding. In mothers treated with amitriptyline, infants are exposed to about 1% to 2% of maternal dose; this amount is considered too small to be harmful.[28]
Venlafaxine should be avoided during pregnancy and breastfeeding.[24][28] Potential associated risks include increased risk of preterm birth and neonatal withdrawal symptoms.[24] Doxepin and mirtazapine are classified by the US Food and Drug Administration (FDA) as Category C drugs in pregnancy; the clinical implication is that they should only be given to pregnant women if the benefit outweighs the risk to the fetus.[36][37] Doxepin and mirtazapine are not recommended as preventive treatments for chronic TTH in pregnant or breastfeeding women in current American College of Obstetricians and Gynecologists (ACOG) guidelines.[24]
Primary options
amitriptyline: 10 mg orally once daily at bedtime initially, increase by 10 mg/day increments every week, maximum 100 mg/day
OR
doxepin: 10mg orally once daily at bedtime initially, increase by 10 mg/day increments every week, maximum 100 mg/day
Secondary options
venlafaxine: 75 mg/day orally (immediate-release) initially given in 2-3 divided doses, increase according to response, maximum 150 mg/day
OR
mirtazapine: 15 mg orally once daily initially, increase according to response, maximum 30 mg/day
non-pharmacological therapies
Additional treatment recommended for SOME patients in selected patient group
Non-pharmacological therapies can be combined with pharmacotherapy or administered on their own.Identification of trigger factors should be performed, as addressing these triggers may be of value. The most frequently reported triggers for tension-type headache (TTH) are stress (mental or physical), irregular or inappropriate meals, high intake or withdrawal of coffee and other caffeine containing drinks, dehydration, sleep disorders, too much or too little sleep, reduced or inappropriate physical exercise, psycho-behavioural problems, hormonal fluctuations during the female menstrual cycle, and hormonal therapy.[6] Patients should be encouraged to make lifestyle improvements, including management of sleep, healthy diet and hydration, stress management, and regular exercise.[3]
Relaxation training, electromyographic (EMG) biofeedback, cognitive behavioural therapy, and myofascial trigger point-focused massage have all been shown to reduce TTH.[38][39] Music therapy is of dubious value.[40] Brief mindfulness therapy may be of value in chronic TTH.[41] Remotely delivered psychological treatments are not convincingly efficacious.[42]
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Physical measures, including physiotherapy, acupuncture, and spinal manipulation, may also provide benefit but, along with hypnosis, the evidence for their effectiveness is weak.[43][44][45]
These techniques may be considered for frequent attacks or for patients who cannot tolerate or do not wish to take medications (e.g., during pregnancy).[24] They may also be used as adjuncts to drug treatments. However, there is a limited body of research to support their use and rationale because the mechanism of TTH remains obscure.
non-pharmacological therapies
Additional treatment recommended for SOME patients in selected patient group
Non-pharmacological therapies can be combined with pharmacotherapy or administered on their own.
Identification of trigger factors should be performed, as addressing these triggers may be of value. The most frequently reported triggers for TTH are stress (mental or physical), irregular or inappropriate meals, high intake or withdrawal of coffee and other caffeine containing drinks, dehydration, sleep disorders, too much or too little sleep, reduced or inappropriate physical exercise, psycho-behavioural problems, hormonal fluctuations during the female menstrual cycle, and hormonal therapy.[6] Patients should be encouraged to make lifestyle improvements, including management of sleep, healthy diet and hydration, stress management, and regular exercise.[3]
Relaxation training, electromyographic (EMG) biofeedback, cognitive behavioural therapy, and myofascial trigger point-focused massage have all been shown to reduce TTH.[38][39] Music therapy is of dubious value.[40] Brief mindfulness therapy may be of value in chronic TTH.[41] Remotely delivered psychological treatments are not convincingly efficacious.[42]
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Physical measures, including physiotherapy, acupuncture, and spinal manipulation, may also provide benefit but, along with hypnosis, the evidence for their effectiveness is weak.[43][44][45]
All of these techniques may be considered for frequent attacks or for patients who cannot tolerate or who do not wish to take medications (e.g., during pregnancy).[24] However, there is a limited body of research to support their use and rationale because the mechanism of TTH remains obscure.
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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