Tension-type headache

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

The goal of treatment is to reduce the discomfort and duration of attacks. Patients with episodic tension-type headache (TTH) usually successfully self-treat. Treatment aims to improve response to acutely administered agents, as well as reduce the likelihood of episodic (TTH) progressing into chronic TTH.

Acute medication

Episodic attacks generally respond well to simple analgesics, such as acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or aspirin.[6][22][23][24] [ ] [ ] [ ] [Evidence B] Treatment with all agents must be of adequate doses and at the early onset of an attack. Acetaminophen is the recommended treatment for pregnant women if medication is needed.[25]

If simple analgesics are inadequate, combination analgesics can be used second-line. It is important, however, to exercise caution due to the potential risk of medication overuse associated with these medications. European guidelines recommend oral use of caffeine combinations for the acute treatment of TTH.[6] Although caffeine alone has not been shown to be effective for acute TTH treatment, there is evidence that the combination of caffeine with acetaminophen, aspirin, or ibuprofen improves the efficacy of these analgesics. It has been proposed that caffeine may increase the antinociceptive effects of analgesics by promoting their gastric absorption.[3] In some individuals, such as children, pregnant or breast-feeding women, and elderly patients, the use of NSAIDs or combinations of caffeine with aspirin or acetaminophen should be avoided for safety reasons. Possible adverse effects of caffeine-containing medications include nervousness, nausea, abdominal pain, and dizziness. Chronic use of caffeine-containing analgesics can lead to medication-overuse headache.[3]

Guidelines recommend that combinations of simple analgesics with codeine or barbiturates should not be used because of the increased risk of developing medication-overuse headache.[6][25]

If the frequency of attacks becomes high, stronger analgesics have limited use because of the risk of transformation into chronic headache. This may be due to the "medication-overuse syndrome" (also termed "analgesic rebound") in which the analgesics cease to provide pain relief and actually perpetuate and intensify the headaches.[6] Withdrawal of the analgesic also causes the headache to worsen in the short term, but it is necessary to break the cycle. The mechanism of the effect is poorly understood. Preventive measures may be necessary. Because, by definition, TTH attacks are rarely disabling, opioid analgesics are never recommended; if needed, the diagnosis of TTH should be reconsidered.[6][25] On rare occasions, a patient presenting with TTH will require parenteral medications (e.g., antiemetics, analgesics) for treatment, having failed on simple analgesics.[26] In these cases, when a patient presents with a disabling TTH, the diagnosis is often incorrect and most such patients are migraineurs.[27]

Pregnancy and breast-feeding

The general principle of prescribing to pregnant and breast-feeding women applies to women with headache: the safest medication should be recommended at the lowest dose for the shortest duration possible to achieve effective symptom control.[28][29] Headache devices, which do not use medications, are preferred.

Where required, acetaminophen is recommended as first-line pharmacologic treatment for short-term relief of episodic TTH throughout pregnancy and breast-feeding.[25][28][29]

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.[28] NSAIDs can be used judiciously as a second-line therapy in the second trimester.[25][29] 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.[30][31] 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.[25][31] Naproxen and ibuprofen are compatible with breast-feeding; ibuprofen is preferred because of its short elimination half-life and low excretion in human milk.[29]

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.[25]

Preventive treatment

Preventive medications are used when patients experience greater than 7 to 9 headache days per month. The optimal length of treatment has not been established.[32] 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.

Tricyclic antidepressants

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] The doses used are generally lower than the range used to treat depression, even when depression is comorbid with TTH.[6][33] However, their analgesic effect is dose-dependent so a lower dose may be suboptimal in reducing pain. In these cases, a higher dose can be tried. If one tricyclic antidepressant does not provide symptom relief or is not tolerated, others should be considered (e.g., doxepin).

Other antidepressants

Small studies suggest that venlafaxine or mirtazapine may be of some value in the preventive treatment of chronic TTH, and they are recommended as second choice options, although one Cochrane review concluded that the use of venlafaxine is not supported by evidence.[6][34] [ ] There is little evidence for effectiveness of selective serotonin-reuptake inhibitors.[34] [ ]

Muscle relaxants

Limited evidence supports the use of muscle relaxants in the management of TTH, and they should only be considered as second-line prevention if tricyclic antidepressant treatment is ineffective, contraindicated, or not tolerated.[35][36] Tizanidine can be used for 3 to 6 months, then discontinued. A return of symptoms may suggest that further therapy with tizanidine is appropriate.

Trigger point injections

If pain is very localized, local anesthetic injections at pericranial myofascial trigger points may be effective for chronic TTH in terms of reducing monthly painful days.[3]

Pregnancy and breast-feeding

Pharmacologic preventive treatments should be reviewed for women wishing to become pregnant and during pregnancy and breast-feeding. No medication is completely free of risk, and decisions should be made on an individual basis, balancing the risk of the treatment against the risk of the untreated headache disorder as a threat to the health of the mother and unborn child, and taking into account the patient’s values and priorities.[25]
Nonpharmacologic interventions should be considered first-line for the prevention of primary headaches. These may include lifestyle modifications such as avoidance of triggers, relaxation techniques, adequate sleep, stress management, adequate hydration, and cognitive behavioral therapy. There are limited data to support the efficacy of these interventions during pregnancy, but they are unlikely to cause harm. The use of a headache journal and a discussion of these interventions in the context of an individual patient’s experience and priorities may be useful.[25] Acupuncture is considered safe in pregnancy and more than half of UK specialist pregnancy acupuncturists report using it to treat headache or migraine.[28]
There is limited evidence regarding both the efficacy and safety of medications for use in the prevention of headaches during pregnancy and, if possible, medication should be avoided. 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.[25] Amitriptyline and nortriptyline are considered to be relatively safe during breast-feeding. 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.[29] Venlafaxine should be avoided during pregnancy and breast-feeding.[25][29] Potential associated risks include increased risk of preterm birth and neonatal withdrawal symptoms.[25] Doxepin and mirtazapine should only be given to pregnant women if the benefit outweighs the risk to the fetus.[37][38] Doxepin and mirtazapine are not recommended as preventive treatments for chronic TTH in pregnant or breast-feeding women in current American College of Obstetricians and Gynecologists (ACOG) guidelines.[25]

Nonpharmacologic therapies

Nonpharmacologic 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-behavioral 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 biofeedback, cognitive behavioral therapy, and myofascial trigger point-focused massage have all been shown to reduce TTH.[39][40] Music therapy is of dubious value.[41] Brief mindfulness therapy may be of value in chronic TTH.[42] Remotely delivered psychologic treatments are not convincingly efficacious.[43] [ ] 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).[25] 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.
Physical measures, including physical therapy, acupuncture, and spinal manipulation, may also provide benefit but, along with hypnosis, the evidence for their effectiveness is weak.[44][45][46]

Treatment failure

If standard treatments fail, the diagnosis should be reconsidered. Clues in the history may lead to a diagnosis of migraine headaches.

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Tension-type headache

Approach

Acute medication

Preventive treatment

Treatment failure