Tension-type headache in adults: Acute treatment
- Frederick R Taylor, MD
Frederick R Taylor, MD
- Professor of Neurology
- University of Minnesota
Tension-type headache (TTH) is the most ubiquitous headache in the general population, and is one of the most common reasons why over-the-counter analgesics are purchased. Despite the high frequency of TTH and the total disability society bears due to this primary headache, treatment has been driven more by anecdote and word-of-mouth consensus than by therapeutic trials . This situation is perhaps due to the typically mild nature of TTH, such that patients with this type of headache usually self-diagnose and self-treat unless they have concurrent migraine or develop chronic TTH.
Understanding the pathophysiology of TTH is likely the key to formulating a mechanistically sound, optimum treatment plan. Unfortunately, the scientific understanding of TTH lags that of migraine, and the postulated TTH mechanisms have produced limited treatment leads. (See "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis", section on 'Pathophysiology'.)
This topic will review the acute treatment of TTH in adults. Preventive treatment of TTH is reviewed elsewhere. (See "Tension-type headache in adults: Preventive treatment".)
Other aspects of TTH are discussed separately. (See "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis".)
APPROACH TO TREATMENT
The acute or abortive (symptomatic) therapy of TTH ranges from nonpharmacologic therapies to simple and combination analgesic medications. In most cases, the treatment of TTH is largely self-directed using over-the-counter medications without any input from a medical provider. Some general principles are relevant to the pharmacologic therapy of TTH:
- Moore RA, Derry S, Wiffen PJ, et al. Evidence for efficacy of acute treatment of episodic tension-type headache: methodological critique of randomised trials for oral treatments. Pain 2014; 155:2220.
- Lampl C, Voelker M, Steiner TJ. Aspirin is first-line treatment for migraine and episodic tension-type headache regardless of headache intensity. Headache 2012; 52:48.
- Rasmussen BK. Epidemiology of headache. Cephalalgia 1995; 15:45.
- Dowson AJ, Tepper SJ, Baos V, et al. Identifying patients who require a change in their current acute migraine treatment: the Migraine Assessment of Current Therapy (Migraine-ACT) questionnaire. Curr Med Res Opin 2004; 20:1125.
- Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol 2010; 17:1318.
- Lenaerts ME. Pharmacotherapy of tension-type headache (TTH). Expert Opin Pharmacother 2009; 10:1261.
- Verhagen AP, Damen L, Berger MY, et al. [Treatment of tension type headache: paracetamol and NSAIDs work: a systematic review]. Ned Tijdschr Geneeskd 2010; 154:A1924.
- Stephens G, Derry S, Moore RA. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev 2016; :CD011889.
- Veys L, Derry S, Moore RA. Ketoprofen for episodic tension-type headache in adults. Cochrane Database Syst Rev 2016; 9:CD012190.
- Bigal ME, Rapoport AM, Sheftell FD, et al. Transformed migraine and medication overuse in a tertiary headache centre--clinical characteristics and treatment outcomes. Cephalalgia 2004; 24:483.
- Martínez-Martín P, Raffaelli E Jr, Titus F, et al. Efficacy and safety of metamizol vs. acetylsalicylic acid in patients with moderate episodic tension-type headache: a randomized, double-blind, placebo- and active-controlled, multicentre study. Cephalalgia 2001; 21:604.
- Lange R, Lentz R. Comparison ketoprofen, ibuprofen and naproxen sodium in the treatment of tension-type headache. Drugs Exp Clin Res 1995; 21:89.
- Diamond S. Ibuprofen versus aspirin and placebo in the treatment of muscle contraction headache. Headache 1983; 23:206.
- van Gerven JM, Schoemaker RC, Jacobs LD, et al. Self-medication of a single headache episode with ketoprofen, ibuprofen or placebo, home-monitored with an electronic patient diary. Br J Clin Pharmacol 1996; 42:475.
- Kubitzek F, Ziegler G, Gold MS, et al. Low-dose diclofenac potassium in the treatment of episodic tension-type headache. Eur J Pain 2003; 7:155.
- Schachtel BP, Furey SA, Thoden WR. Nonprescription ibuprofen and acetaminophen in the treatment of tension-type headache. J Clin Pharmacol 1996; 36:1120.
- Packman B, Packman E, Doyle G, et al. Solubilized ibuprofen: evaluation of onset, relief, and safety of a novel formulation in the treatment of episodic tension-type headache. Headache 2000; 40:561.
- Mehlisch DR, Weaver M, Fladung B. Ketoprofen, acetaminophen, and placebo in the treatment of tension headache. Headache 1998; 38:579.
- Dahlöf CG, Jacobs LD. Ketoprofen, paracetamol and placebo in the treatment of episodic tension-type headache. Cephalalgia 1996; 16:117.
- Miller DS, Talbot CA, Simpson W, Korey A. A comparison of naproxen sodium, acetaminophen and placebo in the treatment of muscle contraction headache. Headache 1987; 27:392.
- Steiner TJ, Lange R, Voelker M. Aspirin in episodic tension-type headache: placebo-controlled dose-ranging comparison with paracetamol. Cephalalgia 2003; 23:59.
- Prior MJ, Cooper KM, May LG, Bowen DL. Efficacy and safety of acetaminophen and naproxen in the treatment of tension-type headache. A randomized, double-blind, placebo-controlled trial. Cephalalgia 2002; 22:740.
- Steiner TJ, Lange R. Ketoprofen (25 mg) in the symptomatic treatment of episodic tension-type headache: double-blind placebo-controlled comparison with acetaminophen (1000 mg). Cephalalgia 1998; 18:38.
- Derry S, Wiffen PJ, Moore RA. Aspirin for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev 2017; 1:CD011888.
- von Graffenried B, Nüesch E. Non-migrainous headache for the evaluation of oral analgesics. Br J Clin Pharmacol 1980; 10 Suppl 2:225S.
- Langemark M, Olesen J. Effervescent ASA versus solid ASA in the treatment of tension headache. A double-blind, placebo controlled study. Headache 1987; 27:90.
- Haag G, Diener HC, May A, et al. Self-medication of migraine and tension-type headache: summary of the evidence-based recommendations of the Deutsche Migräne und Kopfschmerzgesellschaft (DMKG), the Deutsche Gesellschaft für Neurologie (DGN), the Österreichische Kopfschmerzgesellschaft (ÖKSG) and the Schweizerische Kopfwehgesellschaft (SKG). J Headache Pain 2011; 12:201.
- Schachtel BP, Thoden WR, Konerman JP, et al. Headache pain model for assessing and comparing the efficacy of over-the-counter analgesic agents. Clin Pharmacol Ther 1991; 50:322.
- Diamond S, Freitag FG. The use of ibuprofen plus caffeine to treat tension-type headache. Curr Pain Headache Rep 2001; 5:472.
- Migliardi JR, Armellino JJ, Friedman M, et al. Caffeine as an analgesic adjuvant in tension headache. Clin Pharmacol Ther 1994; 56:576.
- Diener HC, Pfaffenrath V, Pageler L, et al. The fixed combination of acetylsalicylic acid, paracetamol and caffeine is more effective than single substances and dual combination for the treatment of headache: a multicentre, randomized, double-blind, single-dose, placebo-controlled parallel group study. Cephalalgia 2005; 25:776.
- Cerbo R, Centonze V, Grazioli I, et al. Efficacy of a fixed combination of indomethacin, prochlorperazine, and caffeine in the treatment of episodic tension-type headache: a double-blind, randomized, nimesulide-controlled, parallel group, multicentre trial. Eur J Neurol 2005; 12:759.
- Kaniecki RG. Tension-type headache. Continuum (Minneap Minn) 2012; 18:823.
- Lenaerts ME, Newman LC. Tension-type headache. In: Wolff's Headache and Other Head Pain, Silberstein SD, Lipton RB, Dodick DW (Eds), Oxford University Press, New York 2008. p.303.
- Scher AI, Lipton RB, Stewart WF, Bigal M. Patterns of medication use by chronic and episodic headache sufferers in the general population: results from the frequent headache epidemiology study. Cephalalgia 2010; 30:321.
- Tfelt-Hansen P, Langemark M. Parenteral treatment of episodic tension-type headache. Is there sufficient evidence? Headache 2014; 54:922.
- Weinman D, Nicastro O, Akala O, Friedman BW. Parenteral treatment of episodic tension-type headache: a systematic review. Headache 2014; 54:260.
- Harden RN, Rogers D, Fink K, Gracely RH. Controlled trial of ketorolac in tension-type headache. Neurology 1998; 50:507.
- Cady RK, Gutterman D, Saiers JA, Beach ME. Responsiveness of non-IHS migraine and tension-type headache to sumatriptan. Cephalalgia 1997; 17:588.
- Lipton RB, Cady RK, Stewart WF, et al. Diagnostic lessons from the spectrum study. Neurology 2002; 58:S27.
- Brennum J, Kjeldsen M, Olesen J. The 5-HT1-like agonist sumatriptan has a significant effect in chronic tension-type headache. Cephalalgia 1992; 12:375.
- Brennum J, Brinck T, Schriver L. Sumatriptan has no clinically relevant effect in the treatment of episodic tension-type headache. Eur J Neurol 1996; 3:23.
- APPROACH TO TREATMENT
- Judging the success of acute treatment
- SIMPLE ANALGESICS
- Nonsteroidal anti-inflammatory drugs
- Acetaminophen and aspirin
- Choice of initial therapy
- OTHER ACUTE INTERVENTIONS
- Combination analgesics containing caffeine
- Combination analgesics containing butalbital and codeine
- Parenteral treatments
- Muscle relaxants
- TREATMENT FAILURES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS