Tension-Type Headache
Not yet clinically reviewed
This protocol was migrated from the earlier Pharmapedia and Ward Guide apps for educational use. Follow your hospital's own policies and consult seniors when in doubt.
Introduction
- Tension-type headache, the most common type of primary headache, is more common in women than men. Pain is usually mild to moderate and nonpulsatile. Episodic headaches may become chronic in some patients.
Pathophysiology
- Pain is thought to originate from myofascial factors and peripheral sensitization of nociceptors. Central mechanisms are also involved. Mental stress, nonphysiologic motor stress, a local myofascial release of irritants, or a combination of these may be the initiating stimulus.
Clinical Presentation
Premonitory symptoms and aura are absent, and pain is usually mild to moderate, bilateral, nonpulsatile, and in the frontal and temporal areas, but occipital and parietal areas can also be affected.
- Mild photophobia or phonophobia may occur. Pericranial or cervical muscles may have tender spots or localized nodules in some patients.
Treatment
- Nonpharmacologic therapies include reassurance and counseling, stress management, relaxation training, and biofeedback. Physical therapeutic options (e.g., heat or cold packs, ultrasound, electrical nerve stimulation, massage, acupuncture, trigger point injections, and occipital nerve blocks) have performed inconsistently.
- Simple analgesics (alone or in combination with caffeine) and NSAIDs are the mainstay of acute therapy. Acetaminophen, aspirin, diclofenac, ibuprofen, naproxen, ketoprofen, and ketorolac are effective.
- High-dose NSAIDs and the combination of aspirin or acetaminophen with butalbital, or rarely, codeine are effective options. Avoid the use of butalbital and codeine combinations when possible.
- Give acute medication for episodic headache no more often than 3 days (butalbital containing), 9 days (combination analgesics),
or 15 days (NSAIDs) per month to prevent the development of chronic tension-type headache.
- There is no evidence to support the efficacy of muscle relaxants.
- Consider preventive treatment if headache frequency is more than two per week, duration is longer than 3 to 4 hours, or severity results in medication overuse or substantial disability.
- The TCAs are used most often for prophylaxis of tension headache, but venlafaxine, mirtazapine, gabapentin, and topiramate may also be effective.