drug therapy in the management of tension headache

Last edited 05/2021 and last reviewed 06/2021

Drugs in tension type headaches can either be used for acute episodes or for prophylaxis (1).

Episodic tension headaches happening on fewer than 2 days per week can be treated symptomatically with over the counter analgesics (2). The drug treatment of episodic tension-type headaches consists of:

  • paracetamol - appears to be less effective (2)
  • NSAID or aspirin
    • use of aspirin is not recommended in children and adolescents under 16 years (2)

As the frequency of headaches increases, so does the risk of medication overuse (2)

  • nevertheless, a 3-week course of naproxen 250-500mg bd, taken regularly, may break the cycle of frequently recurring or unremitting headaches and the habit of responding to pain with analgesics. If it fails, it should not be repeated (2)

Codeine and dihydrocodeine should be avoided (2).

Clinicians must be careful about over usage of symptomatic treatment since it may lead to medication overuse headaches. Episodic tension headaches occurring for >2 days per week should prompt clinicians to use prophylaxis treatment rather than symptomatic treatment (1).

The drug treatment of frequent episodic/chronic tension-type headaches (TTH) is aimed at long-term remission:

  • prophylaxis treatment
    • tricyclic antidepressants:
      • amitriptyline is the drug of choice for frequently recurring episodic TTH or for chronic TTH (2)
      • low doses are effective e.g. amitriptyline, initially 10-25 mg nocte rising if required to 75-100mg at night
      • a significant effect can be expected in 25-50% of patients
      • a trial without medication may be attempted if symptoms improve for 6 months
      • after 6 months of clinical improvement withdrawal may be attempted (2)
      • although better tolerated the effects of Nortriptyline and protriptyline is less well documented (2)

Other antidepressants and benzodiazepines are probably not effective.

Despite best treatment efforts chronic tension type headaches is often refractory in some patients and will require pain management programs e.g - cognitive therapies, transcutaneous electrical nerve stimulation (TENS) (1,2).

NICE state that (3):

  • acute treatment
    • consider aspirin, paracetamol or an NSAID for the acute treatment of tension type headache, taking into account the person's preference, comorbidities and risk of adverse events
    • do not offer opioids for the acute treatment of tension-type headache
  • prophylactic treatment
    • consider a course of up to 10 sessions of acupuncture over 5-8 weeks for the prophylactic treatment of chronic tension-type headache

For NICE guidance regarding management of chronic pain (pain that lasts for more than 3 months) then see linked item.

Notes (4):

  • chronic daily headache (CDH), a heterogeneous group of headache disorders occurring on at least 15 days per month, affects up to 4% to 5% of the general population
    • CDH disorders include transformed (or chronic) migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua
    • there is evidence of benefit in the prophylactic treatment of CDH for topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and botulinum toxin type A

  • syndol (contain paracetamol, codeine, caffeine and doxylamine succinate) has become available again as an option for the acute treatment of tension type headaches (5) - this previously was my first-line treatment for acute tension headache and was introduced to me as such by my GP trainer, Dr Andrew Raeburn. There is some very ancient study evidence of benefit (6) but this again is a management option for GPs to consider (Personal comment - Dr Jim McMorran, Editor in Chief GPnotebook, 21/8/19)

Reference:

Related pages:

tricyclic antidepressants

NICE summary guidance - management of chronic pain