An Overview of the Recent EFNS Guidelines on the Treatment of Tension-type Headache
mild pain means that patients are rarely severely incapacitated by pain. TTH is the most featureless of the primary headaches and, since many secondary headaches may mimic TTH, a diagnosis of TTH requires exclusion of other organic disorders.
The diagnosis of TTH is based on the patient’s history and a normal neurological examination. The diagnosis should be confirmed by means of a headache diary.4
The most difficult differential diagnosis is
between TTH and mild migraine. The diary may also reveal triggers and medication overuse. It also will establish the baseline against which to measure the efficacy of treatments. Identification of a high intake of analgesics is essential because medication overuse requires specific treatment.9
Paraclinical investigations, in particular brain
imaging, are necessary if secondary headache is suspected (e.g. the headache characteristics are atypical); if the course of headache attacks changes; or if persistent neurological or psychopathological abnormalities are present. Significant co-morbidity – e.g. anxiety or depression – should be identified and treated concomitantly. It should be explained to the patient that frequent TTH is only seldomly cured, but that meaningful improvements often can be obtained using combinations of drug and non-drug treatments.
Acute Drug Treatment of Tension-type Headache
Acute drug therapy refers to the treatment of individual attacks of headache in patients with episodic and chronic TTH. Most headaches in patients with episodic TTH are mild to moderate and the patients often can self-medicate with simple (non-opiate) analgesics (paracetamol or aspirin) or non-steroidal anti-inflammatory drugs (NSAIDs). The efficacy of simple analgesics tends to decrease with increasing frequency of the headaches. In patients with chronic TTH, the headaches are often associated with stress, anxiety and depression. Simple analgesics are usually ineffective and should be used with caution because of the risk of medication-overuse headache (MOH) when they are used regularly for more than 14 days a month. MOH is also a risk when triptans or combination analgesics are used for more than nine days a month.10
Other interventions, such
as non-drug treatments and prophylactic pharmacotherapy, should be considered.
Simple Analgesics and Non-steroidal Anti-inflammatory Drugs
Paracetamol 1,000mg was significantly more effective than placebo in most,11–17
but not all,18,19 paracetamol 500–650mg compared with placebo.11,18,20 500–650mg11,22–24 and 250mg.22
trials; three trials found no significant effect for Aspirin has
consistently been reported to be more effective than placebo at doses of 1,000mg,11,21,22
no difference in efficacy between solid and effervescent aspirin.24 Doses of ibuprofen at 800mg,23
400mg14,15,23,25,26 and 200mg27
effective than placebo, as are ketoprofen 50mg,18,27 12.5mg.19 effective.25
have been shown to be effective. Optimal Dosing
One study demonstrated a significant dose–response relationship for aspirin, with 1,000mg being superior to 500mg and 500mg being superior to 250mg.22
EUROPEAN NEUROLOGICAL REVIEW Ketoprofen 25mg tends to be more effective than 25mg17,19,27 One study found Caffeine comb. 65–200mg
are more and
Diclofenac 25mg and 12.5mg have been reported to be
There are no TTH trials of the higher doses of 50–100mg proved effective in migraine. Naproxen 375mg16
and 550mg20,28 also 12.5mg,19 while one study found very similar effects of ketoprofen
Paracetamol 1,000mg seems to be superior to 500mg, since only the former dose has been shown to be effective. In the absence of any evidence about a drug’s efficacy, the most effective dose that is well tolerated by the patient should be chosen. Suggested doses are presented in Table 2.
25mg and 50mg.27 65 B Aspirin 500–1,000mg A Naproxen 375–550mg A Diclofenac 12.5–100mg A Paracetamol 1,000mg (oral) A
Table 1: Diagnostic Criteria for Tension-type Headache (International Headache Society Classification)2
2.1 Infrequent Episodic Tension-type Headache
A. At least 10 episodes occurring on <1 day per month on average (<12 days per year) and fulfilling criteria B–D B. Headache lasting from 30 minutes to 7 days C. Headache has at least two of the following characteristics: 1. bilateral location 2. pressing/tightening (non-pulsating) quality 3. mild or moderate pain intensity 4. not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following: 1. no nausea or vomiting (anorexia may occur) 2. no more than one of photophobia or phonophobia E. Not attributed to another disorder
2.2 Frequent Episodic Tension-type Headache As 2.1 except for:
A. At least 10 episodes occurring on ≥1 but <15 days per month for at least 3 months (≥12 and <180 days per year) and fulfilling criteria B–D
2.3 Chronic Tension-type Headache As 2.1 except for:
A. Headache occurring on ≥15 days per month on average for >3 months (≥180 days per year) and fulfilling criteria B–D B. Headache lasts hours or may be continuous D. Both of the following: 1. no more than one of photophobia, phonophobia or mild nausea 2. neither moderate or severe nausea or vomiting
Table 2: Recommended Drugs for Acute Therapy of Tension-type Headache
Substance Dose Level of Recommendation Ibuprofen 200–800mg A Ketoprofen 25mg A
Gastrointestinal side effects, risk of bleeding
Side effects as for ibuprofen
Side effects as for ibuprofen
Side effects as for ibuprofen
Side effects as for ibuprofen, only doses of 12.5–25mg tested in TTH
Lower risk of gastrointestinal side effects than seen with NSAIDs See below*
The level of recommendation considers side effects and consistency of the studies. There is sparse evidence for optimum doses. The most effective dose that is well tolerated by the patient should be chosen. *Combination with caffeine 65–200 mg increases the efficacy of ibuprofen32
and paracetamol,13,31 medication-overuse headache.35,40 but may also increase the risk of developing Level of recommendation of combination drugs
containing caffeine is therefore B. NSAID = non-steroidal anti-inflammatory drug; TTH = tension-type headache.
Comment
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