para>Use of abortive agents >2 days/week may lead to medication-overuse headaches; must withdraw acute treatment to diagnose.
Pediatric Considerations
ASA and antidepressants are contraindicated.
ADDITIONAL THERAPIES
- The combination of stress management therapy and a TCA (amitriptyline) may be most effective for CTTH.
- Maprotiline: 75 mg/day (not FDA approved for CTTH) (3)[C]
- Topiramate: 100 mg/day (limited clinical evidence for prevention of CTTH; not FDA approved for CTTH)
- Alternative TCAs (although limited evidence of benefit, all are widely used for prophylaxis) (5)[B]
- Desipramine (Norpramin): 50 to 100 mg/day
- Imipramine (Tofranil): 50 to 100 mg/day
- Nortriptyline (Pamelor): 25 to 50 mg/day
- Protriptyline (Vivactil): 25 mg/day
- Drugs with conflicting clinical evidence for CTTH (not FDA approved for CTTH):
- Tizanidine: 2 to 6 mg TID
- Memantine: 20 to 40 mg/day
- Botulinum toxin type A is not likely to be effective for ETTH or CTTH (6)[A).
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Electromyographic (EMG) biofeedback may be effective and is enhanced when combined with relaxation therapy (3,7)[C].
- Cognitive-behavioral therapy may be helpful (3,7)[C].
- Physical therapy, including positioning, ergonomic instruction, massage, transcutaneous electrical nerve simulation, and application of heat/cold may help.
- Alternative agents (not FDA approved for TTH)
- Tiger Balm or peppermint oil applied topically to the forehead may be effective for ETTH.
- Limited evidence for use of acupuncture and physical therapy (7)[B]
- Chiropractic spinal manipulation cannot be recommended for the management of ETTH; recommendations cannot be made for CTTH (8)[B].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Outpatient treatment
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Regulate sleep schedule.
- Regular exercise
DIET
- Identify and avoid dietary triggers.
- Regulate meal schedule.
PATIENT EDUCATION
For additional information, contact:
- National Headache Foundation: http://www.headaches.org
- American Council for Headache Education: http://www.achenet.org
PROGNOSIS
- Usually follows a chronic course when life stressors are not changed
- Most cases are intermittent.
COMPLICATIONS
- Lost days of work and productivity (more with CTTH)
- Cost to health system
- Dependence/addiction to narcotic analgesics
- GI bleeding from NSAID use
REFERENCES
11 Ferrante T, Manzoni GC, Russo M, et al. Prevalence of tension-type headache in adult general population: the PACE study and review of the literature. Neurol Sci. 2013;34(Suppl 1):S137-S138.22 Freitag F. Managing and treating tension-type headache. Med Clin North Am. 2013;97(2):281-292.33 Bendtsen L, Jensen R. Treating tension-type headache-an expert opinion. Expert Opin Pharmacother. 2011;12(7):1099-1109.44 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(11):1318-1325.55 Verhagen AP, Damen L, Berger MY, et al. Lack of benefit for prophylactic drugs of tension-type headache in adults: a systematic review. Fam Pract. 2010;27(2):151-165.66 Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA. 2012;307(16):1736-1745.77 Sun-Edelstein C, Mauskop A. Complementary and alternative approaches to the treatment of tension-type headache. Curr Pain Headache Rep. 2012;16(6):539-544.88 Bryans R, Descarreaux M, Duranleau M, et al. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther. 2011;34(5):274-289.
SEE ALSO
Algorithm: Headache, Chronic
CODES
ICD10
- G44.209 Tension-type headache, unspecified, not intractable
- G44.219 Episodic tension-type headache, not intractable
- G44.229 Chronic tension-type headache, not intractable
- G44.201 Tension-type headache, unspecified, intractable
- G44.221 Chronic tension-type headache, intractable
- G44.211 Episodic tension-type headache, intractable
ICD9
- 339.10 Tension type headache, unspecified
- 339.11 Episodic tension type headache
- 339.12 Chronic tension type headache
- 307.81 Tension headache
SNOMED
- 398057008 Tension-type headache (disorder)
- 230470007 Episodic tension-type headache
- 230471006 Chronic tension-type headache
- 66551002 Psychogenic headache (finding)
CLINICAL PEARLS
- Tension-type headache may be difficult to distinguish from migraine without aura. A tension-type headache is typically described as bilateral, mild to moderate, and dull pain, whereas a migraine is typically pulsating, unilateral, and associated with nausea, vomiting, and photophobia or phonophobia.
- Evidence suggests that NSAIDs may be more effective than APAP for ETTH. Consider APAP for patients who cannot tolerate, or have a contraindication, to NSAIDs. Initial dose of APAP should be 1,000 mg (500 mg may not be as effective).
- CTTH is difficult to treat, and these patients are more likely to develop medication-overuse headache. Clinical evidence supports the use of amitriptyline + stress-management therapy for CTTH.
- Medication-overuse headaches must be avoided by limiting use of abortive agents to no more than 2 days/week.
- A headache diary may be useful to identify triggers, response to treatment, and medication-overuse headaches.