Episodic Tension-Type Headache (TTH)
Drug Treatment
Once a more serious underlying condition has been ruled out, the goal of TTH therapy is acute intervention with the simplest, most effective, and best-tolerated agent (see figure 5.1 of the original guideline document). Selection of an appropriate therapeutic approach is based on a thorough history, including the patient's response to previous treatments and an assessment of the impact of the attacks on the patient's quality of life. Physicians should specifically inquire about over-the-counter (OTC) medications, as few patients recognize how differences in this class of analgesics can affect subsequent treatment (see table 5.1 of the original guideline document for guidelines for use of selected abortive therapies in the treatment of TTH).
Simple OTC Analgesics
Unless the patient has already tried simple analgesics without success, treatment of TTH should begin with a nonprescription aspirin, acetaminophen, or nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen, naproxen sodium, or ketoprofen. In general, recommend a relatively high dose and stress the importance of early intervention to maximize effectiveness.
OTC Combination Analgesics
If simple analgesics fail, consider recommending a nonprescription medication that contains aspirin and/or acetaminophen with the addition of caffeine. Caffeine is an adjunct that provides mild vasoconstrictive, psychomimetic, and pain-enhancing action as well as a gastrokinetic effect.
Prescription Medications
If OTC analgesics are unsuccessful, prescription medications are the next appropriate step, including NSAIDs and barbiturate-containing medications (see table below). Keep in mind that the response to NSAIDs is highly individual, and failure of one agent should not preclude the use of another for future attacks. Further, prescribe barbiturate-containing products only with extreme caution, as they have a strong tendency to induce analgesic rebound, which often leads to their overuse.
| Prescription NSAIDs and Barbiturate-Containing Analgesics |
| NSAIDs |
Barbiturate-Containing Analgesics |
- Celecoxib
- Diclofenac
- Etodolac
- Fenoprofen
- Flurbiprofen
- Indomethacin
- Ibuprofen
- Ketoprofen
- Ketorolac
- Mefenamic acid
- Meloxicam
- Nabumetone
- Naproxen
- Naproxen sodium
- Rofecoxib*
- Salsalate
- Valdecoxib**
|
- Butalbital/aspirin/caffeine
- Butalbital/acetaminophen/caffeine
- Butalbital/acetaminophen
|
*On September 30, 2004, Vioxx (rofecoxib) was withdrawn from the U.S. and worldwide market due to safety concerns of an increased risk of cardiovascular events. See the U.S. Food and Drug Administration (FDA) Web site for more information.
**Subsequently, on April 7, 2005, after concluding that the overall risk versus benefit profile is unfavorable, the FDA requested that Pfizer, Inc voluntarily withdraw Bextra (valdecoxib) from the market. The FDA also asked manufacturers of all marketed prescription nonsteroidal anti-inflammatory drugs (NSAIDs), including Celebrex (celecoxib), a COX-2 selective NSAID, to revise the labeling (package insert) for their products to include a boxed warning and a Medication Guide. Finally, FDA asked manufacturers of non-prescription (over the counter [OTC]) NSAIDs to revise their labeling to include more specific information about the potential gastrointestinal (GI) and cardiovascular (CV) risks, and information to assist consumers in the safe use of the drug. See the FDA Web site for more information.
Additional Prescribing Considerations
Preventive therapy is not required unless the number of TTH attacks exceeds 15 per month. Muscle relaxants with or without analgesics may be used effectively, if the attacks are associated with the pericranial muscles (see table below). In rare cases, depression, anxiety, or both may be associated with TTH and should be treated as appropriate.
| Muscle Relaxants with/without Analgesics |
- Baclofen
- Carisoprodol
- Carisoprodol/aspirin
- Chlorzoxazone
- Cyclobenzaprine
- Metaxalone
- Methocarbamol
- Orphenadrine
- Orphenadrine/aspirin/caffeine
- Tizanidine
- Isometheptene/dichloralphenazone/acetaminophen
|
Safety Issues
Physicians should be aware of, and should thoroughly explain to the patient, any potential side effects associated with treatments for TTH. For example, prolonged use or abuse of analgesics may lead to gastrointestinal irritation, impair platelet function, and cause renal or hepatic complications. Barbiturate-containing analgesics may cause drowsiness, analgesic rebound headache, and habituation.
Patients should always be reminded to follow precisely the recommended usage for any acute headache medication. For example, patients who medicate their attacks on a daily or near-daily basis may be susceptible to the rebound phenomenon. Although the medication initially relieves the pain, response may gradually decrease over time, prompting the gradual use of additional medication. As this cycle continues - and worsens - the patient may ultimately develop chronic TTH or daily headache. Reminding patients to limit their use of acute medications to a single dose (with one repeat dose if pain persists) may help to avoid a serious problem before it begins.
Nondrug Treatments
Nondrug treatments can be an effective approach to TTH treatment, especially when used in conjunction with medication. Strategies include relaxation techniques, proper sleep and diet habits, exercise, and avoidance of behaviors or situations that may trigger an attack. Biofeedback has been used successfully in practice, but clinical studies on its effectiveness have been inconclusive. Physical interventions, such as acupuncture and acupressure, as well as simple heat or cold applications may also be useful.
