Treatment Of Tension-type Headache Research Articles

An Overview of the Recent European Federation of Neurological Societies Guidelines on the Treatment of Tension-type Headache

Tension-type headache (TTH) is the most prevalent headache type and causes a high degree of disability. This paper provides an overview of the recently published European Federation of Neurological Societies guideline on the treatment of TTH, which recommended that non-drug management should always be considered for this condition. For example: information, reassurance and identification of trigger factors may be rewarding; electromyograph biofeedback has a documented effect in TTH; cognitive-behavioural therapy and relaxation training most likely also are effective; and physical therapy and acupuncture may be valuable options for patients with frequent TTH. Simple analgesics and non-steroidal anti-inflammatory drugs are recommended for treatment of episodic TTH. Combination analgesics containing caffeine are drugs of second choice. Excessive use of analgesics should be avoided to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is the first choice for prophylactic treatment of chronic TTH. Mirtazapine and venlafaxine may be used second line.

Biofeedback in the Treatment of Tension-type Headache

Biofeedback in the Treatment of Tension-type Headache

Tension-Type Headache in Children: The Cinderella of Headache Disorders!

Tension-type headache (TTH) may be as common a headache disorder as migraine in children and adolescents. TTH has a neurobiological basis with genetic and environmental factors making variable contributions to the different sub-types. The diagnostic criteria for TTH in the second edition of the "International Classification of Headache Disorders" appear to be applicable to children. Anxiety and mood disorders may be co-morbid with frequent episodic and chronic TTH. Psychosocial stressors play an important role in precipitating and maintaining TTH. Hence, a biopsychosocial approach should be adopted for care. Standardized histories and examinations together with prospective headache diaries are the foundations for good management; attention to 'red flags' will help identify secondary causes that present with headache similar to TT. There are no randomized controlled drug trials for the treatment of TTH. Relaxation and cognitive behavioral therapies are effective. TTH in children and adolescents warrants greater recognition from the clinician and scientist. Studies focusing on TTH are overdue.

Utilidad de la acupuntura y sus técnicas relacionadas en neurología: Resultados de una encuesta a expertos

Objective Neurology encompasses a wide variety of diseases and disorders, which diff er in cause, prognosis and therapeutic options. A survey among experts was conducted to determine, which neurological diseases and disorders respond well to acupuncture and related techniques, and if these diagnoses are preferably to be treated with classical acupuncture alone or rather using related techniques such as micro systems, special needle techniques, or additional therapeutic means. Methods 37 MDs (35 neurologists, 2 general practitioners) were asked to complete a questionnaire with 7 questions regarding prognosis and therapeutic options of several neurological diseases and disorders, and to comment on their preferred therapeutic approach, respectively. Results Five of the experts (13.5 %) returned the questionnaire. Several neurological diseases and disorders were found to respond well to acupuncture and related techniques. The best results (improvement of more than 50 % in 70 % of the cases) could be achieved in the treatment of tension-type headache and migraine. Treatment of poststroke paralyses only seems promising if therapy is initiated shortly after the incident. All experts frequently used micro systems, among which ear acupuncture was most widely preferred. Special caution should be taken in the treatment of patients with epilepsy. Discussion The expert answers turned out to be highly consistent. However, there remained diff erences regarding contraindications. Surprisingly, scalp acupuncture only scarcely applied. Conclusions With only five questionnaires returned, only a general tendency could be determined. A greater readiness in specialists of sharing their expertise with fellow acupuncturists remains to be desired for the future.

Complementary and alternative approaches to the treatment of tension-type headache

Although pharmacotherapy with NSAIDs and tricyclic antidepressants comprises the traditional treatment of tension-type headaches (TTHs), the use of other therapeutic approaches in combination with medications can increase the success of treatment. Patients with comorbid mood disorders and unremitting headaches may particularly benefit from some nonpharmacologic approaches. This review focuses on complementary and alternative approaches to TTH treatment, including psychological therapies, acupuncture, and physical treatments.

Advances in the pharmacologic treatment of tension-type headache

Tension-type headache (TTH) is the most prevalent form of primary headache in the general population. We discuss advances in the treatment of TTH. We briefly review nonpharmacologic therapies and then focus on current pharmacologic strategies. For acute treatment, the most common interventions involve the use of simple analgesics and anti-inflammatory medications, often taken by the patient without a prescription. For preventive treatment, amitriptyline is the best-studied drug, but nortriptyline, mirtazapine, tizanidine, the selective serotonin reuptake inhibitors, and other medications can be used. We close by discussing potential future therapies, including calcitonin gene-related peptide receptor antagonism, as well as substance P and the nitric oxide pathways.

Psychological issues in the evaluation and treatment of tension-type headache

Tension-type headache (TTH) is a common disease that is usually minimally impairing. However, more chronic TTH can be associated with significant disability and psychological comorbidity. Psychological assessment can help elucidate the biopsychosocial issues that complicate TTH and reveal the patient's coping styles. Psychological therapies, such as relaxation training, cognitive behavioral therapy, and biofeedback, may be helpful in reducing the frequency of TTHs and decrease the associated disability. Special populations, including pediatric patients, pregnant patients, and geriatric patients, may especially benefit from psychological interventions. Further work needs to be done in researching the effects of psychological treatments and making them available to a wider population.

Tolerability and efficacy of a combination of paracetamol and caffeine in the treatment of tension-type headache: a randomised, double-blind, double-dummy, cross-over study versus placebo and naproxen sodium

The main aim of this study was to confirm in an Italian population affected by tension-type headache (TTH) the good profile of safety and tolerability of the combination paracetamol 1,000 mg–caffeine 130 mg (PCF) observed in previous studies, by a comparison with naproxen sodium 550 mg (NAP) and placebo (PLA). A secondary objective was to assess the efficacy of PCF in the acute treatment of TTH. This was a multicentre, randomised, double-blind, double-dummy, crossover, placebo-controlled trial. Tolerability was assessed by recording adverse events by the patient in the 4-h post-dose treatment. To assess the efficacy, the sum of pain intensity differences (SPID) and the total pain relief (TOTPAR) were calculated. Comparing PCF and NAP and PCF and PLA for tolerability, the difference was nonsignificant but the result regarding noninferiority was inconclusive, whilst NAP was noninferior to PLA. As regards SPID and TOTPAR, both PCF and NAP were better than placebo (P < 0.05), but not significantly different from each other. In conclusion, PCF was well-tolerated and effective in the treatment of acute TTH.

Was ist möglich mit Akupunktur und Related Techniques in der Neurologie?: Ergebnisse einer Expertenbefragung

Objective Neurology encompasses a wide variety of diseases and disorders, which differ in cause, prognosis and therapeutic options. A survey among experts was conducted to determine, which neurological diseases and disorders respond well to acupuncture and related techniques, and if these diagnoses are preferably to be treated with classical acupuncture alone or rather using related techniques such as micro systems, special needle techniques, or additional therapeutic means. Methods 37 MDs (35 neurologists, 2 general practitioners) were asked to complete a questionnaire with 7 questions regarding prognosis and therapeutic options of several neurological diseases and disorders, and to comment on their preferred therapeutic approach, respectively. Results Five of the experts (13.5 %) returned the questionnaire. Several neurological diseases and disorders were found to respond well to acupuncture and related techniques. The best results (improvement of more than 50 % in 70 % of the cases) could be achieved in the treatment of tension-type headache and migraine. Treatment of post-stroke paralyses only seems promising if therapy is initiated shortly after the incident. All experts frequently used micro systems, among which ear acupuncture was most widely preferred. Special caution should be taken in the treatment of patients with epilepsy. Discussion The expert answers turned out to be highly consistent. However, there remained differences regarding contraindications. Surprisingly, scalp acupuncture only scarcely applied. Conclusions With only five questionnaires returned, only a general tendency could be determined. A greater readiness in specialists of sharing their expertise with fellow acupuncturists remains to be desired for the future.

Acupuncture for Tension-Type Headache: A Meta-Analysis of Randomized, Controlled Trials

We investigated the efficacy and safety of acupuncture for the treatment of tension-type headache by conducting a systematic review and meta-analysis of randomized, controlled trials. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from inception through August 2007. No search or language restrictions were applied. Eight randomized, controlled trials met our inclusion criteria. Pooled data from 5 studies were used for the meta-analysis. Our primary outcome was headache days per month. We assessed data from 2 time points: During treatment and at long-term follow-up (20-25 weeks). The weighted mean difference (WMD) between acupuncture and sham groups was used to determine effect size, and a validated scale was used to assess the methodological quality of included studies. During treatment, the acupuncture group averaged 8.95 headache days per month compared with 10.5 in the sham group (WMD, -2.93 [95% CI, -7.49 to 1.64]; 5 trials). At long-term follow-up, the acupuncture group reported an average of 8.21 headache days per month compared with 9.54 in the sham group (WMD, -1.83[95% CI, -3.01 to -0.64]; 4 trials). The most common adverse events reported were bruising, headache exacerbation, and dizziness. This meta-analysis suggests that acupuncture compared with sham for tension-type headache has limited efficacy for the reduction of headache frequency. There exists a lack of standardization of acupuncture point selection and treatment course among randomized, controlled trials. More research is needed to investigate the treatment of specific tension-type headache subtypes.

Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its efficacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45-minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereafter. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7±0.7 episodes per week during baseline to 3.7±0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2±1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0±1.3 to 2.8±0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.

Challenges of nonpharmacologic interventions in chronic tension-type headache

Interest in nonpharmacologic interventions for chronic tension-type headache has increased in recent years, with many professional organizations recommending behavioral treatments such as relaxation training, biofeedback, and cognitive-behavioral therapy alongside pharmacologic treatments. Although the efficacy of behavioral interventions is well-documented, several potential barriers in dissemination and implementation exist that have precluded more widespread adoption of behavioral treatments. This article briefly reviews the core components and efficacy of behavioral treatments for tension-type headache and outlines challenges to their broader clinical use as they occur at the levels of empirical research, treatment availability and delivery, and common clinical problems. Strategies for addressing these challenges are suggested, and directions for needed research are noted.

Multi-center Randomized Control Trial of Etizolam Plus NSAID Combination for Tension-type Headache

Benzodiazepines are commonly used for the treatment of tension-type headache (TTH), however, there are few randomized controlled trials recommending the use of these drugs in Japan. This study was undertaken to evaluate the efficacy of etizolam, a thienodiazepine derivative, in combination with a non-steroidal anti-inflammatory drug (NSAID) as an acute treatment for TTH. The study design was a multi-center randomized control trial and included 144 patients. The diagnosis of TTH was based on the criteria of the International Classification of Headache Disorders-1 and all patients were diagnosed with episodic tension-type headache (ETTH). Changes in the severity of headache and shoulder pain were graded using a Visual Analogue Scale (VAS) before and after administration of drugs. Patients were randomized into NSAID alone (NSAID, mefenamic acid, 250 mg) group and NSAID (mefenamic acid, 250 mg) plus etizolam (0.5 mg) (NSAID-ET) group prior to treatment. Although both groups showed a significant drop in VAS for headache and shoulder pain (p<0.01), there was no overall significant difference between the NSAID-ET and NSAID groups. However, headache was improved significantly in female patients (p<0.05), and shoulder pain was improved in young and female patients (p<0.05, p<0.04) in the NSAID-ET group. This study indicates that the combination treatment of etizolam and NSAID is useful in young or female patients.

Investigating prophylactic botulinum toxin type A for chronic headache disorders

There is an increasing number of studies on botulinum toxin A in the treatment of idiopathic and symptomatic headache; however, many studies can hardly be compared with each other because of different end points and different trial designs. For the prophylactic treatment of tension-type headache, migraine and cervicogenic headache, no sufficient positive evidence for a successful treatment can be obtained from the randomised, double-blind and placebo-controlled trials performed so far. For the treatment of chronic daily headache (including medication-overuse headache), there is inconsistent positive evidence for subgroups (e.g., patients without other prophylactic treatment). This means that most of the double-blind and placebo-controlled studies do not confirm the assumption that botulinum toxin A is efficacious in the treatment of idiopathic headache disorders; however, it is possible that some subgroups of patients with chronic migraine benefit from a long-term treatment for ≥ 6 months.

A Comparison of Selected Osteopathic Treatment and Relaxation for Tension‐Type Headaches

The objective of this study was to compare the effects of osteopathic treatment and progressive muscular relaxation (PMR) exercises on patients with tension-type headache (TTH). Relaxation is generally accepted as a treatment for TTH. Osteopathy is considered by some practitioners to be useful for headache management but there is limited scientific evidence regarding the effectiveness. This study compares relaxation and relaxation plus selected osteopathic techniques in the treatment of people with TTH. This was a single-blind, randomized, clinical study using an experimental design. Twenty-nine patients with TTH according to the International Headache Classification Subcommittee, 2004, were recruited for this study and randomly placed in either a control or experimental group. Both groups practiced PMR exercises at home while the experimental group also received 3 osteopathic treatments. All participants recorded headache frequency and intensity in a headache diary (HD) for 2 weeks pretreatment, and continued recording during the treatment period until reassessment for a total of 6 to 7 weeks. All tests of significance were set at P</= .05. Twenty-six people completed the study. Results indicated that the number of Headache Free Days Per Week was significantly improved (P= .016) in the experimental group. Two other measures, the Headache Degree of Improvement (P= .075) and the HD rating (P= .059), which combine headache frequency and intensity, did not meet our criteria for statistical significance but both scores are <.10 indicating a trend toward improvement in the experimental group that is clinically significant. The HD Rating also showed that the experimental group improved 57.5%, while the control group improved 15.6%. The intensity of headache did not show a significant improvement (P= .264). The people in this study who did relaxation exercises and received 3 osteopathy treatments had significantly more days per week without headache than those who did only relaxation exercises.

Status on the use of botulinum toxin for headache disorders

Reports and studies on botulinum toxin A in headache treatment are increasing. The studies available from reference systems and published congress contributions on the prophylactic treatment of idiopathic and symptomatic headache with botulinum toxin were analyzed with respect to the study design, the headache diagnosis, and the significance of results. For the prophylactic treatment of tension-type headache and migraine, no sufficient positive evidence for a treatment with botulinum toxin A is obtained from randomized, double-blind, and placebo-controlled trials to date. For the treatment of chronic daily headache (including medication overuse headache), there is inconsistent positive evidence for subgroups (e.g. patients without other prophylactic treatment). The majority of double-blind and placebo-controlled studies do not confirm the assumption that botulinum toxin A is efficacious in the treatment of idiopathic headache disorders. It is possible that subgroups of patients with chronic daily headache benefit from a long-term treatment with this substance. Future clinical trials should focus on these defined patient groups.

Early treatment of migraine attacks with triptans: a strategy to enhance outcomes and patient satisfaction?

Treating migraine attacks early with triptans may be more effective than late triptan administration. However, in published studies, the definition of ‘early’ varied (in terms of time, pain intensity or presence of allodynia) or was unclear. Therefore, clear clinical indications have not been established. Appropriately designed trials to address this issue remain a priority. Early triptan treatment may also have disadvantages, including inadvertent treatment of tension-type headaches and danger of medication overuse. At present, only those migraineurs with rapid pain worsening, high pain recurrence rate and clinical indications of allodynia should be encouraged to take triptans as quickly as possible. This recommendation implies a requirement for patient education and the need to carefully tailor treatment to individual needs.

Headache and botulinum toxin

The authors discuss clinical and international experience about botulinum toxins (BTX types A and B) in headache treatment. Data from literature suggest good results for the treatment of tensiontype headache, migraine and chronic tension–type headache. In the present paper mechanisms of action and injection sites will also be discussed.

Physical Treatments for Headache: A Structured Review

Primary headache disorders, especially migraine, are commonly accompanied by neck pain or other symptoms. Because of this, physical therapy (PT) and other physical treatments are often prescribed. This review updates and synthesizes published clinical trial evidence, systematic reviews, and case series regarding the efficacy of selected physical modalities in the treatment of primary headache disorders. The National Library of Medicine (MEDLINE), The Cochrane Library, and other sources of information were searched through June 2004 to identify clinical studies, systematic reviews, case series, or other information published in English that assessed the treatment of headache or migraine with chiropractic, osteopathic, PT, or massage interventions. PT is more effective than massage therapy or acupuncture for the treatment of TTH and appears to be most beneficial for patients with a high frequency of headache episodes. PT is most effective for the treatment of migraine when combined with other treatments such as thermal biofeedback, relaxation training, and exercise. Chiropractic manipulation demonstrated a trend toward benefit in the treatment of TTH, but evidence is weak. Chiropractic manipulation is probably more effective in the treatment of tension-type headache (TTH) than it is in the treatment of migraine. Evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration, and disability in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality. Further studies of improved quality are necessary to more firmly establish the place of physical modalities in the treatment of primary headache disorders. With the exception of high velocity chiropractic manipulation of the neck, the treatments are unlikely to be physically dangerous, although the financial costs and lost treatment opportunity by prescribing potentially ineffective treatment may not be insignificant. In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management; in most cases, the use of these modalities should complement rather than supplant better-validated forms of therapy.

Noninvasive treatments for headache

Primary headache disorders are often accompanied by neck pain or other symptoms referable to neck muscles. Therefore, physical therapy and other physical treatments are commonly prescribed for headache management. A medical literature review was completed in order to gather information regarding the efficacy of selected physical modalities in the treatment of primary and cervicogenic headache disorders. After analyzing the collected data, expert opinions were developed regarding the utility and efficacy of selected physical modalities in the management of primary and cervicogenic headaches. Based on this review, the following four expert opinions are presented: physical therapy is more effective than massage therapy or acupuncture for the treatment of tension-type headache and appears to be most beneficial for patients with a high frequency of headache attacks. Physical therapy is most effective for the treatment of migraine when combined with other treatments such as thermal biofeedback, relaxation training and exercise. Chiropractic manipulation demonstrated a trend towards benefit in the treatment of tension-type headache, but evidence is weak. Chiropractic manipulation is probably more effective in the treatment of tension-type headache than it is in the treatment of migraine. In general, strong evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration and disability in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality. Physical treatments are unlikely to pose a significant risk, with the exception of high velocity chiropractic manipulation of the neck. Consideration must be given to financial costs and lost treatment opportunity by prescribing potentially ineffective treatment. In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management. In most cases, the use of physical modalities should complement rather than replace better validated forms of therapy. The evidence base to determine the safety and efficacy of physical treatments in the management of headache disorders would be substantially improved by using standard scientific rigor in the development and conduct of future clinical studies.