appear to be more relevant to the processes underlying
are ineffective, it is recommended to next try products
episodic tension-type headache. On the other hand,
that combine pain relievers with caffeine since these may
“central” brain abnormalities are more likely to explain
be more potent. The use of any analgesic-containing
those with chronic tension-type headache. Various
products should be strictly limited to an average of 2 to 3
measures of central nervous system pain processing reflect
days per week at most. More frequent use could eventu-
a hypersensitivity of nerve fibers in those with chronic
ally contribute to toxic side effects (kidney, liver, stomach)
tension-type headache.
or to the potential development of a medication-overuse
(“rebound”) headache disorder.
Additionally, brain MRI scans in these patients have
documented reduced size of several structures along the
For those individuals who experience headaches more
pain processing circuitry. Additional research is required
frequently than 2 to 3 days per week, certain prescription
to provide clarification to these findings.
“preventive” medications may be used on a daily basis to
decrease the frequency of episodes. Most clinicians advise
forms of antidepressants or anti-seizure medications to
The typical approach to the management of tension-type
help stabilize tension-type headaches. One review sug-
headache involves a combination of lifestyle, as well as
gested that the antidepressants (amitriptyline, venlafaxine,
physical and medical measures. We generally recommend
and mirtazapine) had the most evidence for use in this
strict regulation of sleep and meal patterns, with avoid-
condition. In general, muscle relaxants do not provide
ance of skipped meals and naps. Adequate hydration is
significant lasting benefit and their long-term use is gen-
important and we suggest 40 to 60 ounces of water intake
erally discouraged. Although onabotulinum toxin (Botox)
daily. Alcohol, caffeine, and artificial sweetener intake
has a known effect on the muscles, studies have not
should all be limited. Exercise is often beneficial and we
demonstrated any significant effect in the management of
recommend walking 1 to 2 miles over 30 minutes each
tension-type headache. There are no surgical procedures
day.
deemed to be either necessary or effective.
Stress management techniques may also be of great
benefit. These may involve prayer, meditation, yoga,
or additional activities that individual patients may
Those with episodic tension-type headache often report
find relaxing. Massage and cervical muscle stretches
headache occurrences spread over years or even decades,
are therapeutic for some individuals. Physical therapy
most with frequency below one episode per month. The
may be indicated for those with significant tightness in
prognosis is generally favorable, with limited disability
the neck muscles or for those with underlying arthritic
during headache occurrences and age-related improve-
changes in the cervical spine. Behavioral therapies such as
ment or resolution of episodes later in life. Those less
biofeedback have also been shown to be helpful in such
likely to improve include patients with the chronic form
situations. Acupuncture may also be beneficial
of tension-type headache, those with coexisting migraine
The acute treatment of a tension-type headache generally involves simple and nonspecific analgesics. Acetamin-
or sleep disorders, and interestingly, those who are
unmarried. HW
ophen, aspirin products, and traditional nonsteroidal
anti-inflammatory agents (NSAIDS) have all been shown
to be helpful in the treatment of these headaches. Among
these agents, the NSAIDS (ibuprofen, naproxen) may
have the highest degrees of success. If simple analgesics
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