Tension-type headaches

American Family Physician,  March, 1993  by Michael B. Stevens

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TABLE 4
Treatment Modalities for Tension-type Headaches
Conservative
Acute           Topical heat or cold packs applied to affected
                 muscles
                Topical analgesic balms applied to affected
                 muscles
                Respite from stressors (rest, sleep, vacations)
                Stress-reduction techniques (e.g., exercise,
                 sexual activity)
Chronic         Regular exercise
                Physical therapy
                Relaxation therapy
                Electromyographic biofeedback
                Hypnotherapy
Pharmacologic
Acute           Analgesics
                Muscle relaxants
                Anxiolytics
                Trigger-point injection (if muscle contraction
                 is a major factor)
Chronic         Analgesics  use with caution)
                Muscle relaxants (use with caution)
                Antidepressants
                Trigger-point injection (if muscle contraction
                 is a major factor)
Psychologic
Chronic         Individual or family counseling

Treatment of episodic tension-type headaches principally involves conservative modalities and pharmacologic agents (especially analgesics). Chronic tension-type headaches are usually treated with conservative modalities, pharmacologic agents (especially antidepressants) and, in some cases, psychologic intervention.

NONPHARMACOLOGIC TREATMENT

The principal conservative treatments for tension-type headaches attempt to reduce muscle contractions (if present) or psychologic stress. Topical heat or cold packs and topical analgesic balm all have been prescribed for the acute treatment of both episodic and chronic tension-type headaches. Respite from stressors (rest, sleep or vacations) may prove useful, particularly if psychologic stress is a major inducer or propagator of the headaches.

Stress-reduction techniques such as exercise and sexual activity may obviate the need for other treatment modalities. Regular exercise and physical therapy may be beneficial in patients with chronic tension-type headaches.[22] Relaxation therapy, electromyographic biofeedback and hypnotherapy are also useful.[23-25]

DRUG THERAPY

The choice of pharmacologic therapy depends on the clinical situation and, more importantly, on whether the tension-type headache is episodic or chronic. In general, severe episodic or chronic tension-type headaches should be treated with the analgesic medication that provides sufficient pain relief. Physicians should not be afraid of the judicious use of narcotic analgesics in patients with severe headache pain.

Treatment of acute and, perhaps, chronic tension-type headaches should be initiated with the least potent and least addictive analgesic medication that relieves most of the patient's pain. A hierarchy of analgesics is shown in Table 5. With either a worsening or a lessening of the severity and frequency of a patient's headaches, the physician can move down or up this list in selecting an analgesic agent to control that patient's pain.