Tension-type headache

For a description of tension-type headache, see Classifying headaches. Advise patients to follow the same lifestyle measures as for migraine. Manage stress and depression appropriately, and refer to an expert if needed. In more frequent tension-type headache, nonpharmacological therapies (eg cognitive behavioural therapy, relaxation training) may be effective. Acupuncture may be effective, but at least six sessions are needed. Physiotherapy (incorporating a neck muscle stretching and endurance program) and general aerobic exercise can help.

For infrequent tension-type headache, nonopioid analgesics are appropriate. A lower dose of aspirin than used for migraine can be effective. Use:

1 aspirin soluble 600 to 900 mg orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 2 g in 24 hours) headache, tension aspirin    

OR

1 diclofenac potassium 50 mg orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 150 mg in 24 hours)1 headache, tension    

OR

1 ibuprofen 400 mg orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 2.4 g in 24 hours) headache, tension ibuprofen    

OR

1 naproxen 500 to 750 mg orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 1250 mg in 24 hours) headache, tension naproxen    

OR

1 paracetamol soluble 1 g orally. Wait 4 to 6 hours before repeating dose if needed (maximum dose 4 g in 24 hours). headache, tension paracetamol    

The efficacy of nonopioid analgesics may decline with increasing headache frequency—if so, try adding a preventive drug (eg a tricyclic antidepressant). For more frequent tension-type headache, use:

1 amitriptyline 10 mg orally, once daily at night. Increase dose by 10 mg every 7 days to a maximum of 75 mg once daily at night, for 8 weeks, then review headache, tension, prophylaxis amitriptyline    

OR

1 nortriptyline 10 mg orally, once daily at night. Increase dose by 10 mg every 7 days to a maximum of 75 mg once daily at night, for 8 weeks, then review. headache, tension, prophylaxis nortriptyline    

If these drugs are effective, continue therapy for 6 months and then consider a trial of withdrawing therapy.

If no response to a preventive drug after 8 to 12 weeks, switch to another preventive drug or refer for expert advice. As an alternative preventive drug, use:

1 mirtazapine 15 to 30 mg orally, once daily at night, for 8 to 12 weeks, then review headache, tension, prophylaxis mirtazapine    

OR

1 venlafaxine modified-release 75 mg orally, in the morning after food. Increase dose according to tolerability and patient response to 150 mg daily. Review after 8 to 12 weeks. headache, tension, prophylaxis venlafaxine    

1 If the patient has nausea, diclofenac is available as a rectal preparation.Return