Medications:

The standard treatments for tension-type headaches are non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, and tricyclic antidepressants, usually amitriptyline (Elavil).

Due to the risks of overuse and dependence, opoids, opoid-like drugs, and sedative hypnotics are not recommended for treatment of tension-type headaches.

Pain Relievers

Several pain relievers are helpful for mild-to-moderate headaches. They should not be used to prevent headaches, however.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). NSAIDs are common pain relievers that block prostaglandins, substances that dilate blood vessels and cause inflammation and pain. NSAIDs are usually the first drugs tried for almost any kind of headache. There are dozens of NSAIDs. Common NSAIDs include:

• Over-the-counter NSAIDs. Aspirin, ibuprofen (Motrin), naproxen (Aleve), ketoprofen (Actron, Orudis KT)
• Prescription NSAIDs. Diclofenac (Voltaren, Cataflam, Solaraze), tolmetin (Tolectin), indomethacin (Indocin)

Patients should be aware that long-term use of high-dose NSAIDs may increase the risk for stomach bleeding and heart problems, including heart attack and stroke.

Acetaminophen. Acetaminophen (Tylenol) is a good alternative to NSAIDs when stomach distress, ulcers, or allergic reactions prohibit their use. A high dose (1,000 mg), however, is needed for this drug to be effective for headaches. Midrin (a combination of a drug that narrows blood vessels, a mild sedative, and acetaminophen) may be very helpful for tension-type headaches.

Acetaminophen does have some adverse effects, however, and the daily dose should not exceed 4 grams (4,000 mg). Patients who take high doses of this drug for long periods are at risk for liver damage, particularly if they drink alcohol and do not eat regularly. Acetaminophen may cause serious kidney problems in people who already have kidney disease. It also may interact with certain medications, including the blood thinner warfarin.

Tricyclics and Other Antidepressants

Antidepressants known as tricyclics are most often used for prevention of severe chronic tension-type headaches. Newer selective serotonin-reuptake inhibitors (SSRIs) antidepressants are also sometimes used in milder cases.

Tricyclic Antidepressants. Tricyclics are not only useful for depression but also appear to help relieve muscle pain and improve sleep. They are sometimes classified in one of two categories: tertiary or secondary amines:

• Tertiary amines include amitriptyline (Elavil) and imipramine (Tofranil). Amitriptyline is the tricyclic most commonly used for tension-type headache. These drugs tend to cause more drowsiness than secondary amines, which may be helpful for patients with sleep problems.)
• Secondary amines include desipramine (Norpramin) and nortriptyline (Pamelor, Aventyl). Secondary amines may have fewer side effects than tertiary amines, but they are just as toxic in high amounts.

A tricyclic antidepressant is usually started at a lower dose and then slowly increased. A headache diary can help the patient and the doctor assess the effectiveness of the treatment. In general, patients should remain on preventive drug treatment for at least 6 months. After that time, the doctor will slowly reduce the dose while continuing to monitor the frequency of headache attacks.

Side effects are fairly common with these medications. Drowsiness is the most common, but may vary by specific drug. In addition, side effects most often reported include dry mouth, constipation, blurred vision, sexual dysfunction, weight gain, trouble urinating, heart rhythm problems, and dizziness. Blood pressure may also drop suddenly when sitting up or standing.

Tricyclics can have serious, although rare, side effects, including heart rhythm problems, which can be dangerous for some patients with certain heart diseases. These drugs can be fatal with overdose.

Other Antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) work by increasing levels of serotonin in the brain. SSRIs used for tension-type headache preventive treatment include paroxetine (Paxil) and citalopram (Celexa). Other antidepressants used for tension-type headache are mirtazapine (Remeron) and venlafaxine (Effexor), which target both serotonin and norepinephrine.

Although these antidepressants have fewer side effects than tricyclics, they do not appear to be as effective for preventive treatment of tension-type headaches.

Investigational Drugs

Tizanidine. Tizanidine (Zanaflex) is a muscle relaxant that is being studied as a possible preventive drug for chronic tension-type headaches. In one study, the combination of tazanidine and amitriptyline provided faster headache relief than amitriptyline alone. It is still not clear how useful this drug is for most patients.

Topiramate. In one study, the anticonvulsant medication topiramate (Topamax), which is used for migraine prevention, was also effective for patients with chronic tension-type headache. Large randomized controlled trials are needed to confirm this result. Other anti-seizure medications are also under investigation.

Botulinum Toxin. Botulinum toxin A (Botox) injections are now widely used to relax muscles and reduce skin wrinkles. Botox is also becoming popular as a treatment for chronic daily headaches, which include tension-type headache. However, at present there is little scientific evidence to support its use. Botox is not approved for headache treatment.

Nitric Oxide Synthase Inhibitors. Nitric oxide synthase inhibitors block nitric oxide, which may play a role in increasing nerve activity that leads to headache. Drugs are currently being investigated in clinical trials for migraine treatment, and may also be studied for tension-type headache.