• Home

Home > Medical Reference > Patient Education

• Highlights
• Introduction
• Prognosis
• Causes
• Risk Factors
• Diagnosis
• Managing Tension-Type Headaches
• Medications
• Treatment
• Lifestyle Changes
• Resources
• References

Headaches - tension

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of common headaches.

Medications

The standard treatments for tension-type headaches are nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, and tricyclic antidepressants, usually amitriptyline (Elavil, Endep). A number of investigational drugs, such as botulinum toxin (Botox), tizanidine (Zanaflex), and nitric synthase inhibitors are showing promise.

Pain Relievers for Mild to Moderate Headache Episodes

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. Aspirin is the most common, but it is not as effective for acute tension-type headache as others. The most common NSAIDs are the following:

• Over-the-counter NSAIDs include aspirin, ibuprofen (Motrin IB, Advil, Nuprin, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT)
• Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox, diclofenac (Voltaren, Cataflam, Solaraze), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), indomethacin (Indocin)

Studies suggest that ibuprofen or naproxen is more effective than aspirin or acetaminophen for acute tension-type headache. However, a low dose of the prescription drug diclofenac was as effective as a high dose (400 mg) of ibuprofen.

Long-term use of these drugs poses a risk for ulcers and gastrointestinal bleeding. They should not be used to prevent tension headaches. Of note, a 2003 study reported a higher risk for miscarriage (particularly if the NSAID is taken for more than a week or around the time of conception).

Acetaminophen. Acetaminophen (Tylenol, Anacin-3, Panadol, Phenaphen, and Valadol) is a good alternative to NSAIDs when stomach distress, ulcers, or allergic reactions prohibit their use. Acetaminophen is inexpensive and generally safe. It does not appear to pose a risk for miscarriage as NSAIDs do, even when used regularly. 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 particularly useful 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. It may pose a small risk for serious kidney complications in people with preexisting kidney disease, although it is still the drug of choice for people with impaired kidney function. There is some evidence that taking even more than 2 grams (2,000 mg) a day for the long term may confer a risk of ulcers and bleeding comparable to that of NSAIDs. It also may interact with certain medications, including the blood thinner warfarin.

Tricyclics and Other Antidepressants

Antidepressants may be useful in preventing tension-type headaches. Those known as the tricyclics are most often used for prevention of severe chronic tension-type headaches. Older drugs called monoamine oxidase inhibitors can be effective as well. Newer antidepressants known as SSRIs 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 as well. They are sometimes referred in one of two categories: tertiary or secondary amines:

• Tertiary amines include amitriptyline (Elavil, Endep) and imipramine (Tofranil). Amitriptyline (Elavil, Endep) is the tricyclic most commonly used for tension-type headache. (These drugs tend to cause more drowsiness than secondary amines. This may be an advantage in 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 as toxic in high amounts.

Less commonly used or investigative tricyclics include doxepin (Sinequan), amoxapine (Asendin), maprotiline (Ludiomill), protriptyline (Vivactil), trimipramine (Surmontil), mianserin (Bolvidon), and dothiepin (Prothiaden).

Tricyclics produce modest benefits against pain, and one study suggested that they may actually reduce the transmission of pain to the nerves in the face.

Unfortunately, these drugs can lose effectiveness over time. Side effects are also 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, difficulty in urinating, disturbances in heart rhythm, and dizziness. Blood pressure may drop suddenly when sitting up or standing.

Tricyclics can have serious, although rare, side effects:

• They tend to cause disturbances in heart rhythm, which can pose a danger for some patients with certain heart diseases.
• Also of concern is a study reporting that tricyclics, particularly imipramine, may be responsible for 10% of cases of a lung disease called idiopathic pulmonary fibrosis (IPF), which can cause lung inflammation and scarring. Initial symptoms are breathlessness and dry cough. The two newer tricyclics, mianserin and dothiepin, also increased the risk.
• Tricyclics can be fatal with an overdose.

Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) work by increasing levels of serotonin in the brain. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). Because they act on serotonin specifically, they have fewer side effects than the older antidepressants, which affect a number of chemicals in the body. SSRIs take 2 - 4 weeks to be effective in most adults and sometimes longer, up to 12 weeks, so their value in headache is limited.

Side effects may include nausea, gastrointestinal problems, agitation, insomnia, mild tremor, impulsivity, temporary weight gain or loss, and sexual dysfunction. Death from overdose is extremely rare. Serious interactions can occur with other antidepressants, such as tricyclics and, of particular note, MAOIs.

Designer Antidepressants. Several drugs have now been developed that target other neurotransmitters, such as norepinephrine, alone or in addition to serotonin, and are showing promise for prevention of tension-type headache. The following are some examples:

• In one study, bupropion (Wellbutrin) was as effective as a tricyclic in preventing tension-type headaches.
• Nefazodone (Serzone), a fast-acting designer antidepressant, was particularly beneficial in a 2001 study of patients with chronic daily headaches. After 3 months of treatment, over 70% of patients experienced a reduction in headache symptoms by at least half and nearly 60% reported symptom improvement of over 75%.
• Venlafaxine (Effexor), a designer antidepressant that targets both serotonin and the brain chemical norepinephrine, is showing promise for preventing chronic tension-type headaches (as well as migraines). In one study, patients who took the extended-release form of the drug for six months went from an average of 24 tension headaches a month to 15.
• Mirtazapine (Remeron) is a unique antidepressant known as a 5-HT2 blocker. It may indirectly enhance the affects of both serotonin and norepinephrine. In a 2003 study, it was as effective in treating chronic tension-type headache as the tricyclic Elavil (the standard antidepressant used for this headache). It has significantly fewer side effects than the tricyclics although it may elevate cholesterol and triglyceride levels slightly. It may also cause blurred vision and slight weight gain.

Antianxiety and Sedative Drugs

Mild antianxiety drugs are occasionally used as an adjunct in treating chronic headaches to decrease muscle contraction or to treat anxiety symptoms during periods of extreme stress. They include alprazolam (Xanax) and clonazepam (Klonopin). They tend to be highly addictive, however, and should therefore be used only on a short-term basis.

Opioids and Potent Sedatives

Tramadol. Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea, but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available and provides more rapid pain relief than tramadol alone and more durable relief than acetaminophen alone. Side effects are the same as for each of these drugs.

Opioids. Opioids, such as codeine or hydrocodone, are sometimes prescribed for severe headaches, although their use is controversial because of the risk for addiction. Methadone is showing promise for patients who do not respond to standard treatments. These drugs are narcotics, however, and may be subject to abuse. Patients must be monitored and reevaluated regularly. Overuse of these drugs can reduce their effectiveness and lead to medication-overuse headaches, so it is important for a doctor to supervise this type of medication. Long-term, high-dosage use of some of these drugs can also lead to kidney disease and ulcers. Other, less serious side effects include gastrointestinal upset, dizziness, and ringing in the ears (tinnitus).

Sedatives. Barbiturates, particularly butalbital (Butalan) and its combinations (Fioricet, Axocet), are occasionally prescribed if other medications fail to provide relief. These drugs are sedatives that also contain pain relievers. Because they pose a very high risk for alcohol-like intoxication, dependence and drug-induced headaches during withdrawal, they should be used very sparingly. Some experts believe they should not be used at all for headaches.

Experimental Medications for Tension Headaches

Valproate. In some studies, the anticonvulsant medication valproate has been effective for stopping headaches in some patients with persistent migraines and tension-type chronic daily headaches. In one study, 75% of patients with either type of headache experienced at least a 50% reduction in headache frequency and severity. Minor side effects occurred in a third of the patients. Other anti-seizure medications are under investigation.

Botulinum Toxin. Botulinum toxin A (Botox) injections are now widely used to relax muscles and reduce skin wrinkles. They are also being investigated for chronic daily headaches, which include tension-type headache. This potentially deadly toxin is very safe when tiny amounts are injected into small muscles. In a 2003 study of various headache types (including tension-type headache), over 85% of all the patients experienced reduction in the number of headaches per month and the intensity of the pain. Several 2005 studies reported that Botox injections every 3 months might help patients with chronic daily headaches have fewer headaches. However, other studies have reported no benefit. Botox is not approved for headache treatment.

It should be noted that Botox also causes headaches in about 1% of cases. In some cases, the headaches can be very severe and long lasting (from 8 days to a month). Some experts suggest that either a contaminated batch of Botox or a specific injection technique may be the cause, but additional investigation is needed.

Tizanidine. Tizanidine (Zanaflex) is a muscle relaxant that is emerging as a possible effective preventive drug in chronic tension-type headaches. Called an alpha2-adrenergic agonist, it blocks the release and effectiveness of a stress chemical in the body called norepinephrine and may also help prevent muscle spasms. Studies have reported that nearly 70% of patients with chronic tension-type headaches experienced a reduction in headache symptoms of 50% or more. It also appears to help patients experiencing medication-overuse headache to withdraw from medications. Side effects are usually minor and include fatigue and dry mouth, although patients taking the drug need to be monitored periodically for potential liver damage.

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 being investigated include L-NG methyl arginine hydrochloride (L-NMMA) and L-NG-nitro-arginine. Studies suggest they may be very helpful in reducing chronic tension-type pain. Animal studies suggest they may also have antidepressant effects.

• Review Date: 10/3/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is the first of its kind, requiring compliance with 53 standards of quality and accountability, verified by independent audit. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial process . A.D.A.M. is also a founding member of Hi-Ethics (www.hiethics.com) and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2007 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.