Pharmacological and Non-pharmacological Management of Tension-type Headache

Pharmacological and Non-pharmacological Management of Tension-type Headache

Published: European Neurological Review - Volume 3 - Issue I
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Tension-type headache (TTH) is the most prevalent headache type and the one with the highest socioeconomic costs.1 It is a complex disorder in which a range of heterogeneous mechanisms are likely to play a role.2 The treatment of an acute episode in patients with infrequent TTH is often straightforward. However, in patients with frequent headaches, biological mechanisms – in particular increased sensitivity of the central nervous system3 – and psychological mechanisms often complicate treatment. It is important to consider which mechanisms may be important for the individual patient and to tailor the treatment accordingly.

The diagnostic problem most often encountered is the difficulty of discriminating between TTH and mild migraines. Measures towards attaining a correct diagnosis include keeping a headache diary4 over at least four weeks. The diary may also reveal triggers and medication overuse, and it will establish the baseline against which to measure the efficacy of treatments. Identification of a high intake of analgesics is essential as other treatments are largely ineffective in the presence of medication overuse.5 Significant co-morbidity, e.g. anxiety or depression, should be identified and treated concomitantly. It should be explained to the patient that frequent TTH can only rarely be cured, but that a meaningful improvement can be obtained with the combination of nondrug and drug treatments. These treatments are described separately in the following article, but should go hand in hand.

Non-pharmacological Management Information, Reassurance and Identification of Trigger Factors
Non-drug management is widely used and should be considered for all patients with TTH. However, the scientific evidence for the efficacy of most treatment modalities is sparse. The fact that the physician is concerned about the problem may have a therapeutic effect, particularly if the patient is troubled about serious disease, e.g. brain tumour, and can be reassured by a thorough examination. A detailed analysis of trigger factors should be performed, since avoidance of trigger factors may have a long-lasting effect. The most frequently reported triggers for TTH are stress (mental or physical), irregular or inappropriate meals, high intake of coffee and other caffeinecontaining drinks, dehydration, sleep disorders, too much or too little sleep, reduced or inappropriate physical exercise, psychological problems, variations during the female menstrual cycle and hormonal substitution.6,7 Most triggers are self-reported and so far none of the triggers has been systematically tested.

Information about the nature of the disease is important. It can be explained that muscle pain may lead to a disturbance of the brain’s painmodulating mechanisms,3,8 so that normally innocuous stimuli are perceived as painful, with secondary perpetuation of muscle pain and risk of anxiety and depression. Moreover, it should be made clear to the patient that the prognosis in the longer run is favourable, since approximately half of all individuals with frequent or chronic TTH experienced remission of their headaches in a 12-year epidemiological follow-up study.9

Psychological Treatments
A large number of psychological treatment strategies have been used to treat TTH. Three strategies have reached reasonable scientific support for effectiveness10 and will be described.

Relaxation Training
The goal of relaxation training is to help the patient to recognise and control tension as it arises in the course of daily activities. During the training, the patient sequentially tenses and then releases specific groups of muscles throughout the body. Advanced stages involve relaxation by recall, association of relaxation with a cue word and maintaining relaxation in muscles not needed for the activity currently engaged in.10

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