EFNS GUIDELINE ON THE

TREATMENT OF TENSION-TYPE
HEADACHE REPORT OF AN EFNS
TASK FORCE
EUROPEAN JOURNAL OF NEUROLOGY 2010, 17: 13181325

Menthored by : dr. Harry H.,

Sp.S
Presented by : Evarista Theofika
Felisia
Laura Cynthia B

Objectives

Acute and prophylactic drug

treatment of TTH
Non-drug treatment of TTH
Clinical description of the headache
disorders
Diagnostic criteria of the International
Headache Society (IHS)

Background
Classification:
infrequent episodic TTH (<1 day per
month)
frequent episodic TTH (114 days per
month)
chronic TTH ( 15 days per month)
Classification
Importance

Background
QoL
Chronic vs
Mild

Pathophysiol
ogy
Episodic ~
peripheral
Chronic ~
central

Classification
Importance

Treatment
Symptomatic
vs Profilactic

Background

Recommendation based on: clinical trial

& expert consensus

Level A: established as effective,

ineffective/harmful
Level B: probably effective,
ineffective/harmful
Level C: possibly effective,
ineffective/harmful

Search Strategy

Keyword: tension-type headache

Sources: databases MedLine, Science
Citation Index, Cochrane Library

Epidemiology

Denmark: 78% population based, majority

infrequent (<1 day/month) TTH without spesific
need medical attention.

Female: male = 5:4

Age:

24-37% several times per month

10% weekly
2-3% chronic

Onset: 25-30 years

Peak: 30-39 years

Burden: TTH >> migraine

Clinical Aspect
Characteristic: a bilateral, pressing
tightening pain of mild to moderate
intensity

short episodes (episodic forms) or

continuously (chronic form)

Migraine: vomiting, severe photophobia

and phonophobia
~ Chronic form: one/two accompanying
symptoms

Diagnosis

Based on:

history, normal neurological examination

Headache diary (at least 4 weeks): triggers,
medication, efficacy of treatments

DD/: TTH vs mild migraine, cervicogenic

headache
Imaging: suspect secondary headache,
persistent
neurological/psychopathological abN
Comorbidity: anxiety, depression

Acute Drug Treatment of TTH

refers to the treatment of individual attacks of

headache in patients with episodic and chronic TTH.
Episodic TTH

Intensity: mild to moderate.

self-manage using simple analgesics or NSAID, but frequency
of the headaches efficacy

Chronic TTH

~ stress, anxiety and depression

simple analgesics ineffective
the risk of medication overuse regular intake of simple
analgesics > 14 days a month or triptans or combination
analgesics > 9 days a month.
Other interventions non-drug treatments and prophylactic
pharmacotherapy.

Acute Drug Treatment of

TTH

International Headache Society painfree after 2 hour as the primary

efficacy measure.
Other efficacy measure pain
intensity difference, time to meaningful
relief comparison of results between
studies difficult.

Simple Analgesics and NSAIDs

aproxen 375 mg and 550 mg & metamizole 500 & 1000 mg risk of agranuloc

Simple Analgesics and NSAIDs

Optimal Dose
Few studies
Aspirin 1000 mg >> 500 mg >> 250
mg.
Ketoprofen 50 mg = 25 mg >> 12,5
mg
Paracetamol 1000 mg >> 500 mg

Simple Analgesics and NSAIDs

Comparison of Simple Analgesics

NSAID >> paracetamol (5 studies), 3
studies not different
Different NSAID (5 studies)
impossible to demonstrate superiority.

Simple Analgesics and NSAIDs

Adverse Event
NSAID gastrointestinal side effect>>
Paracetamol.
Large amount of paracetamol liver
injury

Combination Analgesics

Simple analgesics, NSAID + caffeine 64200 mg efficacy

Caffeine withdrawal headache &
chronic daily headache, induced MOH.
+ Codein / barbiturates no
comparative studies, risk of medication
overuse headache (MOH).
= Simple analgesics, NSAID + caffeine
second choice for acute treatment of TTH

Triptans, Muscle Relaxants & Opioids

Triptans not recommended in TTH,

effective for mild migraines, in
migraine.
Muscle Relaxant not effective in
episodic TTH.
Opioids not recommended in TTH,
risk of medication overuse headache.

Conclusions

Simple analgesics & NSAID mainstay in

acute therapy TTH
Paracetamol 1000 mg << effective than
NSAID, better gastric side effect.
Ibuprofen 400 mg recommended as drug
of choice amongst NSAID
Combination with caffeine efficacy ,
induce medication overuse headache
Triptans, muscle relaxant, opioid not
recommended.

Conclusions

Degree of efficacy has to be put in perspective.

Pain free 2 h after Paracetamol 1000 mg,
naproxen 375 mg, placebo 37%, 32%, 26%.

Recommendation:
Simple analgesics & NSAID first choice for
episodic TTH.
Combination with caffeine second choice
Avoid frequent & excessive use of analgesics
prevent Medication-overuse headache.

Prophylatic drug treatment

of TTH

Should be considered in patients with

very frequent episodic TTH
Co-morbid disorders should be taken
into account
The guideline for drug trials of TTH
recommended days with TTH, pain
reduction from baseline, headache
intnsity as primary efficay measure.

Amitriptyline

Lance and Curan : amitriptyline 10-25

mg three times daily to be effctive.
Amitriptyline 75mg/day was reported to
reduce headache duration in the last
week of a 6 week study.
The other study : amitriptyline 75mg
daily reduce AUC by 30% compared with
placebo.

Other Antidepresants

The tricyclic antidepresant clomipramine 75150mg daily, maprotiline 75mg daily and
mianserin 30-60mg daily have been reported
more effective than placebo
The noradrenegic and spesific serotonergic
anti depresants mirtazapine 30mg/day reduce
headache index by 34% more than placebo.
The serotonin and noradrenaline reuptake
inhibitor venlafaxine 150mg/day reduced
headache days from 15-12 per month.

Low dose mirtazapine 4.5 mg/day alone

or in combination with ibuprofen 400
mg/ not effective
The SSRIs citalopram and sertraline not
effective than placebo
SSRIs << tricyclic antidepressants for
the treatment of TTH.

Miscellaneous agents

There have been conflicting results for

the treatments with the muscle relaxants
tizanidine, whilst NMDA-antagonist
memantine was not effective.
A systematic review concluded that
botulinum toxin is likely to be ineffective
or harmful.
Topiramate and buspirone hav been
reported effective in open label studies

Conclusios

Non-pharmacologic treatment of TTH

Psycho-behavioral treatments

EMG biofeedback
Cognitive-behavioral therapy
Relaxation training

Non-invasive physical therapy

Acupuntur and nerve block

EMG biofeedback

The aim is to help the patients to

recognize and control muscle tension by
providing continuous feedback about
muscle activity.
Sessions include an adaptation phase,
baseline phase, training phase and
control phase
A meta-analysis concluded that
biofeedback has a medium to large
effect and to be enhanced by
combination with relaxation therapy.

Cognitive-behavioral therapy

The aim is to teach the patient to identify

thougts and benefits that generate stres and
aggravate headache
Results : CBT cobinations treatments with
tryciclic antidepressants >> placebo with no
significant diffrence.
The other study : no diffrence between CBT
and amitrptyline.
Cognitive-behavioral therapy may be
effective but there is no convincing evidence.

Relaxation training

The goal is to help the patient to

recognize and control tension s it arises
in the coure of daily activities
Relaxation training involves breathing
exercises and meditation.
A recent review concluded that there is
conflicting evidence that relaxation is
better than no treatment, waiting list or
placebo

Non-invasive physical therapy

It is include : the improvement of

posture, massage, spinal manupulation,
oromandibular treatment, exercise
progrmas, hot and cold packs, ultrasouns
and electrical stimulation.

Acupunture and nerve block

A review and meta-analysis conclude

that there is no evidence for efficacy
ofacupunture in TTH
No effect of greater occopital nerve
block in patients with chronic TTH.

Conclusions