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Headaches are one of the most frequent causes of consultations in general practice. Of more than 350 known headache tendencies, tension-type headache and migraine are particularly common in general practice. Medication overuse headache (MOH) is also common but rarely diagnosed. The medical consultation with a targeted anamnesis is the cornerstone of the diagnosis and correct classification. A detailed neurological examination completes the basic diagnosis. Additional laboratory and instrumental diagnostics follow in cases of atypical headache or clinical suspicion of secondary headache. This article focuses on the diagnosis and treatment of Tension-type Headache, migraine and Medication Overuse Headache., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Tension-type headache is the most frequent form of headache. The local topical treatment with peppermint oil (oleum menthae piperitae) has proven to be significantly more effective than placebo in controlled studies. Peppermint oil targets headache pathophysiology in multiple ways. The efficacy is comparable to that of acetylsalicylic acid or paracetamol. Solutions of 10 % peppermint oil in ethanol are licensed for the treatment of tension-type headache in adults and children above 6 years. It is included in treatment recommendations and guidelines by the respective professional societies and is regarded as a standard treatment for the acute therapy of tension-type headaches.

The criteria of the International Headache Society (IHS) define four different primary headache syndromes with daily chronic headaches: chronic migraine, episodic and chronic tension type headache, hemicrania continua, new daily persisting headache. A further important differential diagnosis is medication overuse headache (previously known as analgesia headache). The German, Austrian, and Swiss headache societies now present the first joint guidelines for therapy of these headache syndromes. The current literature was reviewed and a summary is presented. The therapy recommendations do not only include the scientific evidence but also the practical relevance.

Headache associated with the chronic use of medications has become a significant problem in the management of headache. Typically, patients overusing analgesics suffer from tension headache, whereas those over-using triptans may experience daily migraine-type headaches or an increase in the frequency of migraine attacks. The treatment of choice in such cases is withdrawal of the medication followed as early as possible by medicinal prophylaxis of the primary headache.

Medication overuse headache (MOH) occurs in about 1% of the general population. A marked increase of its prevalence has to be expected in the future, since more and more adolescents are subject to medication overuse. The revised International Classification of Headache Disorders contains detailed diagnostic criteria for headache due to particular groups of substances. They help recognizing MOH due to ergots, triptans, analgesics and opioids, and to distinguish them from each other MOH almost exclusively occurs in patients with a long history of migraine or chronic tension type headache, which suggests some genetic disposition. The treatment of choice of MOH is withdrawal of the causing drug. Long-term treatment for headache is ineffective during medication overuse. Relapse rate is variable depending on the substance overused, and may be considerable. Therefore, prophylaxis in patients with migraine or chronic tension type headache who do not yet suffer from MOH, is essential.

Botulinum toxin has meanwhile been approved for a number of indications. It is also gaining acceptance in other indications with a major focus on pain. The most common type of headache is tension-type headache (TTH) the pathogenesis of which has not yet been unfolded. As it looks there are vascular, myofascial and supraspinal factors intertwined. It is felt that headache is triggered by myofascial stimuli. The application of botulinum toxin is an intelligent alternative since the favorable effect of pharmacologic and other therapies is limited. Application of BTX should be considered when the pericranial muscles are involved. One of the effects produced lies in the reduction of muscular stress, muscular ischemia and muscle tone. We still don't know whether additional mechanisms such as retrograde uptake and direct antiinflammatory potential are involved. Current data permit the conclusion that headaches are decreased in their frequency and distinctiveness. Significant untoward effects are not to be expected. Neither the ideal dose nor the optimum selection of injection sites have been established as yet, an individual injection scheme is apparently most promising. Injection of the trigger points seems to make sense.

Background: Flupirtine with its specific mode of action as Selective Neuronal Potassium Channel Opener (SNEPCO) shows analgesic, muscle tone normalizing properties and iprotects from chronification. By means of an open multicentre drug monitoring study new data should be accumulated in terms of efficacy and patient's tolerance of flupirtine upon treatment of acute and chronic pain associated with muscle tenseness., Results: Regarding acute and chronic pain, significant reduction of pain intensity, pain upon pressure and muscular tenseness could be proved. Simultaneously, decrease of sleep disorders due to pain and strong reduction of restrictions in daily life caused by pain improved distinctly patient's quality of life. Efficacy and tolerance has mainly been rated as good and very good respectively by physicians and patients, the number of undesired drug reactions being under 1%., Conclusion: Data of this study confirm the analgesic and muscle tone normalizing efficacy of flupirtine upon treatment of acute and chronic pain associated with muscle tenseness and show, that flupirtine has to be considered as a substance of first choice for the treatment of these disorders.

According to the principles of evidence-based medicine, the controlled studies on the treatment of idiopathic headache in childhood have been analysed and compiled to treatment recommendations. For the acute treatment of migraine attacks or tension-type headache, ibuprofen (10 mg per kg body weight) or acetaminophen (15 mg per kg body weight) are recommended with highest evidence, intranasal sumatriptan (10 to 20 mg) can be given as second choice. For the prophylaxis of migraine, betablockers (propranolol and metoprolol), flunarizine, and valproic acid are recommended. Flunarizine is the drug of first choice in the treatment of migraine-related disorders. No controlled studies are available for the treatment of further headache types. First line methods for the non-drug treatment of headache in childhood are relaxation therapies, biofeedback, and specific training schedules.