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Objective: Tension-type headache is the most common type of primary headache and results in a huge socioeconomic burden. This network meta-analysis (NMA) aimed to compare the efficacy and safety of simple analgesics for the treatment of episodic tension-type headache (ETTH) in adults., Methods: We searched the Cochrane Library, PubMed, Web of Science, Embase, Chinese BioMedical Literature database and International Clinical Trials Registry Platform databases for eligible randomized clinical trials reporting the efficacy and/or safety of simple analgesics. A Bayesian NMA was performed to compare relative efficacy and safety. The surface under the cumulative ranking curve (SUCRA) was calculated to rank interventions. PROSPERO registration number: CRD42018090554., Results: We highlighted six studies including 3507 patients. For the 2 h pain-free rate, the SUCRA ranking was ibuprofen > diclofenac-K > ketoprofen > acetaminophen > naproxen > placebo. All drugs except naproxen reported a higher 2 h pain-free rate than placebo, with a risk ratio (RR) of 2.86 (95% credible interval, CrI: 1.62-5.42) for ibuprofen and 2.61 (1.53-4.88) for diclofenac-K. For adverse events rate, the SUCRA ranking was: metamizol > diclofenac-K > ibuprofen > lumiracoxib > placebo > aspirin > acetaminophen > naproxen > ketoprofen. The adverse event rates of all analgesics were no higher than those of placebo, except for ketoprofen. Moreover, all drugs were superior to placebo in the global assessment of efficacy. In particular, the RR of lumiracoxib was 2.47 (1.57-4.57). Global heterogeneity I 2 between the studies was low., Conclusions: Simple analgesics are considered more effective and safe as a placebo for ETTH in adults. Our results suggest that ibuprofen and diclofenac-K may be the two best treatment options for patients with ETTH from a comprehensive point of view (both high-quality evidence).

Background-Purpose : Low serum vitamin D (VD) has been already associated with a series of highly prevalent pain-related conditions, including fibromyalgia, migraine and chronic widespread pain. Considering the potential interplay between VD and pain signalling pathways, the association of VD with tension-type headache (TTH) was reviewed., Methods : A multifaceted narrative approach assessing the relationship of serum VD with TTH and TTH parameters, as well as the efficacy of VD supplementation for the prevention of TTH, was fostered. MEDLINE, CENTRAL and EMBASE were comprehensively searched for this purpose, while Google Scholar was also explored according to a structured approach. ClinicalTrials.gov and European Union Clinical Trials Register were explored for ongoing prevention trials., Results : Although available evidence was suggestive of an association between VD and TTH, mainly of the chronic type, the causal nature of the association remains to be determined. Considering the lack of longitudinal evidence, this relationship could arguably reflect behavioural patterns of headache sufferers. On the other hand, evidence principally originated from tertiary clinical settings (severe comorbidity burden) and researchers tend to report a concomitant association of both entities with generalized musculoskeletal compromise. In this context, the association between TTH and VD may represent nothing more than a secondary by-product of the simultaneous relationship of other comorbid diseases-conditions with both TTH and low serum VD. Regarding its efficacious properties, only one ongoing trial specifically designed to explore the efficacy of VD in chronic TTH in adults was retrieved., Conclusions : There is no evidenced based indication for VD supplementation in TTH.

Introduction: Tension-type headache (TTH) is a highly prevalent disorder with enormous costs for the individual and the society., Areas Covered: Nonpharmacological and pharmacological treatments are reviewed. Electromyographic (EMG) biofeedback has a documented effect in TTH, while cognitive-behavioral therapy and relaxation training are most likely to be effective. Physical therapy and acupuncture may be valuable options for patients with frequent TTH. Simple analgesics and nonsteroidal anti-inflammatory drugs are recommended for treatment of episodic TTH. Combination analgesics containing caffeine are drugs of second choice. Triptans, muscle relaxants and opioids should not be used. It is crucial to avoid frequent and excessive use of analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is the drug of first choice for the prophylactic treatment of chronic TTH. Mirtazapine and venlafaxine are second-choice drugs., Expert Opinion: There is an urgent need for more research in nonpharmacological as well as pharmacological treatment possibilities of TTH. Future studies should examine the relative efficacy of the various treatment modalities and clarify how treatment programs can be optimized and combined to best suit the individual patient. Frequent TTH may be difficult to treat, but an acceptable result can usually be obtained by a combination of nonpharmacological and pharmacological treatments., (© 2011 Informa UK, Ltd)

Background: Tension-type headache (TTH) is a highly prevalent condition, yet it requires less medical attention than migraine, mostly because the pain and disability burden are milder., Methods: Proper diagnosis is a paramount step in therapeutic adequacy. It comes from careful history, thorough physical examination and use of ancillary investigations when appropriate to rule out underlying causes of secondary headaches that could mimic TTH, as there is no biological marker for the condition., Results: Research in TTH is insufficient. Thus, pathophysiologic understanding and therapeutic innovations are lagging. In that context, the clinicians should not be surprised by the paucity of pharmacotherapeutic options., Conclusion: In this article, we review the existing literature on medications and make practical recommendations based on the evidence of their efficacy. We review both abortive and prophylactic medications (such as tricyclic antidepressants and non-steroidal anti-inflammatory drugs, respectively). Both are used for chronic TTH and abortive medications only for infrequent episodic TTH (ETTH). As far as frequent ETTH, abortive medications are used and prophylactic medications often but not systematically. We comment and advise on general therapeutic principles of TTH management.

Objective: This study was conducted to evaluate the prevalence of migraine and its responsiveness to migraine-specific therapy in patients with self-reported tension-type headache., Methods: Patients were adults (n = 423) consulting one of 54 North American study sites including primary care clinics, neurology clinics, and headache clinics. The study comprised an initial diagnosis phase to determine the headache diagnosis of patients entering the study with self-reported tension/stress headache, including that previously diagnosed by a health care provider. Patients reporting tension/stress headache were evaluated and diagnosed as having migraine with or without aura, probable migraine, tension-type headache, or another headache type. Exclusion criteria included prior diagnosis of migraine or probable migraine and the presence of headache for at least 15 days monthly during either of the 2 months before screening. The initial phase was followed by a randomized, double-blind treatment phase to evaluate the efficacy of sumatriptan 100 mg tablets for the treatment of a single migraine attack in those meeting International Headache Society (IHS) criteria for migraine during the diagnosis phase., Results: Of 423 patients reporting tension/stress headache at study entry, 84% (n = 357) were diagnosed at the clinic visit as fulfilling IHS criteria for migraine without aura or migraine with aura, and 65% (n = 276) were diagnosed with migraine only (i.e., with no other concurrent headache diagnosis). Three hundred thirty-two (332) patients entered the double-blind treatment phase. Headache relief rates 2h post-dose, the primary efficacy endpoint, did not significantly differ between sumatriptan and placebo (p = 0.099). However, improvements were significantly (p < 0.05) greater with sumatriptan than placebo on several other headache-related efficacy measures., Conclusions: Migraine headache may go unrecognized in patients with self-reported tension headache. Among patients having self-reported tension headache and diagnosed with migraine during the study, response to acute treatment with sumatriptan was inconclusive. Improvement with sumatriptan versus placebo was observed for some measures and not for others. The results should be interpreted in the context of study limitations including use of patient self-reports to assess headache diagnosis and possible lack of representativeness arising from the predominantly white sample.

Botulinum toxin has been increasingly applied to the treatment of a wide variety of neurological disorders. Its application to headache disorders, and specifically those classified as migraine or tension-type, followed the observation of its effectiveness in decreasing pain. Studies that have primarily used botulinum toxin type A, but with varying dose regimens and sites of administration, have since observed its beneficial effects and in those subjects, headaches have lessened in their frequency or severity. However, questions that have primarily concerned dose and sites of administration have since arisen and clear guidelines for botulinum toxin use in headache disorders have yet to be developed.

The first International Headache Society classification defined tension-type headaches (TTHs) by itemising those characteristics of migraines TTHs did not possess [1]. As a result, TTHs, both episodic and chronic, remain the most nonspecific of all the commonly observed primary headaches. Until recently, there has been little impetus on the part of the pharmaceutical industry to investigate TTHs; many of the potentially useful drugs are now generic and unprofitable. In addition, few investigators have pursued the study of TTHs in lieu of its more glamorous neighbour, migraine. As a result, there are few well-designed studies on the pharmacotherapy of TTHs. The few studies that exist support the use of age-old standard drug classes, the tricyclic antidepressants and the NSAIDs. New research is now emerging that points to the potential utility of botulinum toxin type A, NMDA-receptor antagonists including Mg(2+) and nitric oxide synthase inhibitors. More scientifically rigorous clinical studies are needed.

Chronic tension-type headache may be caused by prolonged painful input from pericranial myofacial tissues, for example tender points, resulting in central sensitisation (increased excitability of neurons in the central nervous system). Animal studies have shown that sensitisation of pain pathways may be caused by or associated with the activation of neuronal nitric oxide synthase and the generation of nitric oxide. Furthermore, it has been shown that nitric oxide synthase inhibitors reduce central sensitisation in animal models of persistent pain. On the basis of this information, the analgesic effect of the nitric oxide synthase inhibitor L-N(G) methyl arginine hydrochloride was investigated. This drug significantly reduced headache and myofacial factors in patients with chronic tension-type headache. These studies show that nitric oxide plays a crucial role in the pathophysiology of tension-type headache. The analgesic effect of nitric oxide synthase inhibition in patients with chronic tension-type headache is probably due to a reduction in central sensitisation at the level of the spinal dorsal horn, trigeminal nucleus or both. Furthermore, inhibition of nitric oxide synthase may become a novel principle in the future treatment of chronic headache.

The sometimes debilitating pain of migraine and other types of primary headache can be difficult to control with acute drug therapy alone. Often patients need both acute and prophylactic treatment to keep headache pain at bay. Dr Ward discusses the current treatment options for migraine with and without aura, tension-type headache, and cluster headache. He also provides practical pointers for use of the various formulations of specific drugs, including the newer "triptan" medications.

A general guideline to successful treatment of headache focuses on a diagnosis that satisfies both physician and patient. Thorough history taking, patient and family education, aggressive approaches, and careful follow-up help patients reach therapeutic goals. Successful long-term therapy for headache enables patients to gain control over their symptoms with a combination of carefully selected medications and nonpharmacologic approaches.