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Muscle Contraction Tension Headache Treatment & Management

  • Author: Manish K Singh, MD; Chief Editor: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS  more...
Updated: Dec 28, 2015

Medical Care

See the list below:

  • Management of TTH consists of pharmacotherapy, psychophysiologic therapy, and physical therapy.
    • Treatment of headache must be tailored for individual patients.
    • Recognition of comorbid illness is essential. Migraine may be associated with TTH, and management overlaps. Other associated conditions may include depression, anxiety, and emotional or adjustment disorders.
    • Management of CTTH with a combination of tricyclic antidepressant medication and stress management therapy may result in a better outcome than monotherapy.[4]
  • Pharmacotherapy consists of abortive therapy (to stop or reduce severity of the individual attack) and long-term preventive therapy. Preventive drugs are the main therapy for CTTH, but they seldom are needed for ETTH.
    • These headaches (especially ETTH) generally respond to simple over-the-counter (OTC) analgesics such as paracetamol (ie, acetaminophen), ibuprofen, aspirin, or naproxen.
    • If treatment is unsatisfactory, the addition of caffeine or use of prescription drugs is recommended. If possible, avoid use of barbiturates or opiate agonists.
    • Also discourage overuse of all symptomatic analgesics because of the risk of dependence, abuse, and development of chronic daily headache.
    • Fiorinal with codeine is generally significantly more effective than placebo or Fiorinal alone. The combination is also significantly better than codeine alone in relieving pain and maintaining ability to perform daily activities. However, Fiorinal with codeine is not first-line therapy and carries a significant risk of abuse.
  • Consider preventive medications if the headaches are frequent (>2 attacks per wk), of long duration (>3-4 h), or severe enough to cause significant disability or overuse of abortive medication.
    • Amitriptyline (Elavil) and nortriptyline (Pamelor) are the most frequently used tricyclic antidepressants.
    • The selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also are used commonly by many physicians. In a double-blind placebo-controlled trial conducted by Saper et al of fluoxetine in patients with chronic daily headache and migraine, it was reported to be helpful.[5]
    • Other antidepressants such as doxepin, desipramine, protriptyline, and buspirone also can be used. According to Cohen, protriptyline may be comparable in effectiveness to amitriptyline in CTTH without producing drowsiness and weight gain.
    • As reported by Bendtsen et al, in one double-blind trial that compared citalopram to amitriptyline and a placebo, patients on citalopram demonstrated lower headache scores than those on placebo, but amitriptyline was significantly more effective.[6]
    • Tizanidine may improve inhibitory function in the central nervous system and can provide pain relief. One recent study by Saper et al provides support for the efficacy of tizanidine in the prophylaxis of chronic daily headache.[7] Currently the use of tizanidine remains investigational in the treatment of this disorder.
  • Physical therapy techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations.
    • Heat, massage, and stretching can be used to alleviate excess muscle contraction and pain.
    • Cranial electrotherapy stimulation is different from TENS, is safe, and may be effective in alleviating the pain intensity of TTH. It may be considered as an alternative to long-term analgesic use.
  • Psychophysiologic therapy includes reassurance, counseling, relaxation therapy, stress management programs, and biofeedback techniques. With these modalities of treatment, both frequency and severity of chronic headache may be reduced.
    • In a few studies, such as that by Holroyd et al, benefits from cognitive-behavioral therapy and biofeedback therapy have been reported.[4]
    • Biofeedback may be helpful in some patients when combined with medications.
    • One prospective study of TTH in an elderly population suggested that relaxation therapy may be an effective intervention.
  • The following various minimally invasive techniques may provide pain relief:
    • Trigger point injections
    • Greater or lesser occipital nerve blocks
    • Auriculotemporal nerve block
    • Supraorbital nerve block
    • Botulinum toxin injection in the pericranial muscle
    • Other alternative treatments: In one study, Biondi and Portuesi suggested that acupuncture results are difficult to assess and that acupuncture should be reserved for selected patients.[8]


Psychiatry consultations: CTTH can mask or be associated with comorbid conditions such as depression, anxiety, or other serious emotional disorders.



Balanced meals



These nonpharmacologic methods have shown improvement of central nervous-system related symptoms:

  • Regular exercise
  • Adequate sleep: The patient should maintain a regular sleep schedule.
  • Relaxation training[9]
Contributor Information and Disclosures

Manish K Singh, MD Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Headache Society, American Association of Physicians of Indian Origin, American Medical Association, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS is a member of the following medical societies: American College of International Physicians, American Heart Association, American Stroke Association, American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Joseph Carcione, Jr, DO, MBA Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans

Joseph Carcione, Jr, DO, MBA is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

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