eMedicine Specialties > Neurology > Headache and Pain

Muscle Contraction Tension Headache: Treatment & Medication

Author: Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University Hospital
Contributor Information and Disclosures

Updated: Sep 18, 2008

Treatment

Medical Care

  • 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.3
  • 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.46
    • 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.4
    • 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.47 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.3
    • 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.5

Consultations

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

Diet

Balanced meals

Activity

  • Regular exercise
  • Adequate sleep: The patient should maintain a regular sleep schedule.

Medication

The goals of pharmacotherapy for tension-type headaches (TTHs) are to relieve the headache, reduce morbidity, and prevent complications.

Analgesics

These agents can be used for abortive therapy.


Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall, Tempra)

First choice for treatment of headache, especially during pregnancy and breastfeeding.

Adult

650-1000 mg PO initially; dose may be repeated if necessary after 6h

Pediatric

<3 years: Not established
3-6 years: 10 mg/kg/dose PO; not to exceed 720 mg/d
6-12 years: 10 mg/kg/dose PO; not to exceed 2.6 g/d
>12 years: Administer as in adults

Probenecid may increase toxicity; may increase serum lithium levels; anticoagulants may prolong PT; may interfere with barbiturates, carbamazepine, ethyl alcohol, hydantoins, rifampin, sulfinpyrazone, and other drugs

Documented hypersensitivity; active peptic ulcer disease; renal or hepatic impairment; concomitant or recent use of anticoagulants; hemorrhagic conditions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Class A in pregnancy for short-term use; should not be used in higher and daily doses; long-term use enhances potential for adverse effects, particularly gastropathy or nephropathy

Nonsteroidal anti-inflammatory drugs (NSAIDs)

These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. They generally are used in mild to moderately severe headaches; however, they also may be effective for severe headaches.


Ibuprofen (Motrin, Advil)

First choice for treatment of headache, especially during pregnancy and breastfeeding.

Adult

400-800 mg PO q8h, not to exceed 3200 mg/d

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Probenecid may increase toxicity; may decrease effects of loop diuretics; may increase serum lithium levels; may prolong PT if given with anticoagulants

Documented hypersensitivity; active peptic ulcer disease; renal or hepatic impairment; concomitant or recent use of anticoagulants; hemorrhagic conditions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Long-term use enhances potential for adverse effects, particularly gastropathy or nephropathy


Naproxen sodium (Anaprox, Naprelan)

First choice for treatment of headache, especially during pregnancy and breastfeeding.

Adult

275 mg PO tid or 550 mg PO bid

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Probenecid may increase toxicity; may increase serum lithium levels; may prolong PT if given with anticoagulants

Documented hypersensitivity; active peptic ulcer disease; renal or hepatic impairment; concomitant or recent use of anticoagulants; hemorrhagic conditions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Long-term use enhances potential for adverse effects, particularly gastropathy or nephropathy

Antidepressants

These drugs increase the synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake by the presynaptic neuronal membrane.

Cymbalta can also be helpful for patients who have coexisting depression.


Nortriptyline (Pamelor, Aventyl HCl)

Has demonstrated effectiveness in treatment of pain.

Adult

25-100 mg PO hs; not to exceed 200 mg/d

Pediatric

Children: 0.1 mg/kg PO hs; increase as tolerated, not to exceed 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO; increase gradually to 100 mg/d

Cimetidine may increase levels; may increase PT in patients stabilized with warfarin

Documented hypersensitivity; narrow-angle glaucoma; MAOIs within 14 d

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Patients with cardiac conduction disturbances or history of hyperthyroidism or renal or hepatic impairment; avoid using in elderly patients


Amitriptyline (Elavil)

Has demonstrated effectiveness in treatment of pain.

Adult

25-100 mg PO hs; not to exceed 150 mg/d

Pediatric

Children: 0.1 mg/kg PO hs; increase as tolerated, not to exceed 0.5-2 mg/d qhs
Adolescents: 25-50 mg/d PO; increase gradually to 100 mg/d

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Documented hypersensitivity; narrow-angle glaucoma; MAOIs within 14 d

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances, history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly patients

Serotonin reuptake inhibitors

These agents specifically inhibit presynaptic reuptake of serotonin. May be considered as an alternative to TCAs.


Fluoxetine (Prozac)

Has potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult

10 mg PO on waking; can be increased q2wk; not to exceed 60 mg/d

Pediatric

Not established

Serious, potentially fatal reactions such as autonomic instability may occur with concurrent MAOIs; other antidepressants, phenothiazines, group IC anti-arrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and warfarin

Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic disease

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation that resolve within 1-2 wk also are noted


Sertraline (Zoloft)

Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult

Start at 50 mg/d PO; increase at weekly intervals after several weeks; not to exceed 200 mg/d

Pediatric

Not established

Serious, potentially fatal reactions such as autonomic instability may occur with concurrent MAOIs; other antidepressants, phenothiazines, group IC anti-arrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and warfarin

Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic disease

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation that resolve within 1-2 wk also are noted


Paroxetine (Paxil)

Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult

10 mg/d PO initially; titrate prn; not to exceed 50 mg/d

Pediatric

Not established

Serious, potentially fatal reactions such as autonomic instability may occur with concurrent MAOIs; other antidepressants, phenothiazines, group IC anti-arrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and warfarin

Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic disease

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation that resolve within 1-2 wk also noted

Electrolyte supplements

Electrolytes such as magnesium may help in the treatment of tension headache.


Magnesium chloride (Slow-Mag, Mag-Delay)

Magnesium metabolism may have a significant role in both the etiology and the treatment of muscle contraction tension headache.

Adult

1-2 tab PO qd/bid

Pediatric

Not established

Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may also worsen neuromuscular blockade seen with aminoglycosides, tubocurarine, vecuronium, and succinylcholine; magnesium may increase CNS effects and toxicity of CNS depressants, betamethasone, and ritodrine

Documented hypersensitivity; heart block; Addison disease; myocardial damage; severe hepatitis

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May alter cardiac conduction leading to heart block in digitalized patients; monitor respiratory rate, deep tendon reflex, and renal function when administered parenterally; caution when administering magnesium dose since may produce significant hypotension or asystole

More on Muscle Contraction Tension Headache

Overview: Muscle Contraction Tension Headache
Differential Diagnoses & Workup: Muscle Contraction Tension Headache
Treatment & Medication: Muscle Contraction Tension Headache
Follow-up: Muscle Contraction Tension Headache
References
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Further Reading

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Keywords

episodic tension-type headache, ETTH (ICD code-339.11), chronic tension-type headache, CTTH (ICD code-339.12), tension-type headache, TTH (ICD code-339.10), tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, psychogenic headache, muscle contraction tension headache, headache

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Contributor Information and Disclosures

Author

Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University Hospital
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center
James H Halsey, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neuroimaging, Medical Association of the State of Alabama, New York Academy of Sciences, Pan American Medical Association, Sigma Xi, Society for Neuroscience, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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