eMedicine Specialties > Emergency Medicine > Neurology
Headache, Tension: Treatment & Medication
Updated: Sep 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Most patients with severe headache should not receive opiate analgesics until the responsible physician can complete an appropriate history and neurologic examination.
Emergency Department Care
- Ascertain that the patient is not overusing medication, shows no evidence of drug dependency, and is not depressed.
- If headache cause includes dental pathology, sinus disease, trigger points, or CNS pathology, initiate care to treat the specific cause.
Medication
While the emergency physician must be able to identify patients with serious headache etiology, more than 90% of patients in the ED have migraine, tension, or mixed-type benign headache. Therefore, providing symptomatic relief should be a priority.
Various modalities are used in the treatment of tension headaches. These include hot or cold packs, ultrasound, electrical stimulation, improvement of posture, trigger point injections, occipital nerve blocks, stretching, and relaxation techniques.
Regular exercise, stretching, balanced meals, and adequate sleep may be part of a headache treatment program.4
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents may alleviate headache pain by inhibiting prostaglandin synthesis, reducing serotonin release, and blocking platelet aggregation. Although the effects of NSAIDs in the treatment of headache pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include naproxen, ketoprofen, and ketorolac.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderately severe headache, if no contraindications.
Adult
200-800 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate upward; not to exceed 2.4 g/d
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; third trimester of pregnancy
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
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Naprelan)
For relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing enzyme cyclooxygenase activity, thus inhibiting prostaglandin synthesis.
Adult
500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
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
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderately severe pain and inflammation. Small dosages initially indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; third trimester of pregnancy
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
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Ketorolac (Toradol)
Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors. PO form offers no advantage over other less expensive PO NSAIDs.
Adult
30 mg IV single dose; most common route used in ED
>65 years, renal impairment, or <50 kg: 15 mg IV single dose
30-60 mg IM initially, followed by 15-30 mg q6h prn
Not to exceed 5 d of treatment; consider only 1-2 days of treatment in elderly because of increased risk of GI bleed
Pediatric
Not established; suggested dose 0.4-1 mg/kg IM once
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; not for CNS administration
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
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs
Indomethacin (Indocin, Indochron E-R)
Absorbed rapidly; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Useful in diagnosis as it helps other headache syndromes (eg, chronic paroxysmal hemicrania).
Adult
Immediate release: 25-50 mg PO bid/tid
Sustained release: 75 mg PO bid; not to exceed 200 mg/d
Pediatric
1-2 mg/kg/d PO divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; GI bleeding or renal insufficiency
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
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if leukopenia, granulocytopenia, or thrombocytopenia persists)
Acetylsalicylic acids
These agents alleviate headache, possibly by inhibiting prostaglandin synthesis.
Aspirin (Anacin, Ascriptin, Bayer Aspirin, Bufferin)
Treats mild to moderately severe pain. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.
Adult
325-650 mg PO q4-6h; not to exceed 4 g/d
Pediatric
10-15 mg/kg/dose PO q4-6h; not to exceed 60-80 mg/kg/d
Antacids and urinary alkalinizers may increase effects; corticosteroids decrease serum levels; anticoagulants may cause additive hypoprothrombinemic effects and increased bleeding time; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, do not use in children (<16 y) with flu
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
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants
Barbiturates
These agents are used in combination with aspirin and acetaminophen for pain relief and to induce sleep. Caffeine is used to increase its GI absorption. However, butalbital is associated with rebound headaches. Increasing use of these combination preparations may fail to provide pain relief and worsen headache symptoms.
Butalbital, aspirin, caffeine (Fiorinal)
Drug combination used to relieve tension headaches. Barbiturate component has generalized depressant effect on CNS.
Adult
1-2 tab/cap PO q4h; not to exceed 6 tab/cap in 24 h
Pediatric
Not established
Effects decreased by phenothiazines, quinidine, tricyclic antidepressants, theophylline, haloperidol, chloramphenicol, ethosuximide, corticosteroids, warfarin, doxycycline, and beta-blockers; effects increased by CNS depressants, methylphenidate, valproic acid, propoxyphene, and benzodiazepines
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Risk of rebound headache and overuse; caution in patients with history of substance abuse
Acetaminophen, butalbital, and caffeine (Fioricet)
Drug combination used to relieve tension headaches. Barbiturate component has generalized depressant effect on CNS.
Adult
1-2 tab PO at onset, repeat q4h; not to exceed 6 doses in 24 h
Pediatric
Not established
Effects decreased by phenothiazines, quinidine, tricyclic antidepressants, theophylline, haloperidol, chloramphenicol, ethosuximide, corticosteroids, warfarin, doxycycline, and beta-blockers; effects increased by CNS depressants, methylphenidate, valproic acid, propoxyphene, and benzodiazepines
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Risk of rebound headache and overuse; caution in patients with history of substance abuse
Analgesics
Patients with infrequent headaches can be treated with simple analgesics initially.
Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs or upper GI disease or taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics who exceed 4000 mg/d; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding safe daily totals
Acetaminophen with codeine (Tylenol #3)
Indicated for treatment of mild to moderately severe headache.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d; not to exceed 4 g acetaminophen in 24 h
Pediatric
0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen in 24 h
CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
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
Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Acetaminophen and oxycodone (Percocet)
Indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab/cap PO q4-6h prn headache
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
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
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Analgesic/antiemetic or sedatives
These agents are useful in aborting headache and treating emesis that results from acute pain.
Promethazine (Phenergan)
Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.
Adult
12.5 mg PO/PR tid and 25 mg hs
25 mg IV/IM, repeat in 2 h prn; switch to PO as soon as possible
Pediatric
<2 years: Contraindicated
>2 years: 0.25-1 mg/kg PO/IV/IM/PR q4-6h prn
Other CNS depressants or anticonvulsants may cause additive effects; with epinephrine, may cause hypotension
Documented hypersensitivity; children younger than 2 y (incidences of death due to respiratory depression)
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
Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma
Prochlorperazine (Compazine)
May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine-receptors, through anticholinergic effects, and depressing reticular activating system. In addition to antiemetic effects, has advantage of augmenting hypoxic ventilatory response, acting as respiratory stimulant at high altitude.
Metoclopramide (Reglan) can be used as an alternative to prochlorperazine. Studies show prochlorperazine is better.
Adult
5-10 mg PO/IM tid/qid; not to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid
Pediatric
2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d
IV dosing not recommended for children
0.1-0.15 mg/kg/dose IM; change to PO as soon as possible
Other CNS depressants or anticonvulsants may cause additive effects; with epinephrine, may cause hypotension
Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac 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
Drug-induced Parkinson syndrome or pseudoparkinsonism occurs quite frequently; akathisia is most common extrapyramidal reaction in elderly persons; lowers seizure threshold; caution in patients with history of seizures
Metoclopramide (Reglan)
Dopamine antagonist that stimulates acetylcholine release in the myenteric plexus. Acts centrally on chemoreceptor triggers in the floor of the fourth ventricle, which provides important antiemetic activity.
Adult
10 mg IV
Pediatric
Not established
Anticholinergic agents may antagonize effects of metoclopramide; opiate analgesics may increase metoclopramide toxicity in CNS
Documented hypersensitivity; pheochromocytoma or GI hemorrhage, obstruction or perforation; history of seizure disorders
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in history of mental illness and Parkinson disease
Ergot alkaloids and derivatives
These are direct vasoconstrictors of smooth muscle in cranial blood vessels. Their activity depends on the CNS vascular tone at the time of administration.
Ergotamine tartrate (Cafergot, Cafatine, Cafetrate)
Alpha-adrenergic and serotonin antagonist. Causes constriction of peripheral and cranial blood vessels.
Adult
2 tabs PO at onset of attach, 1 tab q30min prn; not to exceed 6 tab per attack or 10 tab/wk
1 tab SL at first sign of attach and 1 tab q30min; not to exceed 3 tabs/d or 5 tabs/wk
1 suppository PR at first sign of attack with second dose after 1h prn; not to exceed 2 suppositories/attack or 5 suppositories/wk
Pediatric
Not established
Increases effects of heparin and toxicity of nitroglycerin, propranolol, erythromycin, and clarithromycin
Documented hypersensitivity hepatic or renal disease; peptic ulcer disease; sepsis; peripheral vascular disease
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Avoid using prolonged regimens due to danger of causing gangrene as well as dependency
Dihydroergotamine (D.H.E. 45, Migranal Nasal Spray)
Alpha-adrenergic blocking agent with direct stimulating effect on smooth muscle of peripheral and cranial blood vessels; depresses central vasomotor centers. Mechanism of action is similar to ergotamine; nonselective 5HT1 agonist with wide spectrum of receptor affinities outside 5HT1 system; also binds to dopamine. Thus, has alpha-adrenergic antagonist and serotonin antagonist effect. Indicated to abort or prevent vascular headache when rapid control needed or when other routes of administration not feasible.
Available in IV or intranasal preparations, tends to cause less arterial vasoconstriction than ergotamine tartrate.
Adult
1 mg IM at first sign of headache, repeat q1 h; not to exceed 3 mg total dose
2 mg IV maximum dose for faster effect; most commonly given at 0.5-1 mg IV with antiemetic; not to exceed 6 mg/wk
Intranasal: 1 spray into each nostril and repeat prn within 15 min; not to exceed 6 sprays/d or 8 sprays/wk
Pediatric
Not established
Increases effects of heparin and toxicity of nitroglycerin, propranolol, erythromycin, and clarithromycin
Documented hypersensitivity; has used sumatriptan or zolmitriptan within previous 24 h; within 2 wk of discontinuing MAO inhibitors
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in angina, hypertension, impaired renal or hepatic function, or peripheral vascular disease
More on Headache, Tension |
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| Differential Diagnoses & Workup: Headache, Tension |
 Treatment & Medication: Headache, Tension |
| Follow-up: Headache, Tension |
| References |
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References
Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. Jan 2008;7(1):70-83. [Medline].
Silver N. Headache (chronic tension-type). Am Fam Physician. Jul 1 2007;76(1):114-6. [Medline]. [Full Text].
[Guideline] Martin V, Elkind A. Diagnosis and classification of primary headache disorders. In: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation; 2004. [Full Text].
[Guideline] Ruoff G, Urban G. Treatment of primary headache: episodic tension-type headache. In: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation; 2004. [Full Text].
Arena JG, Bruno GM, Hannah SL, et al. A comparison of frontal electromyographic biofeedback training, trapezius electromyographic biofeedback training, and progressive muscle relaxation therapy in the treatment of tension headache. Headache. Jul-Aug 1995;35(7):411-9. [Medline].
Bogaards MC, ter Kuile MM. Treatment of recurrent tension headache: a meta-analytic review. ALYSIS. Sep 1994;10(3):174-90. [Medline].
Carlsson J, Augustinsson LE, Blomstrand C, et al. Health status in patients with tension headache treated with acupuncture or physiotherapy. Headache. Sep 1990;30(9):593-9. [Medline].
De Benedittis G, Lorenzetti A, Sina C, Bernasconi V. Magnetic resonance imaging in migraine and tension-type headache. Headache. May 1995;35(5):264-8. [Medline].
[Best Evidence] Detsky ME, McDonald DR, Baerlocher MO, et al. Does this patient with headache have a migraine or need neuroimaging?. JAMA. Sep 13 2006;296(10):1274-83. [Medline].
Ficek SK, Wittrock DA. Subjective stress and coping in recurrent tension-type headache. Headache. Sep 1995;35(8):455-60. [Medline].
Goldstein JN, Camargo CA Jr, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. Jun 2006;26(6):684-90. [Medline].
Iversen HK, Langemark M, Andersson PG, et al. Clinical characteristics of migraine and episodic tension-type headache in relation to old and new diagnostic criteria. Headache. Jul 1990;30(8):514-9. [Medline].
Landy S. Migraine throughout the life cycle: treatment through the ages. Neurology. Mar 9 2004;62(5 Suppl 2):S2-8. [Medline].
Silberstein SD. Tension-type headaches. Headache. Sep 1994;34(8):S2-7. [Medline].
Silberstein SD, Olesen J, Bousser MG, et al. The International Classification of Headache Disorders, 2nd Edition (ICHD-II)--revision of criteria for 8.2 Medication-overuse headache. Cephalalgia. Jun 2005;25(6):460-5. [Medline].
Tfelt-Hansen P. Acute pharmacotherapy of migraine, tension-type headache, and cluster headache. J Headache Pain. Apr 2007;8(2):127-34. [Medline].
Further Reading
Keywords
tension headache, tension-type headache, chronic tension headache, episodic tension headache, chronic recurring head pain, cluster headache, migraine headache, muscle contraction headache
