Headache (chronic tension-type)

Overview

General background | Focus of the review | Comments on evidence | Search and appraisal summary | Substantive changes at this update | Abstract | Cite as

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General background

Chronic tension-type headache (CTTH) is a disorder that evolves from episodic tension-type headache, with daily, or very frequent, episodes of headache lasting hours or they may be continuous. The 2004 International Headache Society (IHS) criteria for CTTH are: headaches on 15 or more days a month (180 days/year) for at least 3 months; pain that is bilateral, pressing, or tightening in quality and non-pulsating, of mild or moderate intensity, which does not worsen with routine physical activity (such as walking or climbing stairs); presence of no more than one additional clinical feature (mild nausea, photophobia, or phonophobia); and without moderate/severe nausea or vomiting.

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Focus of the review

Tension-type headache is a common disorder, which can cause anxiety and interfere with daily living. If treated incorrectly, it can lead to worsening of symptoms, such as comorbid analgesia overuse headache. Therefore, effective management, which is discussed in this overview, is important to prevent further complications and restore functionality. For non-drug treatments, we focused specifically on acupuncture and CBT as areas where there might be new evidence since the previous update. The authors determined that there was no change in the evidence-base for other non-invasive physical or manual therapies since the previous version, which also included Indian head massage, relaxation or electromyographic biofeedback, and spinal manipulation (chiropractic and osteopathic treatment).

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Comments on evidence

There is very limited evidence on prophylactic treatment of CTTH, including for amitriptyline and mirtazapine, which are common treatments for this condition. Most studies are small, short-term in duration, and use different outcome measures. The interpretation of clinical trials in the area of CTTH is further complicated by varying diagnostic expertise, difficulties in obtaining reliable retrospective patient histories, and patient selection.

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Search and appraisal summary

The update literature search for this overview was carried out from the date of the last search, March 2007, to December 2013. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 125 studies. After deduplication, 77 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 56 studies and the further review of 21 full publications. Of the 21 full articles evaluated, three systematic reviews and one RCT were included at this update.

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Additional information

Overall, based on current evidence, the best treatment for CTTH is amitriptyline with lifestyle advice, which should include avoidance of analgesia and caffeine. There is limited evidence to suggest that non-pharmacological treatments, such as relaxation techniques and acupuncture, are of any benefit.

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Substantive changes at this update

Amitriptyline One systematic review added.[10] Categorisation unchanged (beneficial).

Anticonvulsant drugs One systematic review[10] and one RCT[18] added. Categorisation unchanged (unknown effectiveness).

Benzodiazepines One systematic review added.[10] Categorisation unchanged (likely to be ineffective or harmful).

Botulinum toxin One systematic review added.[22] Categorisation unchanged (likely to be ineffective or harmful).

Non-steroidal anti-inflammatory drugs (NSAIDs) Condition re-structured. One systematic review added.[10] Categorisation unchanged (likely to be ineffective or harmful).

Noradrenergic and specific serotonergic antidepressants One systematic review added.[10] Categorisation unchanged (likely to be beneficial).

Opioid analgesics Condition restructured. No new evidence. Categorisation unchanged (unknown effectiveness).

Paracetamol Condition restructured. No new evidence. Categorisation unchanged (unknown effectiveness).

Serotonin re-uptake inhibitors One systematic review added.[10] Categorisation unchanged (unknown effectiveness).

Tricyclic antidepressants (other than amitriptyline) One systematic review added.[10] Categorisation unchanged (unknown effectiveness).

Acupuncture One systematic review added.[33] Categorisation unchanged (unknown effectiveness).

Cognitive behavioural therapy One systematic review added.[10] Categorisation unchanged (unknown effectiveness).

Abstract

INTRODUCTION: Chronic tension-type headache (CTTH) is a disorder that evolves from episodic tension-type headache, with daily, or very frequent, episodes of headache lasting hours or they may be continuous. It affects up to 4% of the general population, and is more prevalent in women (up to 65% of cases). METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical questions: What are the effects of drug treatments for CTTH? What are the effects of non-drug treatments for CTTH? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2013 (BMJ Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 125 studies. After deduplication, 77 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 56 studies and the further review of 21 full publications. Of the 21 full articles evaluated, three systematic reviews and one RCT were included at this update. We performed a GRADE evaluation for 15 PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for 12 interventions based on information about the effectiveness and safety of non-drug treatments acupuncture and cognitive behavioural therapy (CBT), as well as the drug treatments amitriptyline, anticonvulsant drugs (sodium valproate, topiramate, or gabapentin), benzodiazepines, botulinum toxin, noradrenergic and specific serotonergic antidepressants (mirtazapine), NSAIDs (e.g. ibuprofen); opioid analgesics (e.g. codeine), paracetamol, serotonin re-uptake inhibitor antidepressants (SSRIs, SNRIs), and tricyclic antidepressants (other than amitriptyline).

Cite as

Ghadiri-Sani M, Silver N. Headache (chronic tension-type). Systematic review 1205. BMJ Clinical Evidence. . 2016 February. Accessed [date].

Latest citations

Lower Sodium Intake and Risk of Headaches: Results From the Trial of Nonpharmacologic Interventions in the Elderly. ( 02 June 2016 )