Treatment of tension type headache: paracetamol and NSAIDs work: a systematic review

OBJECTIVE: Tension-type headache (TTH), also known as tension headache or muscle contraction headache is the most commonly experienced type of headache. Our aim was to evaluate the effectiveness of interventions in patients with TTH. METHOD: We performed a systematic review according to the guidelines of the Cochrane Collaboration. Randomised trials reporting conservative treatments in patients with TTH with headache as outcome were included. In the analysis studies were grouped according to type of intervention: acute pain medication, preventive medication, physiotherapy interventions, behavioural interventions and interventions in children. RESULTS: A total of 152 trials were included in this review with 17.523 patients, of which 37 studies (24.3%) were considered to be of high quality. Nine studies could not be included in one of the five subgroups. ACUTE MEDICATION: (41 trials). The pooled analyses showed that NSAIDs and acetaminophen are more effective than placebo. No significant differences could be found between different types of NSAIDs, but ibuprofen showed fewer short-term side effects when compared to other NSAIDs. There was a significant difference in favour of NSAIDs when compared to acetaminophen. PREVENTIVE MEDICATION: (44 trials). Overall, the use of antidepressants does not show to be more effective than placebo, and no significant differences between different types of antidepressants were found. Furthermore there is limited evidence concerning the negative effects of propranolol on depression in TTH patients, when compared to placebo or biofeedback. There is conflicting evidence about the effectiveness of benzodiazepines and vasodilator agents compared to placebo. There is no evidence concerning the effectiveness of muscle relaxants compared to placebo. BEHAVIOURAL THERAPY: (44 trials). Eight studies compared relaxation treatment with a waiting list or attention placebo control, and 11 studies compared EMG biofeedback with placebo and in both interventions we found inconsistent results. Most trials lack adequate power to show statistical significant differences, but frequently recovery/improvement rates did not reach clinical relevance. PHYSIOTHERAPEUTIC INTERVENTIONS: (12 trials). A wide variety of interventions were evaluated, such as spinal manipulations, exercise and physical applications. Overall the studies showed inconsistent results. CHILDREN: (11 trials). Eight studies evaluated the effectiveness of relaxation training. We found conflicting evidence for relaxation therapy compared with no treatment or other treatments. CONCLUSION: The evidence in this review suggests that NSAIDs and acetaminophen are both effective for short-term pain relief in patients with TTH. No specific type of NSAID was clearly more effective than others, but ibuprofen showed fewer side effects. There is insufficient evidence to either support or refute the effectiveness of preventive medication, physiotherapy, (spinal) manipulation, EMG biofeedback or cognitive behavioural treatment in patients with TTH.

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