Headaches: Tension-Type |
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DescriptionAn in-depth report on the causes, diagnosis, treatment, and prevention of common headaches. |
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MedicationsCurrently, the standard treatments for tension-type headaches are nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, and tricyclic antidepressants, usually amitriptyline (Elavil, Endep). A number of investigative agents, such as botulinum toxin (Botox), tizanidine (Zanaflex), and nitric synthase inhibitors are showing promise. Pain Relievers for Mild to Moderate Headache EpisodesA number of pain relievers are helpful for mild to moderate headaches. They should not be used to prevent headaches, however. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). NSAIDs are common pain relievers that block prostaglandins, substances that dilate blood vessels and cause inflammation and pain. NSAIDs are usually the first drugs tried for almost any kind of headache. There are dozens of NSAIDs. Aspirin is the most common, but it is not as effective for acute tension-type headache as others. The most common NSAIDs are the following:
Studies suggest that ibuprofen or naproxen is more effective than aspirin or acetaminophen for acute tension-type headache. However, a low dose of the prescription agent diclofenac was as effective as a high dose (400 mg) of ibuprofen. Long-term use of these agents poses a risk for ulcers and gastrointestinal bleeding. They should not be used to prevent tension headaches. Of note, a 2003 study reported a higher risk for miscarriage (particularly if the NSAID is taken for more than a week or around the time of conception). Acetaminophen. Acetaminophen (Tylenol, Anacin-3, Panadol, Phenaphen, and Valadol) is a good alternative to NSAIDs when stomach distress, ulcers, or allergic reactions prohibit their use. Acetaminophen is inexpensive and generally safe. It does not appear to pose a risk for miscarriage as NSAIDs do, even when used regularly. A high dose (1000 mg), however, is needed for this agent to be effective for headaches.Midrin (a combination of an agent that narrows blood vessels, a mild sedative, and acetaminophen) may be particularly useful for tension-type headaches. Acetaminophen does have some adverse effects, however, and the daily dose should not exceed 4 grams (4000 mg). Patients who take high doses of this drug for long periods are at risk for liver damage, particularly if they drink alcohol and do not eat regularly. It may pose a small risk for serious kidney complications in people with preexisting kidney disease, although it is still the drug of choice for people with impaired kidney function. There is some evidence that taking even more than 2 grams (2000 mg) a day for the long term may confer a risk of ulcers and bleeding comparable to that of NSAIDs. This finding needs to be confirmed, however. It also may interact with certain medications, including the blood thinner warfarin. Tricyclics and Other AntidepressantsAntidepressants may be useful in preventing tension-type headaches. Those known as the tricyclics are most often used for prevention of severe chronic tension-type headaches. Older agents called monoamine oxidase inhibitors can be effective as well. Newer antidepressants known as SSRIs are also sometimes used in milder cases. Tricyclic Antidepressants. Tricyclics are useful not only for depression, but appear to help relieve muscle pain and improve sleep as well. They are sometimes referred in one of two categories: tertiary or secondary amines:
Less commonly used or investigative tricyclics include doxepin (Sinequan), amoxapine (Asendin), maprotiline (Ludiomill), protriptyline (Vivactil), trimipramine (Surmontil), mianserin (Bolvidon), and dothiepin (Prothiaden). Tricyclics produce modest benefits against pain, and one study suggested that they may actually reduce the transmission of pain to the nerves in the face. Unfortunately, these drugs can lose effectiveness over time. Side effects are also fairly common with these medications. Drowsiness is the most common, but may vary by specific agent. In addition, side effects most often reported include dry mouth, constipation, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, and dizziness. Blood pressure may drop suddenly when sitting up or standing. Tricyclics can have serious, although rare, side effects:
Selective Serotonin-Reuptake Inhibitors.Selective serotonin-reuptake inhibitors (SSRIs) work by increasing levels of serotonin in the brain. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). Because they act on serotonin specifically, they have fewer side effects than the older antidepressants, which affect a number of chemicals in the body. SSRIs take two to four weeks to be effective in most adults and sometimes longer, up to 12 weeks, so their value in headache is limited. In one study, however, Prozac was more effective than a tricyclic for patients with headache who were not depressed. Side effects include nausea, gastrointestinal problems, agitation, insomnia, mild tremor, impulsivity, temporary weight loss, and sexual dysfunction. Death from overdose is extremely rare. Serious interactions can occur with other antidepressants, such as tricyclics and, of particular note, MAOIs. Designer Antidepressants.A number of drugs have now been developed that target other neurotransmitters, such as norepinephrine, alone or in addition to serotonin, and are showing promise for prevention of tension-type headache. The following are some examples:
Antianxiety Agents and SedativesMild antianxiety agents are occasionally used as an adjunct in treating chronic headaches to decrease muscle contraction or to treat anxiety symptoms during periods of extreme stress. They include alprazolam (Xanax) and clonazepam (Klonopin). They tend to be highly addictive, however, and should therefore be used only on a short-term basis. Opioids and Potent SedativesTramadol. Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea, but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available and provides more rapid pain relief than tramadol alone and more durable relief than acetaminophen alone. Side effects are the same as for each of these agents. Opioids. Opioids, such as codeine or hydrocodone, are sometimes prescribed for severe headaches, although their use is controversial because of the risk for addiction. Methadone is showing promise for patients who do not respond to standard treatments. These agents are narcotics, however, and may be subject to abuse. Patients must be monitored and reevaluated regularly. Overuse of these drugs can reduce their effectiveness and lead to medication-overuse headaches, so physician involvement is essential. Long-term, high-dosage use of some of these drugs can also lead to kidney disease and ulcers. Other, less serious side effects include gastrointestinal upset, dizziness, and ringing in the ears (tinnitus). Sedatives. Barbiturates, particularly butalbital (Butalan) and its combinations (Fioricet, Axocet), are occasionally prescribed if other medications fail to provide relief. These agents are sedatives that also contain pain relievers. Because they pose a very high risk for alcohol-like intoxication, dependence and drug-induced headaches during withdrawal, they should be used very sparingly. Some experts believe they should not be used at all for headaches. Other Drugs Being Tested for Treating or Preventing Chronic Tension-Type HeadachesValproate. In some studies, the anticonvulsant medication valproate has been effective for stopping headaches in some patients with persistent migraines and tension-type chronic daily headaches. In one study, 75% of patients with either type of headache experienced at least a 50% reduction in headache frequency and severity. Minor side effects occurred in a third of the patients. Other anti-seizure medications are under investigation. Botulinum Toxin. Botulinum toxin A (Botox) injections are now widely used to relax muscles and reduce skin wrinkles. They are also being investigated for chronic headaches. (This potentially deadly toxin is very safe when minuscule amounts are injected into small muscles.) In a 2003 study of various headaches types (episodic migraine or tension-type headache, mixed headache, and chronic daily headache), over 85% of all the patients experienced reduction in the number of headaches per month and the intensity of the pain. On average, they had received an average of 3.4 doses three months apart for a period of eight months. Although current data are promising, some studies have reported no benefit for people with tension-type headache. More studies are needed to determine if specific patients may be helped by Botox. (Studies on migraines have been more consistently positive, for example, than on other headaches.) More research is needed. It should be noted that Botox also causes headaches in about 1% of cases. In some cases, the headaches can be very severe and long lasting (from eight days to a month). Some experts suggest that either a contaminated batch of Botox or a specific injection technique may be the cause, but additional investigation is needed. Tizanidine. Tizanidine (Zanaflex) is a muscle relaxant that is emerging as a possible effective preventive agent in chronic tension-type headaches. Called an alpha2-adrenergic agonist, it blocks the release and effectiveness of a stress chemical in the body called norepinephrine and may also help prevent muscle spasms. Studies have reported that nearly 70% of patients with chronic tension-type headaches experienced a reduction in headache symptoms of 50% or more. It also appears to help patients experiencing medication-overuse headache to withdraw from medications. Side effects are usually minor and include fatigue and dry mouth, although patients taking the drug need to be monitored periodically for potential liver damage. Nitric Oxide Synthase Inhibitors. Nitric oxide synthase inhibitors block nitric oxide, which may play a role in increasing nerve activity that leads to headache. Agents being investigated include L-NG methyl arginine hydrochloride (L-NMMA) and L-NG-nitro-arginine. Studies suggest they may be very helpful in reducing chronic tension-type pain. Animal studies suggest they may also have antidepressant effects. Herbal and Other Natural RemediesA number of herbal remedies are promoted for tension-type headache. It is critical that anyone taking herbal or so-called natural remedies should be aware of the lack of regulations governing their quality and effectiveness. Essential Oils. Some patients find relief using two drops of peppermint, eucalyptus, or lavender oil added to one cup of water. The patient soaks a cloth in the solution and applies it as a compress to the head. Other Herbs. Other herbs used in teas or as supplements for tension-type headache include feverfew, white willow bark or meadowsweet (which contain chemicals found in aspirin), St. John's wort (an herbal antidepressant), valerian (which has sedative and anti-spasmodic properties), and ginkgo biloba (which may increase blood circulation to the brain). Because of the lack of data and unregulated nature of these products, none are recommended. No one should take these remedies without consulting a physician, particularly people on other medications or with chronic or serious medical conditions.
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