Efns guideline on the treatment of tensiontype headache report of an efns task force

European Journal of Neurology 2010, 17: 1318–1325 E F N S G U I D E L I N E S / C M E A R T I C L E EFNS guideline on the treatment of tension-type headache –Report of an EFNS task force L. Bendtsena, S. Eversb, M. Lindec, D. D. Mitsikostasd, G. Sandrinie and J. SchoenenfaDepartment of Neurology, Danish Headache Centre, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark; bDepartment of Neurology, University of Mu¨nster, Mu¨nster, Germany; cInstitute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden and Norwegian National Headache Centre, St. Olavs Hospital, Trondheim Norway and Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway; dDepartment of Neurology, Headache Clinic, Athens Naval Hospital, Athens, Greece; eUniversity Centre for Adaptive Disorders and Headache, IRCCS C. Mondino Institute of Neurology Foundation, University of Pavia, Pavia Italy; and fDepartment of Neurology, Headache Research Unit, University of Lie`ge, Lie`ge, Belgium Background: Tension-type headache (TTH) is the most prevalent headache type and is causing a high degree of disability. Treatment of frequent TTH is often difficult.
Objectives: To give evidence-based or expert recommendations for the different treat- ment procedures in TTH based on a literature search and the consensus of an expert panel.
Methods: All available medical reference systems were screened for the range of clinical studies on TTH. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A, B or C recommendations andgood practice points.
Recommendations: Non-drug management should always be considered although thescientific basis is limited. Information, reassurance and identification of trigger factorsmay be rewarding. Electromyography (EMG) biofeedback has a documented effect inTTH, whilst cognitive-behavioural therapy and relaxation training most likely areeffective. Physical therapy and acupuncture may be valuable options for patients withfrequent TTH, but there is no robust scientific evidence for efficacy. Simple analgesicsand non-steroidal anti-inflammatory drugs are recommended for the treatment ofepisodic TTH. Combination analgesics containing caffeine are drugs of second choice.
Triptans, muscle relaxants and opioids should not be used. It is crucial to avoidfrequent and excessive use of analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is drug of first choice forthe prophylactic treatment of chronic TTH. Mirtazapine and venlafaxine are drugs ofsecond choice. The efficacy of the prophylactic drugs is often limited, and treatmentmay be hampered by side effects.
meta-analyses, whilst the vast amount of uncontrolled reports of non-drug treatment will not be considered.
These guidelines aim to give evidence-based recom- A brief clinical description of the headache disorders is mendations for the acute and prophylactic drug treat- included. The definitions follow the diagnostic criteria ment of TTH. In addition, the guidelines aim to provide of the International Headache Society (IHS) [1].
a short overview on non-drug treatment of TTH basedon the best performed controlled trials, reviews and Tension-type headache is classified into three subtypes Correspondence: L. Bendtsen, Chairperson, Department of according to headache frequency: infrequent episodic Neurology, Danish Headache Centre, Glostrup Hospital, Universityof Copenhagen, DK-2600 Glostrup, Copenhagen, Denmark TTH (<1 day of headache per month), frequent epi- (tel.: +45 432 32062; fax +45 4323 3839; e-mail: [email protected]
sodic TTH (1–14 days of headache per month) and chronic TTH (‡15 days per month) [1] (Table 1). This This is a Continuing Medical Education article, and can be found with division may seem artificial but has proved to be highly corresponding questions on the Internet at http://www.efns.org/EFNS relevant for several reasons. First impact on quality of Continuing-Medical-Education-online.301.0.html. Certificates forcorrectly answering the questions will be issued by the EFNS.
life differs considerably between the subtypes. A person European Journal of Neurology Ó 2010 EFNS Guideline for treatment of tension-type headache Table 1 Diagnostic criteria of tension-type headache of the IHS class III evidence, whilst a level C rating (possibly effective, ineffective or harmful) requires at least twoconvincing class III studies [4].
2.1 Infrequent episodic tension-type headache A. At least 10 episodes occurring on <1 day per month on average In general, non-pharmacological management should (<12 days per year) and fulfilling criteria B–D always be considered in TTH [5]. When it comes to B. Headache lasting from 30 min to 7 days pharmacological management, the general rule is that C. Headache has at least two of the following characteristics: patients with episodic TTH [1] are treated with symp- tomatic (acute) drugs, whilst prophylactic drugs should 2. Pressing/tightening (non-pulsating) quality3. Mild or moderate pain intensity be considered in patients with very frequent episodic 4. Not aggravated by routine physical activity such as walking or TTH and in patients with chronic TTH [1]. Analgesics are often ineffective in patients with chronic TTH.
Furthermore, their frequent use produces risk of tox- 1. No nausea or vomiting (anorexia may occur) icity (e.g. kidney and liver problems) as well as of 2. No more than one of photophobia or phonophobia 2.2 Frequent episodic tension-type headache A. At least 10 episodes occurring on ‡1 but <15 days per month for at least 3 months (‡12 and <180 days per year) and fulfilling A literature search was performed using the reference databases MedLine, Science Citation Index and the Cochrane Library; the key word used were Ôtension-type A. Headache occurring on ‡15 days per month on average headacheÕ (last search October 2009). In addition, a for >3 months (‡180 days per year) and fulfilling criteria B–D review book [7] and treatment recommendations from B. Headache lasts hours or may be continuous the British Association for the Study of Headache [8] 1. No more than one of photophobia, phonophobia or mild were considered. Trials published in English and con- ducted amongst adult patients (aged 18 and older) with 2. Neither moderate or severe nausea or vomiting reasonable criteria designed to distinguish TTH frommigraine were considered. For drug treatments, ran- having headache every day from the time of waking, domized placebo-controlled trials and trials comparing persisting until bedtime, month in and month out, is different treatments were considered. For non-drug disabled. At the other extreme, a mild headache once treatments, controlled trials were considered.
every other month has very little impact on health orfunctional ability and needs little if any medical atten- tion. Second, the pathophysiological mechanisms maydiffer significantly between the subtypes; peripheral All authors performed an independent literature search.
mechanisms are probably more important in episodic The first draft of the manuscript was written by the TTH, whereas central pain mechanisms are pivotal in chairman of the task force. All other members of the chronic TTH [2]. Third, treatment differs between the task force read the first draft and discussed changes by subtypes, with symptomatic and prophylactic treat- email. Three more drafts were then written by the ments being more appropriate for episodic and chronic chairman and each time discussed by email. All recom- TTH, respectively. Therefore, a precise diagnosis is mendations had to be agreed to by all members of the mandatory and should be established by means of a task force unanimously. The background of the research headache diary [3] completed for at least 4 weeks.
strategy and of reaching consensus and the definitions The recommendations in this article are based on the of the recommendation levels used in this article have scientific evidence from clinical trials and on the expert been described in the EFNS recommendations [4].
consensus by the respective task force of the EFNS. Thelegal aspects of drug prescription and drug availability in the different European countries will not be consid-ered. The definitions of the recommendation levels The lifetime prevalence of TTH was as high as 78% in a follow the EFNS criteria [4]. Briefly, a level A rating population-based study in Denmark, but the majority had (established as effective, ineffective or harmful) requires episodic infrequent TTH (1 day a month or less) without at least one convincing class I study or at least two specific need of medical attention [9]. Nevertheless, 24– consistent convincing class II studies. A level B rating 37% had TTH several times a month, 10% had it weekly (probably effective, ineffective or harmful) requires at and 2–3% of the population had chronic TTH usually least one convincing class II study or overwhelming lasting for the greater part of a lifetime [9,10].
Ó 2010 The Author(s)European Journal of Neurology Ó 2010 EFNS European Journal of Neurology 17, 1318–1325 The female:male ratio of TTH is 5:4 indicating that, secondary headache is suspected (e.g. the headache unlike migraine, women are only slightly more affected characteristics are untypical), if the course of headache than men [11,12]. The average age of onset of TTH is attacks changes or if persistent neurological or psycho- higher than that in migraine, namely 25–30 years in pathological abnormalities are present. Significant cross-sectional epidemiological studies [10]. The preva- co-morbidity, e.g. anxiety or depression, should be lence peaks between the age of 30 to 39 and decreases identified and treated concomitantly. Poor compliance slightly with age. Poor self-rated health, inability to with prophylactic treatment may be a problem in chronic relax after work and sleeping few hours per night have TTH as it is in migraine [18]. It should be explained to the been reported as risk factors for developing TTH [13].
patient that frequent TTH only seldom can be cured, but A recent review of the global prevalence and burden that a meaningful improvement often can be obtained of headaches [11] showed that the disability of TTH as a with the combination of drug and non-drug treatments.
burden of society was greater than that of migraine,which indicates that the overall cost of TTH is greater than that of migraine. Two Danish studies have shownthat the number of workdays missed in the population Acute drug therapy refers to the treatment of individual was three times higher for TTH than for migraine attacks of headache in patients with episodic and [10,14], and a US study has also found that absenteeism chronic TTH. Most headaches in patients with episodic because of TTH is considerable [15]. The burden is TTH are mild to moderate, and the patients often can particularly high for the minority who have substantial self-manage using simple analgesics (paracetamol or and complicating co-morbidities [16].
aspirin) or non-steroidal anti-inflammatory drugs(NSAIDs). The efficacy of the simple analgesics tends todecrease with increasing frequency of the headaches. In patients with chronic TTH, the headaches are often TTH is characterized by a bilateral, pressing tightening associated with stress, anxiety and depression, and pain of mild to moderate intensity, occurring either in simple analgesics are usually ineffective and should be short episodes of variable duration (episodic forms) or used with caution because of the risk of medication- continuously (chronic form). The headache is not overuse headache at a regular intake of simple analge- associated with the typical migraine features as vomit- sics above 14 days a month or triptans or combination ing, severe photophobia and phonophobia. In the analgesics above 9 days a month [19]. Other interven- chronic form, only one of the latter two accompanying tions such as non-drug treatments and prophylactic symptoms or mild nausea is accepted [1] (Table 1).
pharmacotherapy should be considered.
Because of lack of accompanying symptoms and the The effect of acute drugs in TTH has been examined relatively milder pain intensity, patients are rarely in many studies, and these have used many different severely incapacitated by their pain. TTH is the most methods for the measurement of efficacy. The guide- featureless of the primary headaches, and because many lines for drug trials in TTH from the International secondary headaches may mimic TTH, a diagnosis of Headache Society recommend pain-free after 2 h as the TTH requires exclusion of other organic disorders.
primary efficacy measure [20]. This has been used insome studies whilst many studies have used other effi-cacy measures such as pain intensity difference, time to meaningful relief. This makes comparison of results The diagnosis of TTH is based on the typical patientÕs A correct diagnosis should be assured by means of a headache diary [3] recorded over at least 4 weeks. Thediagnostic problem most often encountered is to dis- Paracetamol 1000 mg was significantly more effective criminate between TTH and mild migraine. If the than placebo in most [21–27] but not all [28,29] trials, headache is strictly unilateral, the debated entity cervi- whilst three trials found no significant effect of paraceta- cogenic headache should be considered [17]. The diary mol 500 mg to 650 mg compared with placebo [21,28,30].
may also reveal triggers and medication overuse, and Aspirin has consistently been reported more effective than it will establish the baseline against which to measure placebo in doses of 1000 mg [21,31,32], 500 mg to 650 mg the efficacy of treatments. Identification of a high intake [21,32–34] and 250 mg [32]. One study found no difference of analgesics is essential because medication overuse in efficacy between solid and effervescent aspirin [34].
requires specific treatment [6]. Paraclinical investi- Ibuprofen 800 mg [33], 400 mg [24,25,33,35,36] and gations, in particular brain imaging, is necessary if 200 mg [37] are more effective than placebo, as are European Journal of Neurology Ó 2010 EFNS European Journal of Neurology 17, 1318–1325 Guideline for treatment of tension-type headache ketoprofen 50 mg [28,37], 25 mg [27,29,37] and 12.5 mg between paracetamol and NSAIDs or between these [29]. One study could not demonstrate a significant drugs and placebo [41]. However, it is well known that effect of ketoprofen 25 mg possibly because of a low NSAIDs have more gastro-intestinal side effects than number of patients [28]. Diclofenac 25 mg and 12.5 mg paracetamol, whilst the use of large amounts of par- have been reported effective [35], whilst there are no acetamol may cause liver injury. Amongst the NSAIDs, trials of the higher doses of 50–100 mg proved effective ibuprofen seems to have the most favourable side effect in migraine. Naproxen 375 mg [26] and 550 mg [30,38] and metamizole 500 and 1000 mg [31] have also beendemonstrated effective. The latter drug is not available in many countries, because it carries a minimal (if at all)risk of causing agranulocytosis. Treatment with intra- The efficacy of simple analgesics and NSAIDs is muscular injection of ketorolac 60 mg in an emergency increased by combination with caffeine 64–200 mg department has been reported effective [39].
[22,23,42–45]. There are no comparative studies exam-ining the efficacy of combination with codeine. It is clinically well known that caffeine withdrawal can cause There are only few studies investigating the ideal dose for headache and chronic daily headache has been reported drugs used for the acute treatment of TTH. One study to be associated with use of over-the-counter caffeine demonstrated a significant dose–response relationship of combination products [46]. Therefore, it is probable aspirin with 1000 mg being superior to 500 and 500 mg that combinations of simple analgesics or NSAIDs with being superior to 250 mg [32]. Ketoprofen 25 mg tended caffeine are more likely to induce MOH than simple to be more effective than 12.5 mg [29], whilst another analgesics or NSAIDs alone. Until otherwise proven, study found very similar effects of ketoprofen 25 and we therefore recommend that simple analgesics or 50 mg [37]. Paracetamol 1000 mg seems to be superior to NSAIDs are drugs of first choice and that combinations 500 mg, as only the former dose has been demonstrated of one of these drugs with caffeine are drugs of second effective. In lack of evidence, the most effective dose of a choice for the acute treatment of TTH. Combinations drug well tolerated by a patient should be chosen. Sug- of simple analgesics with codeine or barbiturates should gested doses are presented in Table 2.
not be used, because use of the latter drugs increases therisk of developing medication-overuse headache [46].
Comparison of simple analgesicsFive studies reported NSAIDs to be significantly more effective than paracetamol [24,25,28–30], whilst threestudies could not demonstrate a difference [21,26,27].
Triptans have been reported effective for the treatment Five studies have compared efficacy of different of interval headaches [47], which were most likely mild NSAIDs, and it has not be possible to clearly demon- migraines [48], in patients with migraine. Triptans most likely do not have a clinically relevant effect in patients with TTH [49,50] and cannot be recommended. Musclerelaxants have not been demonstrated effective in epi- sodic TTH [51]. Use of opioids increases the risk of A thorough review of the acute drug treatment of TTH developing medication-overuse headache [46]. Opioids could not detect any difference in adverse events are not recommended for the treatment of TTH.
Table 2 Recommended drugs for acute therapy of tension-type headache Gastrointestinal side effects, risk of bleeding Side effects as for ibuprofen, only doses of 12.5–25 mg tested in TTH Less risk of gastrointestinal side effects compared with NSAIDs The level of recommendation considers side effects and consistency of the studies. There is sparse evidence for optimal doses. The most effectivedose of a drug well tolerated by a patient should be chosen; NSAID, non-steroidal anti-inflammatory drugs; TTH, tension-type headache;aCombination with caffeine 65–200 mg increases the efficacy of ibuprofen [43] and paracetamol [23,42], but possibly also the risk for developingmedication-overuse headache [46,53]. Level of recommendation of combination drugs containing caffeine is therefore B.
Ó 2010 The Author(s)European Journal of Neurology Ó 2010 EFNS European Journal of Neurology 17, 1318–1325 curve (AUC) to be used as primary efficacy measure [20].
These parameters have been used in some studies, whilst Simple analgesics and NSAIDs are the mainstays in the other studies have used other efficacy measures such as acute therapy of TTH (Table 2). Paracetamol 1000 mg is pain reduction from baseline, headache intensity. This probably less effective than the NSAIDs but has a better makes comparison of results between studies difficult.
gastric side effect profile [52]. Ibuprofen 400 mg may berecommended as drug of choice amongst the NSAIDs because of a favourable gastrointestinal side effect pro-file compared with other NSAIDs [52]. Combination Lance and Curran [54] reported amitriptyline 10–25 mg analgesics containing caffeine are more effective than three times daily to be effective, whilst Diamond and simple analgesics or NSAIDs alone but are regarded by Baltes [55] found amitriptyline 10 mg/day but not 60 mg/ some experts [53] to more likely induce medication- day to be effective. Amitriptyline 75 mg/day was reported overuse headache. Physicians should be aware of the risk to reduce headache duration in the last week of a 6-week of developing medication-overuse headache as a result of study [56], whilst no difference in effect size between ami- frequent and excessive use of all types of analgesics in triptyline 50–75 mg/day or amitriptylinoxide 60–90 mg/ acute therapy [6]. Triptans, muscle relaxants and opioids day and placebo was found in one study [57]. However, do not play a role in the treatment of TTH.
also the frequencies of side effects were similar on ami- Although simple analgesics and NSAIDs are effective triptyline and placebo in the latter study. The inability to in episodic TTH, the degree of efficacy has to be put in detect the well-known side effects of amitriptyline suggests perspective. For example, the proportion of patients that insensitivity of the trial for reasons which remain obscure.
were pain-free 2 h after treatment with paracetamol Bendtsen et al. [58] found that amitriptyline 75 mg daily 1000 mg, naproxen 375 mg and placebo were 37%, 32% reduced the area-under-the-headache curve (calculated as and 26%, respectively [26]. The corresponding rates for headache duration times headache intensity) by 30% paracetamol 1000 mg, ketoprofen 25 mg and placebo compared with placebo, which was highly significant.
were 22%, 28% and 16% in another study with 61%, Holroyd and colleagues [59] treated patients with antide- 70% and 36% of subjects reporting worthwhile effect, pressants (83% took amitriptyline median dose 75 mg respectively [27]. Thus, efficacy is modest, and there is daily and 17% took nortriptyline median dose 50 mg clearly room for better acute treatment of episodic TTH.
daily) and compared this with stress management therapyand with a combination of stress management and anti-depressant treatment. After 6 months, all three treatments reduced headache index with approximately 30% more Simple analgesics and non-steroidal anti-inflammatory than placebo, which was highly significant.
drugs are recommended for the treatment of episodicTTH. Combination analgesics containing caffeine are drugs of second choice. It is crucial to avoid frequentand excessive use of analgesics to prevent the develop- The tricyclic antidepressant clomipramine 75–150 mg ment of medication-overuse headache.
daily [60] and the tetracyclic antidepressants maprotiline75 mg daily [61] and mianserin 30–60 mg daily [60] havebeen reported more effective than placebo. Interestingly, some of the newer more selective antidepressants with Prophylactic pharmacotherapy should be considered in action on serotonin and noradrenaline seem to be as patients with chronic TTH, and it can be considered in effective as amitriptyline with the advantage that they patients with very frequent episodic TTH. Co-morbid are tolerated in doses needed for the treatment of a disorders, e.g. overweight or depression, should be taken concomitant depression. Thus, the noradrenergic and into account. For many years, the tricyclic anti- specific serotonergic antidepressant mirtazapine 30 mg/ depressant amitriptyline has been used. More lately day reduced headache index by 34% more than placebo other antidepressants, NSAIDs, muscle relaxants, in difficult to treat patients without depression including anticonvulsants and botulinum toxin have been tested in patients who had not responded to amitriptyline [62].
chronic TTH. The effect of prophylactic drugs in TTH The efficacy of mirtazapine was comparable to that of has been examined in surprisingly few placebo-con- amitriptyline reported by the same group [58]. A sys- trolled studies, which have used different methods for tematic review concluded that the two treatments may be the measurement of efficacy. The guidelines for drug equally effective for the treatment of chronic TTH [63].
trials in TTH from the International Headache Society The serotonin and noradrenaline reuptake inhibitor recommend days with TTH or area-under-the-headache venlafaxine 150 mg/day [64] reduced headache days European Journal of Neurology Ó 2010 EFNS European Journal of Neurology 17, 1318–1325 Guideline for treatment of tension-type headache from 15 to 12 per month in a mixed group of patients Table 3 Recommended drugs for prophylactic therapy of tension-type with either frequent episodic or chronic TTH. Low-dose mirtazapine 4.5 mg/day alone or in combination with ibuprofen 400 mg/day was not effective in chronic TTH.
The selective serotonin reuptake inhibitors (SSRIs), citalopram [58] and sertraline [65], have not been found more effective than placebo. SSRIÕs have been compared with other antidepressants in six studies. These studies were reviewed in a Cochrane analysis that concluded that SSRIÕs are less efficacious than tricyclic antide- pressants for the treatment of chronic TTH [66].
The level of recommendation considers side effects and number andquality of the studies.
There have been conflicting results for treatment withthe muscle relaxant tizanidine [61,67], whilst theNMDA-antagonist memantine was not effective [68].
dose [58]. Therefore, it is advisable to change to other Botulinum toxin has been extensively studied [69–79]. It prophylactic therapy, if the patient does not respond was concluded in a systematic review that botulinum after 4 weeks on maintenance dose. The side effects of toxin is likely to be ineffective or harmful for the amitriptyline include dry mouth, drowsiness, dizziness, treatment of chronic TTH [63]. The prophylactic effect obstipation and weight gain. Mirtazapine, of which the of daily intake of simple analgesics has not been studied major side effects are drowsiness and weight gain, or in trials that had this as the primary efficacy parameter, venlafaxine, of which the major side effects are vomiting, but explanatory analyses indicated that ibuprofen nausea, dizziness and loss of libido, should be considered 400 mg/day was not effective in one study [80]. On the if amitriptyline is not effective or not tolerated. Dis- contrary, ibuprofen increased headache compared with continuation should be attempted every 6–12 months.
placebo indicating a possible early onset of medication- The physician should keep in mind that the efficacy of overuse headache [80]. Topiramate [81] and buspirone preventive drug therapy in TTH is often modest and that [82] have been reported effective in open-label studies.
the efficacy should outweigh the side effects.
Amitriptyline has a clinically relevant prophylactic Amitriptyline is drug of first choice for the prophylactic effect in patients with chronic TTH and should be drug treatment of chronic TTH. Mirtazapine and venlafax- of first choice (Table 3). Mirtazapine or venlafaxine are probably effective, whilst the older tricyclic and tetra-cyclic antidepressants, clomipramine, maprotiline and mianserin, may be effective. A recent systematic review[63] concluded that amitriptyline and mirtazapine are Information, reassurance and identification of trigger the only forms of treatment that can be considered proven beneficial for the treatment of chronic TTH.
However, the last search was performed in 2007 before Non-drug management should be considered for all publication of the study on venlafaxine [64].
patients with TTH and is widely used. However, the Amitriptyline should be started at low dosages scientific evidence for efficacy of most treatment (10–25 mg/day) and titrated by 10–25 mg weekly until modalities is sparse [83–86]. The very fact that the the patient has either good therapeutic effect or side physician takes the problem serious may have a thera- effects are encountered. It is important that patients are peutic effect, particularly if the patient is concerned informed that this is an antidepressant agent but has an about serious disease, e.g. brain tumour, and can be independent action on pain. The maintenance dose is reassured by thorough examination. Identification of usually 30–75 mg daily administered 1–2 h before bed- trigger factors should be performed, as coping with time to help to circumvent any sedative adverse effects.
triggers may be of value [87]. The most frequently The effect is not related to the presence of depression reported triggers for TTH are stress (mental or physi- [58]. A significant effect of amitriptyline may be cal), irregular or inappropriate meals, high intake or observed already in the first week on the therapeutic withdrawal of coffee and other caffeine containing Ó 2010 The Author(s)European Journal of Neurology Ó 2010 EFNS European Journal of Neurology 17, 1318–1325 Table 4 Non-pharmacological treatments for tension of tension-type cause of low power there is conflicting evidence to support or refute the effectiveness of EMG biofeedbackcompared with placebo or any other treatments [85].
However, a recent extensive and thorough meta-anal- ysis including 53 studies concluded that biofeedback has a medium-to-large effect. The effect was found to be long lasting and enhanced by combination with relax- ation therapy [97]. The majority of the studies included employed EMG biofeedback. It was not possible todraw reliable conclusions as to whether the effect dif- The level of recommendation considers number and quality of thestudies.
fered between patients with episodic and chronic TTH.
drinks, dehydration, sleep disorders, too much or too The aim of cognitive-behavioural therapy is to teach the little sleep, reduced or inappropriate physical exercise, patient to identify thoughts and beliefs that generate psycho-behavioural problems as well as variations stress and aggravate headaches. These thoughts are then during the female menstrual cycle and hormonal sub- challenged, and alternative adaptive coping self- stitution [88–90]. It has been demonstrated that stress instructions are considered. A variety of exercises may be induces more headache in patients with chronic TTH used to challenge thoughts and beliefs, including exper- than in healthy controls probably through hyperalgesic imenting with adoption of another personÕs view of the effects on already sensitized pain pathways [91].
situation, actively generating other possible views of a Information about the nature of the disease is situation and devising a behavioural experiment to test important. It can be explained that muscle pain can lead the validity of a particular belief [96]. One study found to a disturbance of the brainÕs pain-modulating mech- cognitive-behavioural therapy, treatment with tricyclic anisms [2,92,93], so that normally innocuous stimuli are antidepressants and a combination of the two treatments perceived as painful, with secondary perpetuation of better than placebo with no significant difference muscle pain and risk of anxiety and depression. The between treatments [59], whilst another study reported prognosis in the longer run was found to be favourable no difference between cognitive-behavioural therapy and in a population-based 12-year epidemiological follow- amitriptyline [98]. Cognitive-behavioural therapy may up study, because approximately half of all individuals be effective but there is no convincing evidence [63,85].
with frequent or chronic TTH had remission of theirheadaches [13]. It is not known whether the same is true for individuals who seek medical consultation.
The goal of relaxation training is to help the patient torecognize and control tension as it arises in the courseof daily activities. Relaxation training involves a range of affective, cognitive and behavioural techniques, such A large number of psycho-behavioural treatment strat- as breathing exercises and meditation. Relaxation egies have been used to treat chronic TTH. EMG bio- training has been compared with no treatment or feedback, cognitive-behavioural therapy and relaxation waiting list control [99–103] and with other interven- training have been investigated the most. However, only tions [104–107]. A recent review concluded that there is few trials have been performed controlled with sufficient conflicting evidence that relaxation is better than no power and clear outcome measures [85]. Hypnotherapy treatment, waiting list or placebo [85].
has been reported effective [94], but there is not con-vincing evidence for its effect in TTH [85,95].
ConclusionsEMG biofeedback has an effect in TTH, whilst cogni- tive-behavioural therapy and relaxation training may The aim of EMG biofeedback is to help the patient to have an effect in TTH, but at this moment, there is no recognize and control muscle tension by providing convincing evidence to support this [63,85]. These continuous feedback about muscle activity. Sessions treatments are relatively time-consuming, but unfortu- typically include an adaptation phase, baseline phase, nately, there are no documented guidelines for which training phase where feedback is provided and a self- psycho-behavioural treatment(s) to choose for the control phase where the patient practices controlling individual patient. Therefore, until scientific evidence is muscle tension without the aid of feedback [96]. A provided, common sense must be used. Thus, it is likely recent review including 11 studies concluded that be- that cognitive-behavioural therapy will be most bene- European Journal of Neurology Ó 2010 EFNS European Journal of Neurology 17, 1318–1325 Guideline for treatment of tension-type headache ficial for the patient where psycho-behavioural prob- [110,113,127], relaxation [113] or a combination of lems or affective distress play a major role [96], whilst massage and relaxation [128]. Collectively, these trials biofeedback or relaxation training may be preferable suggest slightly better results for some outcomes with the latter therapies according to the recent Cochrane anal-ysis [86]. Together, the available evidence suggests thatacupuncture could be a valuable option for patients suffering from frequent TTH, but more research is nee- Physical therapy is widely used for the treatment of ded before final conclusions can be made.
TTH and includes the improvement of posture, mas- A recent study reported no effect of greater occipital sage, spinal manipulation, oromandibular treatment, nerve block in patients with chronic TTH [129].
exercise programs, hot and cold packs, ultrasound andelectrical stimulation, but the majority of these modal- ities have not been properly evaluated [108]. Activetreatment strategies are generally recommended [108].
Non-drug management should always be considered A recent review concluded that exercise may have a although the scientific basis is limited (Table 4). Infor- value for TTH [109]. Carlson et al. [110] reported better mation, reassurance and identification of trigger factors effect of physiotherapy than acupuncture. A controlled may be rewarding. EMG biofeedback has a docu- study [111] combined various techniques such as mas- mented effect in TTH, whilst cognitive-behavioural sage, relaxation and home-based exercises and found a therapy and relaxation training most likely are effective, modest effect. It was reported that adding craniocervi- but there is no convincing evidence. Physical therapy cal training to classical physiotherapy was better than and acupuncture may be valuable options for patients physiotherapy alone [112]. A recent study found no with frequent TTH, but there is no robust scientific significant long-lasting differences in efficacy amongst relaxation training, physical training and acupuncture[113]. Spinal manipulation has no effect in episodic TTH [114] and no convincing effect in chronic TTH[115,116]. Oromandibular treatment with occlusal These recommendations should be updated within splints is often recommended but has not yet been tes- ted in trials of reasonable quality and cannot be rec-ommended in general [117]. There is no firm evidence for efficacy of therapeutic touch, cranial electrotherapyor transcutaneous electrical nerve stimulation [84].
The present guidelines were developed without external It can be concluded that there is a huge contrast financial support. The authors report the following between the widespread use of physical therapies and financial supports: Lars Bendtsen: Salary by Glostrup the lack of robust scientific evidence for efficacy of these University Hospital. Honoraria in 2009 from MSD and therapies and that further studies of improved quality Pfizer; Stefan Evers: Salary by the University of Mu¨n- are necessary to either support or refute the effective- ster. Honoraria or grants by Addex Pharma, AGA ness of physical modalities in TTH [84,108,118,119].
Medical Corporation, Allergan, AstraZeneca, BerlinChemie, Boehringer Ingelheim, CoLucid, Desitin, Eisai,GlaxoSmithKline, Ipsen, Janssen-Cilag, Merz, MSD, Novartis, Pfizer, Reckitt-Benckiser and UCB; Mattias The prophylactic effect of acupuncture has been inves- Linde: Salary from the Cephalea Headache Centre and tigated in several trials in patients with frequent episodic Gothenburg University, Sweden. Honoraria or grants or chronic TTH. A review [63] and a meta-analysis [120] in 2009 from Allergan, AstraZeneca, MSD and The concluded that there is no evidence for efficacy of acu- Swedish Migraine Association; Dimos D. Mitsikostas: puncture in TTH. Two trials reported better effect of Salary by Athens Naval Hospital. Honoraria or grants acupuncture than basic care or waiting list but no better for 2009 by Bayer-Schering, Janssen-Cilag, Lilly, Merk- effect of Chinese acupuncture when compared to sham Serono, Novartis, MSD and UCB; Giorgio Sandrini: acupuncture [121,122], whilst a recent Cochrane analysis Salary from University of Pavia. Honoraria in 2009 [86] concluded that there was overall a slightly better from Allergan, Solvay Pharma and Newrons Alpha and effect from acupuncture than from sham acupuncture Jean Schoenen: Salary from the University of Lie`ge.
based on the results from five trials [122–126]. Four Honoraria or grants in 2009 from Janssen-Cilag, GSK, Ó 2010 The Author(s)European Journal of Neurology Ó 2010 EFNS European Journal of Neurology 17, 1318–1325 19. Olesen J, Bousser MG, Diener HC, et al. New appendix criteria open for a broader concept of chronic migraine.
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Material Técnico Bupropiona Cloridrato ______________________________________________ Identificação Fórmula Molecular: C13H18CINO - HCl Peso molecular: 276,21 DCB / DCI: 01558 CAS: 31677-93-7 INCI: Não aplicável Denominação botânica: Não aplicável Sinonímia: Bupropion hydrochloride Descrição / especificação técnica: Pó cristalino br

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