16. Treatment of Tension-Type Headache

  1. Nils Erik Gilhus MD, PHD8,9,
  2. Michael P. Barnes MD, FRCP10,11 and
  3. Michael Brainin MD12,13,14
  1. L. Bendtsen1,
  2. S. Evers2,
  3. M. Linde3,4,
  4. D. D. Mitsikostas5,
  5. G. Sandrini6 and
  6. J. Schoenen7

Published Online: 21 SEP 2011

DOI: 10.1002/9781444346268.ch16

European Handbook of Neurological Management, Volume 2, Second Edition

European Handbook of Neurological Management, Volume 2, Second Edition

How to Cite

Bendtsen, L., Evers, S., Linde, M., Mitsikostas, D. D., Sandrini, G. and Schoenen, J. (2011) Treatment of Tension-Type Headache, in European Handbook of Neurological Management, Volume 2, Second Edition (eds N. E. Gilhus, M. P. Barnes and M. Brainin), Wiley-Blackwell, Oxford, UK. doi: 10.1002/9781444346268.ch16

Editor Information

  1. 8

    Department of Clinical Medicine, University of Bergen, Norway

  2. 9

    Department of Neurology, Haukeland University Hospital, Bergen, Norway

  3. 10

    University of Newcastle, Newcastle upon Tyne, UK

  4. 11

    Hunters Moor Neurorehabilitation Ltd, Newcastle upon Tyne, UK

  5. 12

    Department of Clinical Medicine and Prevention, Austria

  6. 13

    Center for Clinical Neurosciences, Donau-Universität Krems, Austria

  7. 14

    Department of Neurology, Landesklinikum Donauregion Tulln, Tulln, Austria

Author Information

  1. 1

    Glostrup Hospital, University of Copenhagen, Denmark

  2. 2

    University of Münster, Münster, Germany

  3. 3

    University of Gothenburg and St Olav's Hospital, Trondheim Norway

  4. 4

    Norwegian University of Science and Technology, Trondheim, Norway

  5. 5

    Athens Naval Hospital, Athens, Greece

  6. 6

    IRCCS Catholic University of Pavia, Pavia, Italy

  7. 7

    University of Liège, Liège, Belgium

Publication History

  1. Published Online: 21 SEP 2011
  2. Published Print: 30 SEP 2011

ISBN Information

Print ISBN: 9781405185349

Online ISBN: 9781444346268



  • treatment of tension-type headache (TTH);
  • guidelines, evidence-based recommendations-for acute and prophylactic drug treatment of TTH;
  • TTH, three subtypes according to headache frequency-and infrequent episodic TTH;
  • acute drug treatment of TTH-individual attacks of headache, episodic and chronic TTH;
  • diagnosis of TTH, based on typical patient's history-normal neurological examination;
  • effect of acute drugs in TTH-methods for measurement of efficacy;
  • simple analgesics and NSAIDs;
  • recommended drugs-for acute therapy of TTH;
  • non-invasive physical therapy-for treatment of TTH, posture improvement and massage;
  • acupuncture and nerve block-prophylactic effect of acupuncture, investigated


Background: Tension-type headache (TTH) is the most prevalent headache type and causes a high degree of disability. Treatment of frequent TTH is often difficult.

Objectives: To provide evidence-based or expert recommendations for the different treatment procedures in TTH based on a literature search and the consensus of an expert panel.

Methods: All available medical reference systems were screened for a range of clinical studies on TTH. The findings of these studies were evaluated according to the recommendations of the EFNS resulting in Level A, B or C recommendations and good clinical practice points.

Recommendations: Non-drug management should always be considered, although the scientific basis is limited. Information, reassurance and identification of trigger factors may be rewarding. EMG biofeedback has a documented effect in TTH, while cognitive-behavioural therapy and relaxation training may also be effective. Physical therapy and acupuncture may be valuable options for patients with frequent TTH, but there is no robust scientific evidence for this.

Simple analgesics and non-steroidal anti-inflammatory drugs are recommended for treatment of episodic TTH. Combination analgesics containing caffeine are drugs of second choice. Triptans, muscle relaxants and opioids should not be used. It is crucial to avoid frequent and excessive use of analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is the drug of first choice for the prophylactic treatment of chronic TTH. Mirtazapine and venlafaxine are drugs of second choice. The efficacy of the prophylactic drugs is often limited and treatment may be hampered by side-effects.