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Tension-type headache
SOHAN PAREKH AND ANDY JAGODA
n Agents
n Triptans
n Antiemetics
n NSAIDs
n Acetaminophen
n Evidence
In the ED, diagnostic differentiation between migrainous pain and tension
headache (TH) can be difficult. Fortunately, the best ED migraine therapies
(the triptans and the antiemetics metoclopromide and prochlorperazine)
are also efficacious for tension-type cephalalgia. 1–4 At a minimum, the “antimigraine”
agents may be used as second-line therapy for TH. In actual
practice, given the often-encountered situation in which NSAIDs have either
failed or are best avoided, the triptans or antiemetics constitute preferred
pharmacotherapy for TH.
For many years, traditional employment of NSAIDs as the ED therapy of
choice for TH was based upon a paucity of supporting data. Recently, the
state of the evidence has improved, with trials assessing NSAIDs’ performance
both against placebo and in comparison with each other. The placebocontrolled
trials find TH benefit from myriad agents (e.g. aspirin, ibuprofen,
diclofenac, naproxen, ketoprofen, lumaricoxib), and similar performance
across different NSAIDs. 5–9 Some representative studies are presented here.
Pain relief in TH is similar for ibuprofen (400 mg PO) and diclofenac
(12.5 mg PO). 10 Low-dose ibuprofen (200 mg PO) relieves TH better than
placebo, but not as well as ketoprofen (25 mg PO). 11 Some of aspirin’s
unique pharmacologic effects (i.e. compared with other NSAIDs) may make
it relatively more useful in TH, but there are no data demonstrating aspirin
superiority for this diagnosis. 6 COX-2 selective NSAIDs have also been found