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386 Tension-type headache
for TH, but lacking evidence basis for current recommendations in acute
care, include niacin and botulinum toxin. 24,25
Although opioids may have some role for refractory TH, evidence support
for their use is limited. Anecdotal reports endorse use of PO tramadol for
TH. 26 One of the few existing comparisons between an opioid and an antiemetic
found meperidine less reliable for TH relief than metoclopramide. 4
Nevertheless, some patients with suspected TH will fail to respond to standard
therapy. The clinician should not assume these patients are drug seekers;
it may well be the case that the diagnosis of TH is in error. Assuming the pain
is real, and providing appropriate rescue analgesia (which will often be best
achieved with opioids), is the best course for TH or any other headache
syndrome.
n Summary and recommendations
First line: NSAID (e.g. ibuprofen 400–600 mg PO q6–8h)
Reasonable: acetaminophen (1000 mg PO q6 h)
Pregnancy: acetaminophen (1000 mg PO q6 h)
Pediatric: NSAID (e.g. ibuprofen 10 mg/kg PO q6–8h)
Special case:
n pain unresponsive to NSAIDs or acetaminophen: triptans (e.g. sumatriptan
6 mg SC) or antiemetic (e.g. prochlorperazine 10 mg IV)
References
1. Miner JR, Smith SW, Moore J, et al. Sumatriptan for the treatment of undifferentiated
primary headaches in the ED. Am J Emerg Med. 2007;25:60–64.
2. Thomas S, Stone C, Ray V, et al. Intravenous vs. rectal prochlorperazine for
the treatment of benign vascular or tension headache. Ann Emerg Med.
1994;23:923–927.
3. Jones J, Sklar D, Dougherty J, et al. Randomized double-blind trial of intravenous
prochlorperazine for the treatment of acute headache. JAMA.
1989;261:1174–1176.