Prophylaxis For Tension Type Headache

You review a 31-year-old woman who is suffering from frequent tension-type headaches. Her headaches partially respond to paracetamol and ibuprofen but she asks if there is any treatment to stop the headaches coming in the first place. What is the most appropriate action?

A. Trial of citalopram
B. Trial of propranolol
C. Issue an exercise prescription
D. Trial of amitriptyline
E. Refer for acupuncture

Answer:
E. Refer for acupuncture

Discussion: 

Tension-type headache is form of episodic primary headache. 

Characteristic features 

 often described as a 'tight band' around the head or a pressure sensation. 

Symptoms tend to be bilateral, where as migraine is typically unilateral 

 tends to be of a lower intensity than migraine

 not associated with aura, nausea/vomiting or aggravated by routine physical activity 

 may be related to stress 

 may co-exist with migraine 

Chronic tension-type headache is defined as a tension headache occur on 15 or more days per month. 

NICE produced guidelines on the management of tension-type headache in 2012: 

 acute treatment: aspirin, paracetamol or an NSAID are first-line 

 prophylaxis: NICE recommend 'up to 10 sessions of acupuncture over 5-8 weeks' 

 low-dose amitriptyline is widely used in the UK for prophylaxis against tension-type headache. 

The 2012 NICE guidelines do not however support this approach '...there was not enough evidence to recommend pharmacological prophylactic treatment for tension type headaches. The GDG considered that pure tension type headache requiring prophylaxis is rare. Assessment is likely to uncover coexisting migraine symptomatology with a possible diagnosis of chronic migraine.'