THE JOURNAL OF FAMILY PRACTICE Arianne P.Verhagen, PhD, Is any one analgesic Léonie Damen, PhD, Marjolein Y.Berger, MD, PhD, Jan Passchier, PhD, superior for episodic Vivian Merlijn, PhD, and Bart W. Koes, PhD tension-type headache? Department of General Practice, Erasmus Medical This systematic review suggests good tolerance Centre, Rotterdam, The Netherlands. of any given agent may be the deciding factor From the Department of General Practice (APV, LD, MYB, BWK) and the Practice recommendation drug that is well tolerated by a patient is a Department of Medical T Though all non-narcotic analgesics have reasonable basis for selection. Ibuprofen, Psychology and Psychotherapy equivalent efficacy against tension-type therefore, generally may be advocated. (JP, VM) ® Dowden Health Media headache, ibuprofen’s generally favorable When acetaminophen is preferred. Our side-effect profile makes it a reasonable results suggest NSAIDs might be more firCopyrightst choice. For personal use onlyeffective than acetaminophen for TTH. However, because NSAIDs are allergenic hereas quantitative and qualita- for some people, and they must not be tive analyses of 41 randomized used in association with anticoagulants,2 W controlled trials (RCTs) strongly acetaminophen might be an alternative in suggests that all types of NSAIDs are more these situations. When giving acetamino- effective than placebo (>50% pain relief) phen, the dose of the medication might be against an acute episode of tension-type important due to a possible dose-response headache (TTH), the evidence also shows relationship. that no single nonsteroidal anti-inflamma- tory drug (NSAID) is more effective than Why this review was needed another in this setting. Tension-type headache, also known as How, then, to choose an NSAID? Many tension headache or muscle contraction of the 41 articles we reviewed reported on headache, is the most commonly experi- the side effects of NSAIDs. No clear differ- enced type of headache (see Episodic ences were reported in the number of side tension-type headache). Population-based effects between the NSAIDs and placebo. studies suggest prevalence rates of 35% to However, differences were found among 40% in adults.3–5 the types of NSAIDs. Our results agree Persons experiencing an acute episode with those found by Henry et al,1 who con- of TTH most often self-treat with mild, cluded from their meta-analysis that non-narcotic analgesics for initial pain C O RRESPONDENCE ibuprofen, compared with other NSAIDs, relief. Studies have suggested that aceta- Arianne P.Verhagen, PhD, Department of General had the lowest relative risk of serious gas- minophen and NSAIDs like aspirin, Practice, Erasmus Medical trointestinal complications. Given the lack ibuprofen, naproxen, and ketoprofen are Centre, PO Box 1738, of important differences in efficacy among effective in reducing headache symptoms. 3000 DR Rotterdam, The Netherlands. E-mail: NSAIDs for relieving an acute episode of But a variety of drugs, dosages, and [email protected] TTH, using the most effective dose of a combinations have been described. No 1064 VOL 55, NO 12 / DECEMBER 2006 THE JOURNAL OF FAMILY PRACTICE For mass reproduction, content licensing and permissions contact Dowden Health Media. Analgesics for tension-type headache L systematic review has, until now, described Episodic tension-type headache the efficacy and tolerability of analgesics for the treatment of acute episodes of Episodic TTH has been defined in the classification of the TTH. Good quality-controlled trials and a International Headache Society (IHS) as headache frequency systematic review form the basis for evi- of greater than 10 lifetime episodes, but fewer than 15 episodes dence-based treatment guidelines, which per month; an average episode duration of 30 minutes to 7 days; provide a basis for the individual patient. and with at least 2 quality of pain features (ie, mild or moderate We aimed to describe and assess the pain intensity, bilateral, pressing or tightening [nonpulsating] feeling, data from RCTs concerning the efficacy and no exacerbation by exercise).7 In addition, the headache and tolerability of analgesics for the treat- does not have the IHS-defining features of migraine (ie, nausea, ment of acute episodes of TTH in adult vomiting, or photophobia and phonophobia). The definition of patients. Details of our Methods and chronic TTH is identical to those for episodic TTH, except that Results follow. the episode frequency is 15 or more episodes per month for at least 6 months, and 1 associated symptom of nausea, photophobia, or phonophobia is permitted. T Methods Search strategy and then again independently reviewed by Medline and EMBASE were searched from 2 authors (LD, AV). Disagreements were inception to January 2005 using the terms resolved through consensus where possi- tension-type headache, tension headache, ble, or by arbitration with a third author stress headache, or muscle contraction (MB). Crossover designs often presented headache together with the search strategy data from treatment groups, as if the trial for identifying RCTs described by was a parallel group trial. The results from Robinson and Dickerson.6 The Cochrane these studies were excluded from data- Controlled Trials Register was searched analysis if no results from both arms were using the words tension headache or ten- presented or a binary correlation coeffi- sion-type headache or muscle contraction cient was available.9 headache. Additional strategies for identi- fying trials included searching the reference Methodological quality lists of review articles and included studies. and data extraction Two authors (LD with MB, BK, or AV) Study selection independently rated the methodological Only RCTs including analgesic medicine quality of the included trials using the used in the treatment or management of Delphi list.10 The Delphi list is a generic cri- TTH conducted among adult patients teria list developed by international consen- (aged 18 years or older), with reasonable sus and consists of the following 9 items: 1) criteria designed to distinguish TTH from randomization; 2) adequate allocation con- migraine, were selected for our review. The cealment; 3) groups similar at baseline; 4) use of a specific set of diagnostic criteria specification of eligibility criteria; 5) blind- (eg, IHS 1988 and Ad Hoc 1962)7,8 was ing of outcome assessor; 6) blinding of care not required, but TTH diagnoses had to be provider; 7) blinding of patient; 8) presen- based on at least some of the distinctive tation of point estimates and measures of features of TTH—eg, bilateral in location, variability; 9) intention-to-treat-analysis. no nausea or vomiting, mild or moderate One extra item was added: 10) withdrawal intensity, or no exacerbation by exercise. or dropout rate unlikely to cause bias. All Main outcome measures were pain selected methodological criteria were relief or recovery over 2 to 6 hours. scored as yes (= 1), no (= 0) or don’t know Two authors (LD, AV) independently (= 0). A quality score of a trial was comput- screened titles and abstracts of identified ed by counting the number of positive studies for eligibility. All potentially rele- scores, with equal weights applied on all vant studies were retrieved as full papers items. In case of a disagreement between www.jfponline.com VOL 55, NO 12 / DECEMBER 2006 1065 THE JOURNAL OF FAMILY PRACTICE FIGURE 1 How the 41 trials made our cut for the review Potential relevant RCTs identified and screened for retrieval (n=1878) M M RCTs retrieved for more detailed RCTs excluded based on title and abstract: evaluation (n=394) no randomized controlled trial or no diagnosis of tension-type headache or no comparisons of different M M RCTs included in meta-analysis RCTs excluded (n=41) • No randomized controlled trial (n= 56) • Participants not restricted to tension-type headache (n=35) • No analgesic treatment (n=138) • No relevant outcome measures (n=10) • No separate analysis for tension-type headache (n=8) • Population of children (n=14) • Insufficient control interventions (n=1) • Review/abstract/letter (n=87) • Double publication (n=4) the 2 authors, consensus was used to were recovered (often defined as more resolve disagreement. When consensus than 50% pain relief) was used to calculate could not be reached, a third author made relative risk (RR) with 95% confidence the final decision (MB or AV). interval (CI). RRs and 95% CI were pre- FAST TRACK Extraction of data from the original sented using the random effects model. The most effective reports was performed by 1 author (LD) Data are presented as treatment success, and checked by a second (AV). indicating that an RR >1 represents a bet- dose of any drug Disagreements were resolved by consen- ter outcome for the first mentioned med- well tolerated sus. Extracted information included (if ication group. by a patient available) demographic data, detailed In parallel studies, when more than 1 description of the intervention and control comparison from the same study (ie, is reasonable (ie, dose given, study duration, rescue med- aspirin 650 mg vs placebo and ibuprofen ication), data on pain relief or recovery, 400 mg vs placebo) was used for the statis- and information on adverse effects meas- tical pooling of NSAIDs vs placebo, the ured during a treatment period of 2 to 6 results from the placebo group were even- hours. When a trial protocol permitted the ly spread out over the 2 comparisons and use of rescue medication prior to the out- the number of patients in the placebo come time (2 to 6 hours), then the latest group was divided by 2 in order to prevent outcome assessment not confounded by double counting (personal communication the use of rescue medication was extracted RJPM Scholten, Dutch Cochrane Centre). Because only a subset of available trials Data analysis provides sufficient data for inclusion in the A quantitative analysis was limited to clin- quantitative analysis, also a qualitative ically homogenous studies for which the analysis was performed.