Parenteral Treatment of Episodic Tension-Type Headache: A Systematic Review

Danielle Weinman, MD; Olivia Nicastro, NP; Olabiyi Akala, MD; BenjaminW. Friedman, MD


Headache. 2014;54(2):260-268. 

In This Article

Abstract and Introduction


Background.—Tension-type headache is highly prevalent in the general population and is a consistent if not frequent cause of visits to acute care settings. Analgesics such as nonsteroidal anti-inflammatory drugs, acetaminophen, and salicylates are considered first-line therapy for treatment of tension-type headache. For patients who present to an acute care setting with persistent tension-type headache despite analgesic therapy, it is not clear which parenteral agent should be administered. We performed a systematic review of the medical literature to determine whether parenteral therapies other than salicylates or nonsteroidals are efficacious for acute tension-type headache.

Methods.—We performed a systematic review of Medline, EMBASE, CINAHL, Google scholar, and the Cochrane Central Registry of Controlled Trials from inception through August, 2012 using the search terms "tension-type headache" and "parenteral or subcutaneous or intramuscular or intravenous." Our goal was to identify randomized trials in which one parenteral treatment was compared to another active comparator or to placebo for the acute relief of tension-type headache. Parenteral was defined as intravenous, intramuscular, or subcutaneous administration. We only included studies that distinguished tension-type headache from other primary headache disorders, such as migraine. The primary outcome for this review was measures of efficacy one hour after medication administration. Data abstraction was performed by two authors. Disagreements were resolved by a third author. We assessed the internal validity of trials using the Cochrane Collaboration risk of bias tool. Because of the small number of trials identified, and the substantial heterogeneity among study design and medications, we decided that combining data and reporting summary statistics would serve no useful function. The results of individual studies are presented using Number Needed to Treat (NNT) with 95%CI when dichotomous outcomes were available and continuous outcomes otherwise.

Results.—Our search returned 640 results. One hundred eighty-seven abstracts were reviewed, and 8 studies involving 486 patients were included in our analysis. The most common reasons for exclusion of abstracts were no assessment of acute pain relief, use of nonparenteral medications only, and no differentiation of headache type. Risk of bias ranged from low to high. The following medications were more effective than placebo for acute pain (NNT, 95%CI): metamizole (4, 2–26), chlorpromazine (4, 2–26), and metoclopramide (2, 1–3). The combination of metoclopramide + diphenhydramine was superior to ketorolac (4, 2–8) The following medications were not more effective than placebo: mepivacaine, meperidine + promethazine, and sumatriptan.

Conclusions.—Various parenteral medications other than salicylates or nonsteroidals provide acute relief of tension-type headache. Comparative efficacy studies are needed.


Tension-type headache, the most common of the primary headache disorders, affects 38% of the American population.[1] Typically, tension-type headache is mild or moderate in intensity, and only uncommonly causes functional disability.[2] Because of its relatively benign nature, tension-type headache causes visits to acute care settings less frequently than migraine. Only 3% of Americans who suffer from severe tension-type headache report use of an acute care setting within the preceding 12 months for management of their headache,[3] though tension-type headache still accounts for 10–15% of all emergency department primary headache visits, resulting in more than 200,000 visits annually[4,5] Tension-type headache is characterized by the absence of the defining features of migraine or cluster headache.[2] Rather than the unilateral pulsating pain of migraine, or the severe peri-orbital boring pain of cluster, tension-type headache patients describe it as a bilateral squeezing or pressure-like pain. It is defined by the absence of migraine's nausea and vomiting, and while photophobia or phonophobia may be present, the combination of these two features excludes the diagnosis. Similarly, the autonomic symptoms of cluster headache do not occur with tension-type headache. Diagnostic guidelines define tension-type headache as a chronic episodic disorder, characterized by acute exacerbations of the typical headache.[2] Subtypes include chronic tension-type headache, which requires headache on greater than 15 days per month, and episodic versions, in which the exacerbations are less frequent.[2]

Patients typically treat acute tension-type headache with oral salicylates, acetaminophen, or nonsteroidal anti-inflammatory agents.[6] These treatments are effective for the majority of patients, during most exacerbations. However, patients with tension-type headache present at times to acute care settings complaining of headache despite appropriate oral therapy. In this scenario, is uncertain what medication should be administered. We therefore performed a systematic review to answer the following question: For adult patients who present to an acute care setting, what parenteral medications, other than salicylates, acetaminophen, or non-steroidal anti-inflammatory drugs (NSAIDs), relieve the acute pain of tension-type headache more than placebo or active comparators?