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


Our search identified 640 abstracts, of which 451 were rejected out of hand as non-pertinent. One hundred eighty-seven were considered relevant and reviewed in more detail (Fig. 1). Ultimately 8 trials, involving 486 patients met our inclusion criteria (Table 2). All 8 of these trials utilized the International Classification of Headache Disorders to identify eligible patients.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

The studies included in this analysis came from multiple different practice settings included emergency departments (EDs), public health clinics, and specialty clinics from 3 different continents (Table 2). No two studies investigated the same medication regimen.

Analyses of efficacy revealed that the anti-emetic metoclopramide, the phenothiazine chlorpromazine, the analgesic metamizole, and the opioid pethidine, when administered as mono-therapy, are efficacious treatments of acute tension-type headache when compared to placebo (Table 3 and Table 4). The anesthetic agent mepivacaine, subcutaneous sumatriptan, the nitrase oxide synthase inhibitor L-N(G) methyl arginine hydrochloride (LNMMA), and the opioid meperidine when co-administered with the anti-emetic promethazine, were not efficacious treatments when compared to placebo (Table 3 and Table 4). When compared to pethidine, metoclopramide demonstrated superiority. The combination of meperidine + promethazine proved comparable to ketorolac, while metoclopramide + diphenhydramine was superior to ketorolac (Table 3 and Table 4).

These medications were generally well tolerated, though sumatriptan and pethidine caused more adverse events than placebo (Table 3 and Table 4).

In general, the quality of studies was unclear or high, without substantial risk of bias (Table 5).