Pain in Primary Care

Tension Headaches: What About Nondrug Therapies?

Charles P. Vega, MD

Disclosures

February 18, 2022

Recently, I posted a case from my own practice to highlight a common issue of pain management in primary care. Alejandra was a 38-year-old woman with a 4-month history of what seemed to be tension-type headache (TTH) complicated by over-the-counter medication overuse. I asked for comments about my management of this patient.

Thank you for the many insightful and helpful comments I received. It appears that Alejandra's case resonated with many readers, either because of their experience with patients with chronic TTH or because they have TTH themselves.

Alejandra's lifestyle is certainly contributing to her TTH, and her life currently centers around work. The intensity of her job is causing psychological and possibly physical stress, and several readers suggested ergonomic changes to help her headache. A randomized trial compared an ergonomic intervention plus neck exercises vs general health promotion among a cohort of office workers with and without neck pain. The ergonomic treatment group experienced significant reductions in neck pain over the 12-week treatment period, with clinically significant improvement of approximately 50% in the cohort with neck pain at baseline. However, unlike some other studies of nonpharmacologic treatment, these positive gains associated with ergonomic treatment were not maintained in the long term (12 months). Ergonomic treatment is certainly worth a try in this case.

There was also support for manipulative therapy for Alejandra, and limited evidence suggests that this is an effective approach for cervicogenic headache in particular. A previous meta-analysis pooled results from seven studies to compare spinal manipulative therapy with other forms of manual therapy in the management of cervicogenic headache. Spinal manipulative therapy was associated with small gains for pain intensity, pain frequency, and disability; however, these improvements subsided after the treatment period.

Multiple responders espoused injection therapy, including dry needling, for TTH. There is evidence that dry needling is an effective therapy. A trial by Gildir and colleagues randomly assigned 168 patients with chronic TTH to six sessions of trigger-point dry needling of the head and neck vs sham dry needling. Trigger-point dry needling was associated with a sharp decline in the intensity, frequency, and duration of headache, and these improvements remained stable for 4 weeks after the 2-week intervention period.

Clearly, multiple modalities are available to treat TTH and, as one response suggested, most patients will use several different treatment options for chronic TTH. That makes sense, but it also requires greater investments of time and effort on the part of the patient. Time is something that Alejandra does not have on her side with her demanding lifestyle.

Alejandra's lifestyle is not healthy; that is clear. But the treatment team needs to be conscious that it is her life to live. Directives to sleep and relax more may be met by resistance, as could scheduling of frequent appointments. Multimodal therapy is time-consuming and may increase Alejandra's stress levels even further.

As an alternative, presenting options to Alejandra and engaging in shared decision-making will promote greater adherence and create an opportunity to establish patterns that result in real lifestyle changes over time. That may help relieve her TTH and improve her overall health status as well.

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