Headache (chronic tension-type) Clinical Evidence BMJ
Headache (chronic tension-type)
New option(s) added for:
Anticonvulsant drugs New option added, for which we found no systematic review or RCTs. Categorised as Unknown effectiveness.
Spinal manipulation (chiropractic and osteopathic treatment) Two systematic reviews and one further RCT added to benefits and harms.
One RCT identified by one review found greater reduction in headache severity after treatment with palpatory examination plus osteopathic manipulation versus palpatory examination alone or versus instruction to rest in people with muscle tension-type headache. One RCT identified by both reviews found a reduction in headache intensity with amitriptyline versus spinal manipulation after 6 weeks’ treatment, but no significant reduction in headache frequency between groups. However, there was a significant reduction in headache intensity and frequency with spinal manipulation compared with amitriptyline at 4 weeks after treatment discontinuation. One further RCT found improved headache frequency with osteopathic treatment plus progressive muscular relaxation exercises versus progressive muscular relaxation exercises alone, but no significant difference between groups in headache intensity after 6–7 weeks’ follow-up. Two systematic reviews of observational studies added to the harms section found reported cases of serious adverse effects, including arterial dissection causing stroke, other stroke syndromes, and cerebellar and spinal cord injuries with the use of spinal manipulation.
Categorisation as Likely to be ineffective or harmful.
New evidence; conclusions changed for:
Noradrenergic and specific serotonergic antidepressants One RCT added found no significant difference in headache frequency, duration, or intensity with low-dose mirtazapine plus ibuprofen or mirtazapine alone versus ibuprofen alone or placebo. Categorisation changed (from Beneficial to Likely to be beneficial).
New evidence; conclusion confirmed for:
Botulinum toxin Two RCTs added, comparing botulinum toxin versus placebo.
One RCT found an increase in headache-free days with botulinum toxin 150 U (but not with lower doses) versus placebo after 60 days. It found no significant difference in headache duration or average headache severity with botulinum toxin versus placebo after 60 days. The other RCT found a reduction in headache intensity, but no significant difference in headache frequency with botulinum toxin versus placebo at an average of 178 days’ follow-up. Categorisation unchanged (Likely to be ineffective or harmful).
Analgesics One RCT added found no significant difference in headache frequency and duration with ibuprofen alone, or plus low-dose mirtazapine, versus low-dose mirtazapine alone or placebo. It found an increase in headache intensity with ibuprofen alone compared with placebo. Categorisation unchanged (Likely to be ineffective or harmful).
Acupuncture One RCT added, comparing acupuncture versus minimum acupuncture versus no intervention. It found improvements in headache frequency, duration, and headache score (assessing headache intensity) with acupuncture compared with no intervention. It found no significant difference in any of these outcomes with acupuncture compared with minimum acupuncture. Categorisation unchanged (Unknown effectiveness).