This protocol addresses episodic tension-type headache — headache occurring on fewer than 15 days per month — in patients who did not achieve adequate relief with a first-line single-agent analgesic or NSAID.
Episodic tension-type headache (fewer than 15 days of headache per month) is managed acutely with symptomatic drugs. Prophylactic treatment is generally reserved for very frequent episodic or chronic TTH; it is not indicated here.
The first-line approach for episodic TTH is a single-agent simple analgesic or NSAID — such as paracetamol, ibuprofen, aspirin, naproxen, ketoprofen, or diclofenac. When this fails to achieve the primary goal — pain-free at 2 hours after treatment — escalation to a second-line strategy is indicated.
When a single analgesic agent is insufficient, guidelines support augmenting analgesic efficacy through a specific type of combination approach. The complete regimen — including which combinations are recommended and the relevant risk considerations — is available in the full protocol.
Pain-free 2 hours after treatment — the primary efficacy measure for acute TTH management per International Headache Society trial standards.
Tension-type headache is classified into three subtypes according to headache frequency: infrequent episodic TTH (<1 day of headache per month), frequent episodic TTH (1–14 days of headache per month) and chronic TTH (≥15 days per month).
When it comes to pharmacological management, the general rule is that patients with episodic TTH are treated with symptomatic (acute) drugs, whilst prophylactic drugs should be considered in patients with very frequent episodic TTH and in patients with chronic TTH.
The efficacy of simple analgesics and NSAIDs is increased by combination with caffeine 64–200 mg.
Until otherwise proven, we therefore recommend that simple analgesics or NSAIDs are drugs of first choice and that combinations of one of these drugs with caffeine are drugs of second choice for the acute treatment of TTH.
Combination with caffeine 65–200 mg increases the efficacy of ibuprofen and paracetamol, but possibly also the risk for developing medication-overuse headache.
The guidelines for drug trials in TTH from the International Headache Society recommend pain-free after 2 h as the primary efficacy measure.
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