Tension-type headache in adults: Acute treatment

INTRODUCTION — Tension-type headache (TTH) is characterized by bilateral, nonthrobbing head pain of a mild to moderate intensity, typically without other associated features. TTH is the most common headache and prevalent neurologic disorder in the population. Due to its high prevalence, TTH is associated with a significant burden of disability.

The acute treatment of TTH in adults is reviewed here. Other aspects of TTH are discussed separately.

●(See "Tension-type headache in adults: Etiology, clinical features, and diagnosis".)

●(See "Tension-type headache in adults: Preventive treatment".)

●(See "Tension-type headache in children".)

GOALS OF TREATMENT — Effective acute treatment of TTH should result in sustained improvement or resolution of headache pain. Validated criteria for judging the effectiveness of acute TTH therapy in clinical practice are not yet available, but such criteria do exist for acute migraine treatment [1]. In the absence of specific TTH measures, the migraine criteria can be used by clinicians to assess the success of acute TTH treatment and to identify patients who may benefit from a change in therapy. Reasonable goals for an acute TTH treatment regimen include:

●Headache pain resolves promptly (eg, within two to four hours of treatment)

●Symptom resolution is durable (ie, is disability limited) without recurrence

●Headaches respond to acute treatment consistently (ie, ≥75 percent of the time)

●Tolerable medication administration, adverse effects, and cost

The treatment should be considered ineffective if two or more of these criteria are not met.

INITIAL TREATMENT — Acute treatment of TTH is most commonly self-directed using over-the-counter medications without any input from a medical provider. For the vast majority of patients affected by TTH requiring medical care, primary care can and should provide management [2].

TTH that is refractory to initial treatment options may warrant diagnostic evaluation or referral to a specialist. (See 'Diagnostic reevaluation' below.)

General treatment principles

●Treat early – Acute TTH treatment is felt to be most effective if given early after onset of symptoms. However, data to support this principle are based on timing of abortive therapy for patients with migraine as no valid data exist for patients with TTH.

●Use effective initial dose – Treatment should be individualized using an effective initial dose. Starting with the maximum medication dose in acute therapy is customary, with the goal of limiting subsequent repeat dosing. However, there is no definitive evidence to support this principle, even though a dose-ranging curve likely exists with simple analgesics [3,4]. Some patients obtain effective pain relief with a low analgesic dose. Others may prefer a low dose to minimize the risk of adverse effects.

●Limit dosing frequency of acute treatment – The frequency of acute treatment should be limited to avoid medication overuse headache. Simple analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) should be used 14 or fewer days a month, combination analgesics nine or fewer days a month, and butalbital-containing analgesics three or fewer days a month. (See "Medication overuse headache: Treatment and prognosis", section on 'Follow-up and relapse prevention'.)

Simple analgesics for most patients — For most patients with episodic TTH (<15 headaches a month), we recommend initial treatment with simple analgesics such as an NSAID or aspirin (algorithm 1). We typically treat as early as possible after headache onset for optimal efficacy. For patients with symptoms unresponsive to initial choice of therapy, we switch to a different analgesic option.

For patients who cannot tolerate NSAIDs or aspirin, we recommend a single dose of acetaminophen. (See 'Acetaminophen' below.)

NSAIDs or aspirin — Nonsteroidal antiinflammatory drugs (NSAIDs) and aspirin are effective for mild to moderate symptoms in TTH. Reasonable initial choices for acute TTH include a single dose of:

●Ibuprofen (400 to 600 mg)

●Naproxen sodium (220 to 550 mg)

●Aspirin (500 to 650 mg)

For those unresponsive to or unable to take initial options, diclofenac (25 to 100 mg) and ketoprofen (25 to 50 mg) are potential alternatives.

Available evidence from clinical trials and systematic reviews supports the use of simple analgesic agents in the acute treatment of TTH [5-11].

●Efficacy – NSAIDs appear to have similar effectiveness for TTH when compared with each other in clinical trials [6,8,12-16].

Ibuprofen, ketoprofen, and naproxen are the best studied agents. In a systematic review of 12 studies including 3094 patients with acute TTH, ibuprofen 400 mg was found to be more effective than placebo at two hours and was well tolerated, with adverse effects that were both minor and similar to placebo [10]. In available studies, the proportion of patients reporting very good or excellent response was 40 percent for ibuprofen compared with 23 percent for placebo. Naproxen at 375 mg was found to have similar efficacy to acetaminophen 1000 mg [17], and naproxen sodium at 550 mg was found to have similar efficacy to acetaminophen 1000 mg with caffeine [18].

Ketoprofen at 25 mg also appears to be effective with studies reporting similar efficacy to acetaminophen 1000 mg, ibuprofen 200 mg, and naproxen sodium 275 mg [13,19,20]. Among the NSAIDs less studied for treating TTH, one trial found that diclofenac (12.5 mg and 25 mg) was effective for episodic TTH compared with placebo [16], but no trials have evaluated diclofenac at the higher doses of 50 to 100 mg that were effective in migraine [6,16].

NSAIDs were found to be more effective for TTH than acetaminophen in several [19-23], but not all [3,17,24], trials.

Although simple analgesics and NSAIDs are useful for episodic TTH, their effectiveness is modest, with pain-free rates at two hours ranging from 16 to 37 percent [10].

Some experts also consider aspirin as first-line therapy for TTH, but there are few trials comparing aspirin with other analgesics for this indication [25]. In a systematic review of five trials including 1812 patients with acute TTH, a single dose of aspirin at 500 or 1000 mg was well tolerated, more effective than placebo, and was associated with a lower rate of subsequent rescue medications (14 versus 31 percent) [26]. However, the certainty of these results is limited by varying treatment doses, different measures of efficacy, and small numbers of events available for analysis.

●Dosing – Systematic reviews of randomized controlled trials concluded that acetaminophen 1000 mg, ibuprofen 400 mg, and ketoprofen 25 mg were more effective than placebo using the preferred efficacy parameter of pain-free rates at two hours [5,10]. In addition, aspirin, naproxen, and diclofenac at typically used doses were each likely more effective than placebo.

Aspirin also has been reported to be more effective than placebo in doses of 500 to 1000 mg [3,6,26]. One study demonstrated a significant dose-response relationship of aspirin with 1000 mg being superior to 500, and 500 mg being superior to 250 mg [4]. In addition, an early trial found that nearly 650 mg of either solid or effervescent aspirin was more effective than placebo for the treatment of TTH with similar efficacy for the two forms of aspirin [27].

●Adverse effects – NSAIDs are associated with risks of cardiovascular events and kidney injury, and both NSAIDs and aspirin increase the risk of gastrointestinal bleeding. In studies of patients with acute TTH, NSAIDs and aspirin were generally well tolerated. Systematic reviews concluded that ibuprofen for acute treatment of TTH is associated with only mild adverse effects at rates lower than other NSAIDs and similar to placebo [8,10]. NSAIDs and aspirin are less likely to lead to medication overuse headache than other commonly used analgesics, such as butalbital, acetaminophen, and codeine [28]. (See "Nonselective NSAIDs: Overview of adverse effects".)

Acetaminophen — Acetaminophen (paracetamol) is preferred initial therapy for patients with TTH who are unable to tolerate or have contraindications to NSAIDs or aspirin and for pregnant patients. Acetaminophen is typically used at 500 to 1000 mg as a single oral dose.

Some experts consider acetaminophen first-line therapy for TTH, based on similar efficacy with NSAIDs in some trials. Acetaminophen 1000 mg was significantly more effective than placebo in most trials while smaller doses were not superior to placebo [9]. As an example, one trial evaluated 638 subjects from the United Kingdom aged 16 to 65 years with episodic TTH [3]. More than 70 percent of patients who received aspirin or paracetamol 1000 mg reported pain relief by two hours, but the response rate with paracetamol 500 mg was similar to placebo (64 versus 55 percent).

However, other trials have failed to find similar efficacy of acetaminophen with other NSAIDs. As an example, one trial of 703 patients with TTH were assigned to acetaminophen 1000 mg, ketoprofen 12.5 mg, or ketoprofen 25 mg [19]. Rates of pain relief at four hours were higher for patients who received either dose of ketoprofen than those assigned to placebo. However, pain relief for those assigned to acetaminophen was similar to placebo.

Acetaminophen is generally well tolerated but is contraindicated for patients with severe liver disease. Acetaminophen is also associated with an elevated risk of liver injury when taken at doses above the therapeutic range. (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and evaluation".)

Parenteral analgesics or antiemetics for severe symptoms — For patients with severe or disabling TTH unresponsive to an initial self-administered simple analgesic who present to an emergency department (ED) or other setting where parenteral medications can be administered, we suggest a single dose of an antiemetic or analgesic medication by intravenous (IV) or intramuscular (IM) route (algorithm 1). While migraine is the most common headache among patients presenting to an ED, some patients with severe TTH may present for treatment when simple analgesics taken prior to presenting are ineffective. Parenteral medications may provide more rapid pain relief than oral agents. Options include:

●Ketorolac 30 mg IV or 60 mg IM (a reduced dose of ketorolac 15 mg IV or 30 mg IM is used for patients weighing <50 kg or >64 years old)

●Metoclopramide 10 mg IV

●Chlorpromazine 12.5 mg IV (given over 15 minutes)

Diphenhydramine (12.5 to 25 mg IV) may be given along with an antiemetic medication to prevent akathisia and other dystonic reactions.

There is limited evidence from small, low-quality trials regarding the efficacy of parenteral treatments for acute TTH [29]. A systematic review of trials that included patients with various types of TTH (episodic, chronic, and unknown frequency) concluded that parenteral medications more effective than placebo for acute relief of TTH include metoclopramide, chlorpromazine, and metamizole; comparative data were limited to the combination of metoclopramide plus diphenhydramine, which was found to be superior to ketorolac [30]. Metamizole is not available in many countries, including the United States, because it is associated with a risk of agranulocytosis.

IM ketorolac may be effective for moderate to severe acute TTH, but data are limited to a trial involving 41 patients with TTH (but only 18 with episodic TTH) who were randomly assigned to treatment with either IM ketorolac 60 mg, meperidine 50 mg plus promethazine 25 mg, or normal saline [31]. Ketorolac treatment was significantly more effective than placebo at 30 minutes and one hour and more effective than meperidine plus promethazine at two hours.

Patients with chronic tension-type headache — For patients who present acutely with chronic TTH (≥15 headache days a month), we start a preventive treatment agent in addition to acute treatment options. Analgesics or antiemetics may be used for patients with chronic TTH presenting with acute symptoms. However, acute treatment options alone may be ineffective for patients with chronic TTH. Such patients have a high rate of comorbid conditions such as anxiety and depression. In addition, patients are at risk for medication overuse headache. (See "Tension-type headache in adults: Preventive treatment", section on 'Indication for preventive treatment'.)

MANAGEMENT OF PATIENTS WITH PERSISTING SYMPTOMS — For patients who do not respond to initial treatment options, we reevaluate the diagnosis to assess for other headache conditions that may also present with bilateral nonthrobbing head pain. For those with TTH, we typically offer combination therapy.

Diagnostic reevaluation — When acute treatment of TTH is ineffective, multiple factors may be contributing. The patient may have refractory TTH or the diagnostic impression of episodic TTH may be incorrect. Alternative causes of headache that may require different treatment strategies should be assessed.

●Common alternative diagnoses include:

•Migraine without aura – Migraine without aura is the most common alternative diagnosis for patients unresponsive to TTH initial treatment. Diagnostic misattribution may be due to underreporting of migraine symptoms or baseline disability of the patient or from failure of the clinician to consider migraine. In one study of 423 adults who were evaluated in headache clinics for self-reported tension headache, 65 percent were determined to have migraine and 84 percent met criteria for both migraine and TTH [32]. Migraine without aura is likelier to cause unilateral and pulsatile symptoms and is frequently associated with nausea, vomiting, photophobia, or phonophobia (table 1). (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults".)

•Chronic tension-type headache – Chronic TTH refers to TTH that occurs ≥15 days a month on average for at least three months [33]. Chronic TTH is less responsive to acute therapies than episodic TTH and is often associated with comorbid stress, anxiety, and depression [34]. In this setting, preventive therapy is typically indicated. Parenteral analgesic or antiemetic agents may be tried for patients with severe acute symptoms, but acute treatment options alone are usually of little or no benefit. (See "Tension-type headache in adults: Preventive treatment", section on 'Indication for preventive treatment'.)

•Medication overuse headache – Some patients with frequent episodes of TTH may also develop medication overuse headache due to excessive use of acute therapies (table 2). Several medications may cause medication overuse headache including opioids, butalbital-containing combination analgesics, triptans, and simple analgesics. Symptoms attributable to medication overuse headache typically resolve following successful withdrawal of the offending agent. (See "Medication overuse headache: Etiology, clinical features, and diagnosis".)

•Secondary headaches – Headaches may be due to several other conditions, including brain tumor, stroke, intracranial hypertension, glaucoma, and giant cell arteritis. The presence of clinical history or features atypical for TTH or abnormalities on neurologic or systemic examination may suggest the possibility of secondary headaches (table 3). (See "Evaluation of headache in adults", section on 'Danger signs'.)

●In some instances, the diagnosis of episodic TTH is correct and effective acute treatment has been administered, but the patient has unrealistic expectations of therapy (eg, an expectation of freedom from pain within 10 minutes of using an analgesic medication). Education on the expected time of onset of efficacy for headache treatments may be warranted to avoid unnecessary additional treatment and risk of medication overuse headache. (See 'Goals of treatment' above.)

The differential diagnosis of TTH is discussed in greater detail separately. (See "Tension-type headache in adults: Etiology, clinical features, and diagnosis", section on 'Differential diagnosis'.)

Treatment for patients with refractory symptoms — For patients with episodic TTH unresponsive to initially administered treatment options, we use combination analgesic therapy along with another agent such as caffeine (algorithm 1).

Adjunctive preventive therapy may be warranted for patients with prolonged acute or worsening TTH. (See 'Adjunctive preventive options' below.)

Combination analgesics with caffeine — For most patients with episodic TTH refractory to simple analgesics, we suggest the use of caffeine 130 mg combined with simple analgesics such as a nonsteroidal antiinflammatory drug (NSAID) or acetaminophen. A reasonable choice is a single dose of two tablets of combined acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg.

The combination of caffeine with simple analgesics is more effective for the treatment of episodic TTH than simple analgesics alone. Several trials have assessed the efficacy of NSAIDs with caffeine [35,36]. In a multicenter trial of 385 patients with TTH that assessed ibuprofen with caffeine, combination therapy was more effective than ibuprofen 400 mg alone, caffeine 200 mg alone, and placebo [36]. The proportion of patients who reported complete pain relief by six hours was 71 percent for combination therapy compared with 58 percent each for ibuprofen or caffeine alone and 48 percent for placebo. Adverse effects with combination therapy were common but typically mild, including nausea, abdominal pain, and dizziness.

The fixed combination of indomethacin, prochlorperazine, and caffeine was more effective than nimesulide (an NSAID) for pain-free relief at two hours (45 versus 10 percent) in a trial of 54 patients with TTH [37]. Patients assigned to combination therapy were likelier to be pain-free at two hours (45 versus 10 percent) and four hours (90 versus 58 percent).

Aspirin has also been found to be effective when combined with caffeine. A trial of 1743 patients with episodic TTH found the combination acetaminophen-aspirin-caffeine (400 mg-500 mg-100 mg) was more effective than the combination without caffeine and to monotherapy with aspirin, acetaminophen, caffeine, or placebo [38].

In multiple clinical trials, the combination acetaminophen-aspirin-caffeine (500 or 1000 mg-500 mg-130 mg) was more effective for the treatment of episodic TTH than acetaminophen alone or placebo [39]. However, combination agents had more adverse effects (mainly gastrointestinal discomfort and dizziness) than acetaminophen alone.

Addition of caffeine may enhance effects of analgesics for TTH but increase the risk of adverse effects such as abdominal pain and dizziness [40-42]. Chronic use of caffeine-containing analgesics can lead to rebound headache.

Limited role of combination analgesics containing barbiturates or opioids — We recommend against the routine use of opioids or barbiturates for treatment of TTH, in agreement with guidelines [6]. We reserve use of combination analgesic therapy with butalbital or opioids for highly selected patients with episodic TTH who are unresponsive to simple analgesics or combination analgesics with caffeine when dose limits have been established and monitoring of therapy is in place. In addition, treatment may also be used for selected patients who are unable take NSAIDs or aspirin due to gastric ulcers or kidney failure or acetaminophen due to liver failure [43].

Opioids and barbiturates are known to increase propensity for overuse, which can cause or contribute to the transformation of episodic TTH to chronic TTH and medication overuse headache [44]. Furthermore, these agents have the potential for the development of tolerance, dependency, and toxicity. Therefore, neither opioids nor barbiturates should be used in TTH when better options (eg, simple analgesics and combination analgesics containing caffeine) are available. There are no comparative studies examining the efficacy of combination analgesics with codeine [6].

When practitioners encounter patients who are using opioids and barbiturates inappropriately for TTH, a "stop or brake" policy should be instituted and firmly maintained. The use of these medications is either stopped, or the frequency of use is braked by limiting the dose to no more than two days per week and an absolute maximum of six tablets per day up to three days per month.

Adjunctive preventive options

Prophylactic therapy — Preventive treatment may also be indicated for patients with TTH that worsens in severity or disability despite effective acute treatment. Patients with episodic TTH who request an increase in the amount or dose of effective acute medications may warrant "preemptive" prophylaxis treatment to reduce the risk of developing chronic TTH or medication overuse headache.

Patients may also prefer to start prophylactic therapy if headaches are frequent (eg, >2 TTHs each month) or of long duration (eg, >4 hours) and only partially responsive to acute therapies.

Preventive treatment of TTH is discussed in greater detail separately. (See "Tension-type headache in adults: Preventive treatment".)

Treat comorbid conditions — Conditions associated with TTH may require treatment separate from strategies for TTH [45]. Depression and/or anxiety disorders may be comorbid with and triggers for TTH. In addition, the burden of TTH may contribute to depression or anxiety. Migraine and TTH may also coexist and can require separate treatments to achieve (combined) headache relief. (See "Tension-type headache in adults: Etiology, clinical features, and diagnosis", section on 'Risk factors' and "Tension-type headache in adults: Etiology, clinical features, and diagnosis", section on 'Clinical features'.)

Treatments of uncertain or dubious benefit — Several other medications have also been used for acute treatment of TTH, including triptans, muscle relaxants, trigger point injections, and nonpharmacologic therapies.

●Triptans – Data are limited and conflicting regarding the value of triptans for TTH. A small trial found that sumatriptan 2 mg or 4 mg given subcutaneously had a modest beneficial effect in patients reported to have chronic TTH [46]. However, another study found that sumatriptan 100 mg tablet was no better than placebo for the treatment of episodic TTH [47]. European guidelines for TTH published in 2010 concluded that triptans most likely do not have a clinically relevant effect in patients with TTH [6].

Other studies in patients with both TTH and migraine have reported some benefit with triptans [48,49]. It is unclear if the benefit is due to the effect of triptans on TTH or on migraine. Headaches regarded as TTH may be a mild form of migraine in these patients.

●Muscle relaxants – We do not use muscle relaxants for acute treatment of TTH. These agents are not considered effective and have a risk of habituation; there are no adequate controlled trials available to support the use of muscle relaxants for the treatment of TTH [6].

●Local injections – Trigger point injections using lidocaine of botulinum toxin have been used for preventive TTH treatment. Their role for acute treatment of TTH is uncertain. Local injections for prevention of TTH are discussed separately. (See "Tension-type headache in adults: Preventive treatment", section on 'Local injection treatments'.)

●Nonpharmacologic therapies – Nonpharmacologic management is a widely used option for preventive therapy for patients with frequent episodic or chronic TTH. However, the evidence for efficacy of most modalities for acute TTH is sparse. Nonpharmacologic acute interventions for TTH include heat, ice, massage, rest, and biofeedback. The use of biofeedback and other nonpharmacologic strategies for preventive treatment of TTH are discussed in greater detail separately. (See "Tension-type headache in adults: Preventive treatment", section on 'Behavioral therapies'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Migraine and other primary headache disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Headache treatment in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Goals of treatment – Goals for an acute TTH treatment regimen include resolution of pain within two to four hours of treatment, durable pain relief without subsequent recurrence symptoms, and consistent effective response to therapy with subsequent TTH episodes. The medication regimen should be well tolerated. (See 'Goals of treatment' above.)

●Initial treatment

•Simple analgesics for most patients – For most patients with episodic TTH (<15 headaches a month), we recommend treatment with simple analgesics such as a nonsteroidal antiinflammatory drug (NSAID) or aspirin (algorithm 1) (Grade 1A). Acetaminophen (paracetamol) is preferred initial therapy for patients with TTH who are unable to tolerate NSAIDs or aspirin and for pregnant patients. Single-dose oral options include (see 'NSAIDs or aspirin' above and 'Acetaminophen' above):

-Ibuprofen (400 to 600 mg)

-Naproxen sodium (220 to 550 mg)

-Aspirin (500 to 650 mg)

-Acetaminophen (500 to 1000 mg)

For patients with symptoms unresponsive to initial choice of therapy, we switch to a different analgesic option. We typically treat as early as possible after headache onset.

•Patients with severe symptoms – For patients with severe or disabling TTH unresponsive to an initial self-administered simple analgesic who present to an emergency department (ED) or other setting where parenteral medications can be administered, we suggest a single dose of an antiemetic or analgesic medication by intravenous (IV) or intramuscular (IM) route (algorithm 1) (Grade 2C). Parenteral medications may provide more rapid pain relief than oral agents. Options include (see 'Parenteral analgesics or antiemetics for severe symptoms' above):

-Ketorolac 30 mg IV or 60 mg IM (a reduced dose of ketorolac 15 mg IV or 30 mg IM is used for patients weighing <50 kg or >64 years old)

-Metoclopramide 10 mg IV

-Chlorpromazine 12.5 mg IV (given over 15 minutes)

Diphenhydramine (12.5 to 25 mg IV) may be given along with an antiemetic medication to prevent akathisia and other dystonic reactions.

•Patients with chronic symptoms – For patients who present acutely with chronic TTH (≥15 headache days a month), we start preventive treatment in addition to analgesics or antiemetics for acute symptoms. Analgesics or antiemetics alone may be ineffective for patients with chronic TTH. (See 'Patients with chronic tension-type headache' above.)

●Patients unresponsive to initial treatment

•Reevaluate the diagnosis – For patients who do not respond to initial treatment options, we reevaluate the diagnosis to assess for other headache conditions that may also present with bilateral nonthrobbing head pain. Common alternative diagnoses include (see 'Diagnostic reevaluation' above):

-Migraine without aura (table 1)

-Chronic TTH

-Medication overuse headache (table 2)

-Secondary causes of headaches (table 3)

•Acute treatment for refractory symptoms – For most patients with episodic TTH refractory to simple analgesics, we suggest the use of caffeine combined with simple analgesics (algorithm 1) (Grade 2A). One such regimen is a single dose of two tablets of combined acetaminophen-aspirin-caffeine (250 mg-250 mg-65 mg). (See 'Combination analgesics with caffeine' above.)

●Treatment of limited or dubious benefit – We recommend against the routine use of opioids or barbiturates for treatment of TTH. We reserve use of combination analgesic therapy with these agents for highly selected patients with episodic TTH who are unresponsive to simple analgesics or combination analgesics with caffeine or those who are unable take NSAIDs, aspirin, or acetaminophen. Prerequisites of therapy for such patients include establishment of dose limits and monitoring of therapy. (See 'Limited role of combination analgesics containing barbiturates or opioids' above.)

We do not use muscle relaxants due to lack of efficacy and risk of adverse effects. The benefit of triptans, local injections, and nonpharmacologic therapies is uncertain. (See 'Treatments of uncertain or dubious benefit' above.)