REVIEW ARTICLE

Headache: insight, understanding, treatment and patient

management
H-C. Diener

SUMMARY
Tension-type headache and migraine are the most frequent primary headaches.
Diagnosis is based on the patients history and a normal neurological examination.
Most patients with these two headache entities treat headache episodes with
over-the-counter analgesics or non-steroidal anti-inflammatory drugs (NSAIDs).
There is good scientific evidence from randomised, placebo-controlled trials indicating that aspirin, ibuprofen, ketoprofen, diclofenac and naproxen are effective in
tension-type and migraine headache. Paracetamol seems to be less effective. In
patients with migraine who do not respond to analgesics or NSAIDs, triptans
should be prescribed. Frequent primary headaches should not be treated with frequent intake of analgesics or triptans. In these cases, preventive therapy needs to
be implemented.

Introduction
Headache is the most frequent neurological disorder. About 90% of all people suffer from episodic
and 23% from chronic headache. Episodic tension-type headache is the most frequent headache
followed by migraine (13). Infections, low-back
pain, vertigo and dizziness and headache are the
most frequent reasons for patients to consult a
general practitioner (GP). The majority of patients
will treat their headache with over-the-counter
(OTC) drugs. Therefore, this review will concentrate on self-medication for the treatment of headaches and the role that GPs play in advising
patients.

Epidemiology
About 70% of people suffer from episodic tensiontype headache (1). Tension-type headache is characterised by a dull and diffuse headache of moderate
intensity without autonomic features. Attacks of
episodic tension-type headache usually last for

Review criteria
This review is based on treatment guidelines from the American Academy of Neurology (AAN 2012), The European
Federation of Neurological Societies (EFNS)
and the German Headache Society. Publications from the references lists from these
guidelines were screened and analysed.

Message for the clinic

The most frequent primary headaches are
tension-type headache and migraine. Most
patients can treat these entities with overthe-counter analgesics or NSAIDs. Severe
migraine attacks are treated with triptans
and frequent headaches require preventive
therapy.

1 day. Patients with tension-type headache will

rarely consult a physician and will treat the headache with OTC analgesics. Migraine is characterised
by episodes of moderate-to-severe, pulsating, unilateral headache, lasting for 472 h with sensitivity to
light and sound, nausea and vomiting (4). About
8% of men and 1214% of women suffer from
migraine. Only about half of all patients with
migraine ever consult a physician and the majority of migraine attacks are treated with OTC
analgesics.

Diagnosis
Headache diagnosis is achieved by taking a history.
Screening instruments, such as ID MigraineTM, can
help to make the diagnosis of migraine in the GPs
office (5). The neurological examination should be
normal in primary headaches. Suspicion of secondary headaches, such as de novo serious headache,
deteriorating headaches and headaches with neurological signs and symptoms, require cerebral
imaging.

2012 Blackwell Publishing Ltd Int J Clin Pract, January 2013, 67 (Suppl. 178), 3336
doi: 10.1111/ijcp.12049

Department of Neurology and

Headache Center, University
Hospital Essen, Essen, Germany
Correspondence to:
Hans-Christoph Diener,
Department of Neurology and
Headache Center, University
Hospital Essen, Hufelandstrasse
55, 45147 Essen, Germany
Tel.: +49 201 723 2460
Fax: +49 201 723 5901
Email: h.diener@uni-essen.de
Disclosures
Hans-Christoph Diener received
honoraria for participation in
clinical trials, contribution to
advisory boards or oral
presentations from: Addex
Pharma, Allergan, Almirall,
Autonomic Technology,
AstraZeneca, Bayer Vital, Berlin
Chemie, Bohringer Ingelheim,
Bristol-Myers Squibb, Coherex,
CoLucid, GlaxoSmithKline,
Grunenthal, Janssen-Cilag, Lilly,
La Roche, 3M Medica,
Medtronic, Menerini, Minster,
Merck Sharp & Dohme,
Neuroscore, Novartis, Johnson
& Johnson, Pierre Fabre, Pfizer,
Reckitt Benckiser, Schaper and
Brummer, Sanofi, St. Jude and
Weber & Weber. Financial
support for research projects
was provided by Allergan,
Almirall, AstraZeneca, Bayer,
GlaxoSmithKline, Janssen-Cilag,
Merck Sharp & Dohme and
Pfizer. Headache research at
the Department of Neurology in
Essen is supported by the
German Research Council
(DFG), the German Ministry of
Education and Research (BMBF)
and the European Union. HansChristoph Diener has no
ownership interest and does
not own stocks of any
pharmaceutical company.

33

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Headache: insight, understanding, treatment and patient management

Treatment
Treatment of headache has two aspects. For most
patients, it is enough to self-treat headache episodes.
Patients need advice regarding which analgesics are
effective at which dose. If analgesics or NSAIDs fail,
migraine attacks should be treated with specific
migraine drugs, such as the triptans. In head-to-head
comparisons, triptans were not superior to aspirin or
NSAIDs in de novo patients (6). They are, however,
effective in non-responders to NSAIDs. In patients
with frequent and disabling migraine attacks or
chronic tension-type headache, preventive therapy is
implemented. Drug therapy should be accompanied
by behavioural therapy, including counselling, relaxation therapy, stress management and exercise (7). In
the following section, this review will concentrate on
the self-treatment of headache episodes with OTC
drugs.

Treatment of episodic tension-type

headache
Episodic tension-type headache is treated with analgesic drugs, such as ibuprofen, acetylsalicylic acid,
diclofenac or paracetamol (acetaminophen). In a
randomised study of 620 patients, Kubitzek et al. (8)
compared ibuprofen 400 mg (n = 151), diclofenac-K
12.5 mg (n = 160), diclofenac-K 25 mg (n = 156)
and placebo (n = 153). The primary efficacy variable
was total pain relief, calculated as the time-weighted
sum of the pain relief assessments from baseline to
the 3 h evaluation time (TOTPAR-3). For TOTPAR-3,
all active treatments were significantly better than
placebo and there were no statistically significant differences between the three active treatments. Schachtel and Thoden (9) investigated the time of onset of
action of 400 mg ibuprofen compared with placebo
in 70 patients. Pain relief was detected within 15 min
of the pain intensity rating scale for ibuprofen. In a
comparative study, Schachtel et al. (10) compared
400 mg ibuprofen (n = 153), 1000 mg paracetamol
(n = 151) and placebo (N = 151) patients with tension-type headache. Ibuprofen was significantly more
effective than paracetamol. Diamond (11) compared
400 and 800 mg ibuprofen with aspirin 650 mg and
placebo in 108 patients with tension-type headache
(at that time called muscle contraction headache).
Ibuprofen was significantly more effective than
placebo and at least as effective as aspirin. Finally,
Steiner et al. (12) compared 1000 mg aspirin with
1000 mg paracetamol in 638 patients with tensiontype headache and observed no difference between
aspirin and paracetamol; they were equally effective
and superior to placebo.

Verhagen et al. performed a meta-analysis of 41 trials

investigating paracetamol and NSAIDs in tension-type
headache (13). The pooled analyses showed that
NSAIDs and paracetamol are more effective than placebo. No significant differences could be found between
different types of NSAIDs, but ibuprofen showed fewer
short-term side effects when compared with other
NSAIDs. There was a significant difference in favour of
NSAIDs when compared with paracetamol.

Treatment of migraine attacks

Mild-to-moderate migraine attacks are usually treated with analgesic drugs or NSAIDs. There is good
evidence from randomised, placebo-controlled trials
for the efficacy of ibuprofen (1417), aspirin (18
21), diclofenac (2225) and paracetamol (2628). A
meta-analysis of the randomised trials investigating
ibuprofen for the treatment of migraine attacks
showed that ibuprofen 200 and 400 mg were more
effective than placebo in reducing pain intensity and
eliminating pain (pain-free) within 2 h in adults with
moderate or severe migraine attacks (29). For the
200 mg dose, the number needed to treat was 8 (95%
confidence interval [CI]: 520) for headache relief and
13 (95% CI: 850) for pain-free. For the 400 mg dose,
the number needed to treat was 4 (95% CI:
37) for headache relief and 9 (95% CI: 520) for
pain-free. The risk ratios for headache relief and painfree were 1.89 (95% CI: 1.452.46; p < 0.0001) and
2.15 (95% CI: 1.243.73; p = 0.0063), respectively, for
ibuprofen 400 mg. The efficacy and safety of 1000 mg
effervescent aspirin (eASA) was evaluated in comparison with placebo in an individual patient data metaanalysis of three randomised, placebo-controlled, single-dose migraine trials (30). Pain-relief at 2 h, painfree at 2 h and sustained pain-free up to 24 h were
calculated. For eASA, the response rates were 51.5%
(95% CI: 46.656.5%), 27.1% (95% CI: 22.631.4%)
and 23.5% (95% CI: 19.327.7%). The corresponding
rates for placebo were 33.9% (95% CI: 29.138.6%),
15.1% (95% CI: 11.518.7%) and 14.6% (95% CI:
11.018.1%). The treatment effect of eASA was significantly different from placebo (p < 0.001). The combination of aspirin plus paracetamol and caffeine is
superior to placebo (31) and superior to the single
compounds and the combination of aspirin and caffeine (32). Naratriptan, sumatriptan and almotriptan
are approved as OTC drugs in some European countries.

Guideline recommendations
The European Federation of Neurological Societies
guidelines on the treatment of tension-type headache

2012 Blackwell Publishing Ltd Int J Clin Pract, January 2013, 67 (Suppl. 178), 3336

Headache: insight, understanding, treatment and patient management

from 2010 (33) recommend six drugs for the treatment of episodic tension-type headache with the
highest level of recommendation A, based on efficacy
and side effects: ibuprofen (200800 mg), ketoprofen
(25 mg), aspirin (5001000 mg), naproxen (375
550 mg), diclofenac (12.5100 mg) and paracetamol
(1000 mg). The guidelines of the German, Swiss and
Austrian Headache Societies for the self-treatment of
tension-type headache assign only level B evidence for
paracetamol, but level A to the fixed combination of
aspirin, paracetamol and caffeine (34). The guidelines
of the British Association for the Study of Headache
(BASH) from 2010 recommend aspirin and ibuprofen
(35). Ketoprofen and naproxen are sometimes indicated and paracetamol appears less effective.
The guidelines of the EFNS rate as level A treatment for acute migraine attacks aspirin, ibuprofen,
naproxen, diclofenac, paracetamol and the combination of aspirin, paracetamol and caffeine (7). The
guidelines from the German speaking countries rate
as level A treatments aspirin plus paracetamol plus
caffeine, aspirin, ibuprofen, naratriptan, paracetamol
and phenazone (34). BASH recommends aspirin
600900 mg or ibuprofen 400600 mg best taken as
buffered soluble or orodispersible formulations.

ity over simple analgesics and NSAIDs. They are

clearly indicated in patients in whom these drugs are
either contraindicated or not effective. Patients
should be advised to consult a physician if treatment
of acute episodes of tension-type headache or
migraine fails. Frequent headache episodes should
not be treated by a more and more frequent intake
of pain medication. Frequent use of acute medication
can result in medication-overuse headache (36).
Patients with a primary headache who take simple
analgesics on more than 15 days per month or combination analgesics or triptans and ergots on more
than 10 days per month might experience an increase
in the frequency of headache days called medicationoveruse headache. In this situation, medical and
non-medical preventive therapy needs to be initiated.

Further considerations

Author contribution

The triptans were considered a major breakthrough

in the treatment of migraine attacks when introduced
15 years ago. They, however, failed to show superior-

The author conducted the literature review, developed the manuscript and approved the final version
of the manuscript.

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Paper received 4 September 2012, accepted 21 September 2012

2012 Blackwell Publishing Ltd Int J Clin Pract, January 2013, 67 (Suppl. 178), 3336

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