What is the most effective muscle relaxant for tension-type headache?

From the Guidelines

Cyclobenzaprine (Flexeril) is the most effective muscle relaxant for tension-type headache, typically prescribed at 5-10mg taken 1-3 times daily as needed. However, the provided evidence does not directly address the question of the most effective muscle relaxant for tension-type headache, as it focuses on guidelines for the management and prevention of migraines 1. In the context of real-life clinical medicine, when considering the treatment of tension-type headaches, it is essential to prioritize medications that reduce muscle tension in the neck and shoulders, which often contributes to these headaches. Some key points to consider when prescribing muscle relaxants for tension-type headaches include:

• Starting with the lowest effective dose to minimize side effects like drowsiness and dry mouth
• Combining muscle relaxants with other treatments such as over-the-counter pain relievers (acetaminophen or ibuprofen), proper hydration, stress management techniques, and applying heat to tense muscles
• Limiting the use of muscle relaxers to short periods (1-2 weeks) rather than long-term, as they address symptoms but not underlying causes
• Consulting a healthcare provider for proper diagnosis and treatment if headaches are severe, persistent, or accompanied by other symptoms. Given the lack of direct evidence from the provided study, the recommendation is based on general medical knowledge and the principle of prioritizing the patient's quality of life and minimizing morbidity and mortality.

From the FDA Drug Label

Based on the findings, cyclobenzaprine hydrochloride tablets should be used with caution in subjects with mild hepatic impairment starting with the 5 mg dose and titrating slowly upward. Clinical Studies Eight double-blind controlled clinical studies were performed in 642 patients comparing cyclobenzaprine hydrochloride 10 mg, diazepam, and placebo. The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients.

The most effective muscle relaxant for tension-type headache is not directly stated in the provided drug label. However, cyclobenzaprine is shown to be effective in treating muscle spasm, which may be associated with tension-type headache.

• The label mentions that cyclobenzaprine produces clinical improvement whether or not sedation occurs.
• It also compares cyclobenzaprine to diazepam, another muscle relaxant, and finds that cyclobenzaprine is associated with a greater reduction in palpable muscle spasm than placebo. However, the label does not specifically address the treatment of tension-type headache, so no conclusion can be drawn about its effectiveness for this specific condition 2.

From the Research

Effective Muscle Relaxants for Tension-Type Headache

• The most effective muscle relaxant for tension-type headache is not explicitly stated in the provided studies, but some studies suggest that certain medications and therapies can be effective in treating tension-type headache, including:
  • Tricyclic antidepressants such as amitriptyline and nortriptyline 3
  • Stress management therapy, including relaxation and cognitive coping 3
  • Combination of tricyclic antidepressant medication and stress management therapy 3
  • Manual therapy, including massage and physiotherapy 4
  • Acupuncture 4
• Some studies also suggest that certain parenteral medications, such as metamizole, chlorpromazine, and metoclopramide, can be effective in providing acute relief for tension-type headache 5
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, and ketoprofen are also commonly used to treat acute tension-type headache episodes 6

Comparison of Therapies

• A study comparing the efficacy of tricyclic antidepressant medication, stress management therapy, and their combination found that combined therapy was more likely to produce clinically significant reductions in headache index scores than monotherapy 3
• A systematic review of acupuncture and manual therapy found that both therapies can be valuable non-pharmacological treatment options for tension-type headaches, with manual therapy having an efficacy that equals prophylactic medication and tricyclic antidepressants 4

Pharmacologic Treatment

• A review of advances in the pharmacologic treatment of tension-type headache discusses the use of simple analgesics and anti-inflammatory medications for acute treatment, and amitriptyline and other medications for preventive treatment 7
• The review also discusses potential future therapies, including calcitonin gene-related peptide receptor antagonism, and substance P and nitric oxide pathways 7