Evidence Against Indomethacin Use for Chronic Tension Headache Treatment
Indomethacin is not recommended for chronic tension headache treatment as there is insufficient evidence supporting its efficacy for this condition, and it carries significant risks of gastrointestinal side effects and potential medication overuse headache. 1
Current Evidence on Indomethacin for Headache Disorders
Specific Indications for Indomethacin
Indomethacin has very specific indications in headache medicine:
Primarily indicated for "indomethacin-responsive headaches" such as:
- Paroxysmal hemicrania (PH)
- Hemicrania continua (HC)
- Some forms of idiopathic stabbing headaches 2
- Certain exertional headaches
The International Classification of Headache Disorders (ICHD-3) requires response to indomethacin as a diagnostic criterion for PH and HC 3
Limited Evidence for Tension Headaches
- Only very limited evidence exists suggesting potential benefit in a small subgroup of patients with bilateral chronic tension-type headache 4
- This evidence is insufficient to recommend indomethacin as a standard treatment for chronic tension headaches
Risks Associated with Indomethacin Use
Adverse Effects
- Significant gastrointestinal side effects requiring gastric protection 1
- Risk of developing medication overuse headache with regular use 5
- Delayed elimination and increased plasma levels with chronic use 5
Medication Overuse Concerns
- Guidelines recommend limiting use of NSAIDs to fewer than 15 days per month to prevent medication overuse headache 1
- Overuse of indomethacin can lead to rebound headaches and perpetuate medication-overuse headache 5
Recommended Approaches for Chronic Tension Headache
First-Line Treatments
- NSAIDs with better evidence (aspirin, ibuprofen, naproxen sodium) are recommended as first-line treatments for most headache disorders 1
- Acetaminophen-aspirin-caffeine combinations have demonstrated efficacy 1
Preventive Therapy
For chronic tension headaches, preventive therapy should be considered when:
- Headaches occur two or more times per month with disability for three or more days
- Rescue medications are used more than twice a week
- Acute treatments fail or are contraindicated 1
Preventive Options with Better Evidence
- Beta-blockers (propranolol, metoprolol, timolol)
- Anticonvulsants (topiramate, valproate)
- Antidepressants (amitriptyline, venlafaxine) 1
Non-Pharmacological Approaches
- Lifestyle modifications (regular meals, adequate hydration, sleep hygiene)
- Stress management techniques (yoga, cognitive-behavioral therapy, mindfulness)
- Regular exercise program 1
Important Clinical Considerations
Medication Limits
- Limit analgesic use to prevent medication overuse headache:
- NSAIDs: fewer than 15 days/month
- Triptans: fewer than 10 days/month 1
Monitoring
- Use of headache diaries to track frequency, severity, and medication use
- Regular assessment of treatment efficacy and adverse effects
- Monitor for signs of medication overuse 1
In conclusion, while indomethacin may have a role in very specific headache disorders, the evidence does not support its use for chronic tension headache treatment, and the risks of adverse effects and medication overuse make other treatment options preferable.