Muscle Relaxers for Tension-Type Headache
Direct Answer: Muscle Relaxers Are Not Recommended
There is no evidence supporting the use of centrally acting muscle relaxants for tension-type headache, and current guidelines do not recommend them. 1
Evidence-Based First-Line Treatment
Recommended Acute Medications
Ibuprofen 400–800 mg is the most effective first-line treatment for episodic tension-type headache, with superior efficacy compared to acetaminophen or aspirin. 2, 3
Acetaminophen 1000 mg provides modest benefit, with a number-needed-to-treat (NNT) of 22 for pain freedom at 2 hours, but is less effective than NSAIDs. 1, 4
Naproxen 550–825 mg is an alternative NSAID option with longer duration of action (up to 12 hours). 2
Ketoprofen 50–75 mg demonstrates efficacy but may have a higher adverse event rate than other NSAIDs. 2, 3
Combination Therapy for Enhanced Efficacy
Adding caffeine to an NSAID or acetaminophen enhances analgesic absorption and provides synergistic pain relief. 5
The combination of aspirin 500 mg + acetaminophen 500 mg + caffeine 130 mg is significantly more effective than acetaminophen alone. 6
Critical Frequency Limitation
- Limit all acute headache medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 6
When First-Line Treatment Fails
Escalation Algorithm
If acetaminophen fails after 2–3 episodes, switch to an NSAID (ibuprofen 400–800 mg or naproxen 500–825 mg). 6
If NSAIDs fail after 2–3 episodes, consider adding caffeine to the regimen or switching to a different NSAID. 6, 5
If headaches occur >2 days per week, initiate preventive therapy rather than increasing acute medication frequency. 1, 6
Preventive Therapy for Chronic Tension-Type Headache
When to Initiate Prevention
- Preventive therapy is indicated when headaches occur ≥2 days per week or when acute medication use exceeds the 2-day-per-week threshold. 1, 6
First-Line Preventive Agent
- Amitriptyline 30–150 mg/day is the only preventive medication with guideline support for chronic tension-type headache, particularly when comorbid depression, anxiety, or sleep disturbances are present. 1, 7
Non-Pharmacologic Options
Relaxation therapies with EMG biofeedback and tricyclic antidepressants have similar efficacy rates of 40–50% for chronic tension-type headache. 2
Physical therapy and acupuncture are generally less effective than pharmacologic and behavioral interventions. 2
Medications to Avoid
Opioids (codeine, hydrocodone, tramadol) are absolutely contraindicated for tension-type headache due to questionable efficacy, high risk of dependence, and precipitation of medication-overuse headache. 7, 6
Butalbital-containing compounds should be avoided because they carry a high risk of medication-overuse headache and should be reserved only when all other evidence-based treatments are contraindicated. 7, 8
Botulinum toxin injection is not recommended for chronic tension-type headache prevention. 1
Common Pitfalls to Avoid
Do not prescribe muscle relaxants (cyclobenzaprine, tizanidine, methocarbamol) for tension-type headache, as they lack evidence of efficacy and are not mentioned in any current guidelines. 1
Do not allow patients to use acute medications more frequently in response to treatment failure; instead, transition to preventive therapy. 1, 6
Do not substitute one acute medication for another when medication-overuse headache is suspected; instead, withdraw all acute medications and initiate preventive therapy. 7
Red Flags Requiring Urgent Evaluation
- Seek immediate medical attention if headache includes: thunderclap onset, fever with neck stiffness, progressive worsening pattern, neurological symptoms, or awakening from sleep. 6