Headache & Facial Pain
National and International Guidelines
NICE clinical guideline 150. Issued: September 2012
SIGN Nov 2008
British Association for the Study of Headache.
Linde K, Rossnagel K. Cochrane Database of Systematic Reviews 2004, Issue 2.
Propranolol, a beta-blocker, is one of the most commonly prescribed drugs for the prevention of migraine. This systematic review identified 58 trials, and these provide evidence that propranolol reduces migraine frequency significantly more than placebo. We did not find any clear differences between propranolol and other migraine-preventing drugs, but firm conclusions cannot be drawn about the relative efficacy of propranolol and other drugs due to the small sample size of most of the trials.
Chronicle EP, Mulleners WM. Cochrane Database of Systematic Reviews2004, Issue 3.
This review systematically examines the evidence supporting this practice. The authors conclude that anticonvulsant drugs are indeed effective in reducing the frequency of migraine attacks by approximately 1 to 2 attacks per month. Patients are also more than twice as likely to reduce the number of their migraine attacks by 50% or more with anticonvulsants than with an inactive placebo. There is, however, considerable variation among the available anticonvulsant drugs. Further research will be necessary to confirm the value of some drugs, and to compare the efficacy of drugs against each other.
Derry S, Rabbie R, Moore RA. Cochrane Database of Systematic Reviews 2013, Issue 4
This review found that oral diclofenac potassium 50 mg was an effective treatment for migraine headache, reducing moderate to severe pain to no more than mild pain within two hours in about half (55%) of those treated, to no pain at two hours in about one in five (22%), and to no pain sustained to 24 hours in about the same number (19%). Adverse events were mostly self limiting and of mild or moderate intensity, and were not significantly different from placebo over the short term. Although diclofenac provided good outcomes for some people, almost half did not experience adequate pain relief within two hours, and as few as one in five became pain-free. It is not clear whether the 100 mg dose provides good outcomes for more people. For those who do not experience adequate responses, a different therapy will be needed.
Moja L, Cusi C, Sterzi R, Canepari C. Cochrane Database of Systematic Reviews 2005, Issue 3.
Selective serotonin re-uptake inhibitors (SSRIs) block the passage of serotonin, a neurotransmitter, in brain cells. They are typically used to treat depression. In view of research suggesting that serotonin may play a role in the genesis of headache pain, SSRIs have also been tested for their potential benefit in preventing headaches. This review identified 13 trials (636 patients) lasting 2 to 3 months. The trials were small, and only a few were of high quality. Results suggest that SSRIs are no better than placebo (sugar pill) for preventing migraine or tension-type headaches. Compared with other active treatments, specifically tricyclic antidepressants, SSRIs were no better for migraine and were less effective for tension-type headache. Effects beyond 3 months are unknown. Minor side effects were no more common with SSRIs than with placebo and were less common with SSRIs than with tricyclics. The numbers of people who stopped taking tricyclics and SSRIs due to side effects were approximately equal.
Kirthi V, Derry S, Moore RA. Cochrane Database of Systematic Reviews 2013, Issue 4.
This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain.
Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain-free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short-term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.
Rabbie R, Derry S, Moore RA. Cochrane Database of Systematic Reviews 2013, Issue 4.
This is an updated version of the original Cochrane review published in Issue 10, 2010 (Rabbie 2010); no new studies were found. A single oral dose of ibuprofen 200 mg or 400 mg is effective in relieving pain in migraine headaches. Pain will be reduced from moderate or severe to no pain by two hours in just over 1 in 4 people (26%) taking ibuprofen 400 mg, compared with about 1 in 10 (12%) taking placebo. It will be reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (57%) taking ibuprofen compared with approximately 1 in 4 (25%) taking placebo. Of those who experience effective headache relief at two hours, more have that relief sustained over 24 hours with ibuprofen than with placebo. A 200-mg dose is slightly less effective, while soluble formulations give more rapid responses. A single 400-mg dose of ibuprofen has efficacy similar to that shown for a single dose of 1000 mg aspirin in a separate Cochrane review (Kirthi 2010 [update in press]).
Adverse events are mostly mild and transient, occurring in the same proportion of participants treated with ibuprofen and placebo. Very few individuals had serious adverse events or needed to withdraw from these studies because of adverse events.
There is no information for ibuprofen combined with a self-administered antiemetic, and little information comparing ibuprofen with other medications. There were no significant differences between ibuprofen 400 mg and rofecoxib 25 mg (now withdrawn) for 2-hour headache relief, 24-hour sustained headache relief, or use of rescue medication.
Derry CJ, Derry S, Moore RA. Cochrane Database of Systematic Reviews 2012, Issue 2.
This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one-third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.
Derry S, Moore RA. Cochrane Database of Systematic Reviews 2013, Issue 4
This is an updated version of the original Cochrane review published in Issue 11, 2010 (Derry 2010). New searches identified one additional study for inclusion; this study compared paracetamol with etodolac and did not contribute to any of the analyses in the review.
A single oral dose of paracetamol 1000 mg will reduce headache pain from moderate or severe to none by 2 hours in 1 in 5 people (19%) taking paracetamol, compared with 1 in 10 (10%) taking placebo. Pain will be reduced from moderate or severe to no worse than mild pain by 2 hours in about 1 in 2 people (56%) taking paracetamol, compared with about 1 in 3 (36%) taking placebo. Too few data were available to assess efficacy beyond 2 hours.
Paracetamol 1000 mg plus metoclopramide 10 mg and oral sumatriptan 100 mg provide similar levels of headache relief at 2 hours. There was insufficient information to compare paracetamol, alone or in combination, with other active treatments.
Adverse events do not differ significantly between paracetamol and placebo. Slightly more serious and/or severe adverse events occur with sumatriptan 100 mg than with paracetamol 1000 mg plus metoclopramide 10 mg.
Bennett MH, French C, Schnabel A, Wasiak J, Kranke P. Cochrane Database of Systematic Reviews 2008, Issue 3.
Both hyperbaric oxygen therapy (HBOT) and normal pressure oxygen therapy (NBOT) have been suggested as effective treatments to end acute attacks and prevent future attacks. HBOT involves people breathing pure oxygen in a specially designed chamber. In our review, we found some weak evidence to suggest that HBOT helps people with acute migraine headaches and possibly cluster headaches, and that NBOT may help people with cluster headache. We found no evidence that either can prevent future attacks. Because many migraines can be treated simply with appropriate drug therapy, further research is needed to help choose the most appropriate patients (if any) to receive HBOT.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Cochrane Database of Systematic Reviews 2009, Issue 1.
We reviewed 22 trials which investigated whether acupuncture is effective in the prophylaxis of migraine. Six trials investigating whether adding acupuncture to basic care (which usually involves only treating acute headaches) found that those patients who received acupuncture had fewer headaches. Fourteen trials compared true acupuncture with inadequate or fake acupuncture interventions in which needles were either inserted at incorrect points or did not penetrate the skin. In these trials both groups had fewer headaches than before treatment, but there was no difference between the effects of the two treatments. In the four trials in which acupuncture was compared to a proven prophylactic drug treatment, patients receiving acupuncture tended to report more improvement and fewer side effects. Collectively, the studies suggest that migraine patients benefit from acupuncture, although the correct placement of needles seems to be less relevant than is usually thought by acupuncturists.
Brønfort G, Nilsson N, Haas M, Evans RL, Goldsmith CH, Assendelft WJJ, Bouter LM. Cochrane Database of Systematic Reviews 2004.
Various physical treatments are often used instead of, or in addition to, medications to treat headaches. Evidence from controlled trials suggests that several non-invasive physical treatments may help prevent chronic/recurrent headaches. Spinal manipulation may be effective for migraine and chronic tension-type headache. Both spinal manipulation and neck exercises may be effective for cervicogenic headache. Weaker evidence suggests that other treatments may also be effective: pulsating electromagnetic fields and transcutaneous electrical nerve stimulation (TENS) for migraine, and therapeutic touch, cranial electrotherapy, TENS, and a combination of self-massage/TENS/stretching for tension-type headache. Although none of these treatments has conclusive evidence for effectiveness, all appear to be associated with little risk of serious adverse effects.
Law S, Derry S, Moore RACochrane Database of Systematic Reviews 2010, Issue 4.
This review found that sumatriptan administered subcutaneously and zolmitriptan taken intranasally, in particular, were significantly more effective than placebo at relieving acute cluster headache in adults. Within 15 to 30 minutes of using an intranasal or subcutaneous triptan about two-thirds had no worse than mild pain, and about half were pain-free. The evidence was strongest for 6 mg subcutaneous sumatriptan and 10 mg intranasal zolmitriptan. The triptans compared favourably to other therapies such as inhaled oxygen. Adverse events were more common with triptans than with placebo but they were generally of mild to moderate severity and rarely led to withdrawal.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Cochrane Database of Systematic Reviews 2009, Issue 1.
11 trials which investigated whether acupuncture is effective in the prophylaxis of tension-type headache. Two large trials investigating whether adding acupuncture to basic care (which usually involves only treating unbearable pain with pain killers) found that those patients who received acupuncture had fewer headaches. Forty-seven percent of patients receiving acupuncture reported a decrease in the number of headache days by at least 50%, compared to 16% of patients in the control groups. Six trials compared true acupuncture with inadequate or 'fake' acupuncture interventions in which needles were either inserted at incorrect points or did not penetrate the skin. Overall, these trials found slightly better effects in the patients receiving the true acupuncture intervention. Fifty percent of patients receiving true acupuncture reported a decrease of the number of headache days by at least 50%, compared to 41% of patients in the groups receiving inadequate or 'fake' acupuncture. Three of the four trials in which acupuncture was compared to physiotherapy, massage or relaxation had important methodological shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes with the latter therapies. In conclusion, the available evidence suggests that acupuncture could be a valuable option for patients suffering from frequent tension-type headache.
Aggarwal VR, Lovell K, Peters S, Javidi H, Joughin A, Goldthorpe J. Cochrane Database of Systematic Reviews 2011, Issue 11.
Studies indicate that psychological factors are associated with chronic pain in the face, mouth or jaws. However, current management, particularly in dentistry, does not target these factors. This review therefore explored whether behavioural interventions like cognitive behavioural therapy (CBT), biofeedback and posture regulation compared with usual care could improve outcomes for patients with chronic orofacial pain. We found that such interventions improved long-term pain intensity, pain interference with daily life activities and depression. However, the quality of the studies was poor and there were few studies from which we could combine results. We therefore recommend further high quality trials are needed to support the use of such interventions for chronic orofacial pain.
Mujakperuo HR, Watson M, Morrison R, Macfarlane TV. Cochrane Database of Systematic Reviews 2010, Issue 10.
Different medicines are used to treat pain due to temporomandibular disorders (TMD). These include simple painkillers (analgesics) and medicines which reduce inflammation and treat pain (for example, non-steroidal anti-inflammatory drugs, corticosteroids). Medicines (called benzodiazepines) are sometimes used to reduce tension and spasm in the muscles affected by TMD. In addition, some antidepressant medicines (called tricyclic antidepressants) are used in low doses to help patients with TMD and are thought to be effective because they reduce muscle tension in patients who grind their teeth. This review found that there was not enough evidence to decide which medicines are effective in reducing pain due to chronic TMD.