PROFILAXIA DA CEFALÉIA TENSIONAL

INDICATIONS AND APPROACH TO TREATMENT — The preventive therapy of TTH ranges from drugs to nonpharmacologic therapies such as behavioral and cognitive interventions. The goals of preventive therapy in TTH are reasonably extrapolated from those devised for migraine headache. These include the following:
• Reduce attack frequency, severity, and duration
• Improve responsiveness to treatment of acute attacks
• Improve function and reduce disability
Prophylactic headache treatment is indicated if the headaches are frequent, long lasting, or account for a significant amount of total disability. With respect to TTH, both the frequent episodic subtype (1 to 14 headache days a month) and chronic subtype (≥15 headache days a month) warrant prevention as they may be associated with significant disability, especially when accompanied by migraine, comorbid depression, or anxiety.
Therefore, preventive treatment is appropriate for most patients with chronic TTH, and is probably appropriate for many patients with frequent episodic TTH. Frequent TTH may be difficult to treat, but an acceptable result can usually be obtained by a combination of nonpharmacologic and pharmacologic treatments. In contrast, patients with infrequent episodic TTH (headache <1 day per month) do not require preventive treatment.
Preventive therapy may be also indicated when acute therapy fails or is inappropriate because of inadequate response, adverse events, overuse, or contraindications.
To achieve benefit, prophylactic headache therapy requires a sustained commitment on the part of the patient and clinician. It is important to address patient expectations and consider patient preferences when deciding between different preventive therapies. In addition, the patient should be informed of the rationale for a particular treatment, the expected benefits of therapy, the duration of treatment that will likely be needed to achieve improvement, and the possible and likely side effects.

A variety of pharmacologic therapies have been studied for the prophylactic treatment of TTH, as discussed in the sections that follow. Evidence of efficacy is limited and inconsistent, but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. Other medications that may be useful include the antidepressants mirtazapine and venlafaxine, the anticonvulsants topiramate and gabapentin, and the muscle relaxant tizanidine. In contrast, the available evidence suggests that the selective serotonin uptake inhibitors are not effective for TTH prophylaxis.

TRICYCLIC ANTIDEPRESSANTS — Supporting evidence that tricyclics are beneficial for TTH comes from a 2010 meta-analysis that evaluated nine small trials of tricyclics for the treatment of TTH, with amitriptyline the sole tricyclic tested in six of the trials. Tricyclics significantly reduced the number of days with TTH compared with placebo (average standardized mean difference -1.29, 95% CI -2.18 to -0.39) and were more likely to reduce the intensity of headache by at least 50 percent compared with placebo (relative risk [RR] 1.41, 95% CI 1.02-1.89) or compared with selective serotonin reuptake inhibitors (RR 1.73, 95% CI 1.34-2.22). In addition, the effectiveness of tricyclics seemed to increase over time.
We suggest the use of amitriptyline for patients with frequent episodic TTH or chronic TTH. Exceptions include patients with obesity, bipolar disease, or cardiac conduction defects. This recommendation is best suited for patients who have a preference for pharmacologic treatment rather than behavioral or other nonpharmacologic therapies. Our recommendation is in agreement with 2010 guidelines from the European Federation of Neurological Societies for the treatment of TTH, which conclude that amitriptyline has a clinically relevant prophylactic effect in patients with chronic TTH and should be the drug of first choice.
It is difficult to reach firm conclusions on the relative efficacy of tricyclics versus other treatment modalities as there are relatively few comparative trials. The utility of combined tricyclic and behavioral therapy for the treatment of chronic TTH is reviewed below. (See 'Combined behavioral and tricyclic therapy' below.)
Dosing and duration of therapy — We suggest the following principles to guide preventive drug therapy for TTH:
• Start the drug at the lowest dose, and increase the dose gradually until therapeutic benefit is achieved, the maximum dose of the drug is reached, or side effects become intolerable.
• Give the prophylactic medication an adequate trial in terms of duration and dosage. Benefit is often first noted only after four to six weeks of therapy. In addition, benefit may continue to accrue for three months.
• Avoid overuse of analgesic medications. Ongoing analgesic overuse must be eliminated, or preventive therapy will likely be ineffective.
• Measure the effectiveness of therapy by use of a patient headache diary to track daily headache frequency and intensity.
• Once effective, maintain drug therapy for at least three to six months. Thereafter, a slow taper off the medication can be performed.
With these principles in mind, we start amitriptyline at 10 to 12.5 mg nightly and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated and as needed for sleep, until there is improvement in headache or until a maximum dose of 100 to 125 mg nightly is reached.
It is common for practitioners to initiate amitriptyline at 25 mg each night and increase the dose in 25 mg increments each week, but in the author's clinical experience, such a regimen is complicated by increased side effects and reduced adherence compared with the one outlined above.
Nortriptyline and protriptyline can be considered as alternative tricyclics if amitriptyline is poorly tolerated. The effects of these tricyclic medications on sleep, anxiety disorders, and body weight can guide the choice among them.
Anticonvulsants — Limited evidence suggests that topiramate and gabapentin may be beneficial for patients with chronic TTH.
• Direct evidence of benefit for gabapentin in TTH prevention is lacking, but one randomized trial evaluated this drug in 95 patients with chronic daily headache, including 25 patients with TTH and 58 with a combination of TTH and migraine. Treatment with gabapentin (2400 mg daily) was associated with a statistically significant improvement in headache-free days compared with placebo. The strength of this finding is limited by methodologic problems with the study, including failure to use an intention-to-treat analysis.
• An open label study of topiramate (initially 25 mg daily, then increased to 100 mg daily) in 51 patients with TTH reported a significant decline in headache frequency after three months of treatment.
Further evidence from randomized clinical trials is needed to clarify whether gabapentin and topiramate have a role in TTH prevention.

TIZANIDINE — There is limited and conflicting data regarding the effectiveness of tizanidine, a muscle relaxant and antispasticity agent, for the prophylaxis of TTH. An early clinical trial of 37 women with chronic TTH found that tizanidine (6 to 18 mg daily) was more effective than placebo. However, a larger trial of 185 patients with chronic TTH showed that tizanidine (6 or 12 mg modified release daily) was without benefit compared with placebo.
An open-label trial of 18 subjects with chronic TTH reported that combined treatment with tizanidine (4 mg daily for three weeks) and amitriptyline (20 mg daily for three months) led to faster reduction in headache frequency, intensity and duration than amitriptyline alone. The small size and open-label nature of this trial precludes definitive conclusions.

BOTULINUM TOXINS — There is evidence from several randomized placebo-controlled clinical trials that botulinum toxin injection is not effective for chronic TTH. As an example, one of these trials enrolled 112 patients with chronic TTH and found that injection of botulinum neurotoxin A (500 U) in a fixed set of predetermined pericranial muscles was without benefit compared with placebo injection. In addition, an evidence-based review published in 2008 by the American Academy of Neurology (AAN) concluded that botulinum toxin is probably ineffective for patients with chronic TTH, and a subsequent 2012 meta-analysis made similar observations.Given these data, use of botulinum toxin therapy for the preventive treatment of TTH cannot be recommended.
The goal of behavioral treatments is to prevent headaches by identifying and defusing headache triggers, which are particularly important in TTH, and by using self-regulation to modulate involuntary and subconscious physiologic processes. European guidelines for the treatment of TTH published in 2010 state that non-drug management should be considered for all patients with TTH even though the scientific evidence is sparse and contradictory. The guidelines note that a therapeutic effect may be attained simply by taking the problem seriously, particularly if the patient is worried that the headache is caused by a serious problem such as a brain tumor.
Behavioral treatments for headache include the following methods:
• Regulation of sleep, exercise and meals
• Cognitive-behavioral therapy
• Relaxation
• Biofeedback
• Combinations of the above (eg, stress management therapy often consists of a combination of behavioral methods, with an emphasis on cognitive-behavioral therapy)

OTHER NONPHARMACOLOGIC THERAPIES

ACUPUNCTURE — The available evidence regarding acupuncture for TTH suggests that any benefit is likely to be modest.
Although of limited benefit for the prevention of TTH, acupuncture is safe and may be used for patients who do not tolerate or desire more effective treatments such as amitriptyline.
PHYSICAL THERAPIES — The benefit of physical therapy for TTH is unproven. Various physical therapy methods, alone or in combination, have been used to treat TTH, including specific exercises, therapeutic heat or cold, massage, postural correction, therapeutic touch, traction, trigger point therapy, spinal manipulation, and electrical therapies such as transcutaneous electrical nerve stimulation (TENS), electromagnetic therapy, ultrasound, and laser. However, there are no true randomized double-blind placebo-controlled trials evaluating the effectiveness of physical therapy for TTH prevention.

REFERÊNCIA:
*http://www.uptodate.com/contents/tension-type-headache-in-adults-preventive-treatment?detectedLanguage=it&source=search_result&translation=tension+headache&search=CEFALEIA+TENSIONAL&selectedTitle=3~72&provider=bing