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Second-Line Tension Headache Abortive Medications
Posted Jan 1999

  1. Butalbital compounds: Effective but habit forming. Fiorinal, Esgic, Esgic Plus, Fioricet, Axotal, and Phrenilin are the primary butalbital compounds. Generic butalbital preparations do not work as well as brand names. Sedation or euphoria is common. Strict limits need to be set for daily and monthly use. If used daily, one or two is the usual limit.

  2. Narcotics: Codeine, hydrocodone, and propoxyphene are commonly utilized. These are a last resort, should be limited per month, and generally should not be used on a daily basis. These need to be discontinued if patients use them to alleviate stress, depression, fatigue, or anxiety. See #6 in Table 2 on page 8 for information on Ultram and Vicoprofen.

  3. Sedatives: Most are benzodiazepines: diazepam (Valium) and clonazepam (Klonopin). Chlordiazepoxide (Librium) is also useful. Sedation is common. Because they are habit forming, these need to be monitored with a monthly limit. They are a last resort, not a first choice.

  4. Triptans: While triptans are generally utilized for migraine and cluster headaches, the triptans can be useful for tension headaches as well, particularly the more severe tension headaches. There are some patients who only do well with a triptan with any of their headaches, such as Imitrex, Amerge, Zomig, or Maxalt.