Medication for Scalp-Localized Tension-Type Headache
For a scalp-localized tension-type headache, start with ibuprofen 400 mg or aspirin 650-1000 mg as first-line treatment; if ineffective, use acetaminophen 1000 mg combined with aspirin and caffeine.
First-Line Treatment Approach
NSAIDs are the primary pharmacologic treatment for episodic tension-type headache (TTH). The evidence consistently supports:
- Ibuprofen 400-800 mg every 6 hours (maximum 2.4 g/day) 1, 2
- Aspirin 650-1000 mg every 4-6 hours (maximum 4 g/day) 1, 2
- Naproxen sodium 275-550 mg every 2-6 hours (maximum 1.5 g/day) 1
The 2010 EFNS guideline explicitly states that simple analgesics and NSAIDs are recommended for episodic TTH treatment 3. These medications target the peripheral pain mechanisms and muscle tenderness characteristic of tension-type headache 4.
Second-Line Options
If NSAIDs alone provide insufficient relief:
Combination therapy with acetaminophen 1000 mg + aspirin + caffeine is the next step 5. This combination has proven efficacy superior to single agents. The NNT for paracetamol 1000 mg to achieve pain-free or mild pain at 2 hours is 10 6.
Important caveat: Acetaminophen (paracetamol) alone is NOT effective for tension-type headache and should not be used as monotherapy 5, 6, 3.
What NOT to Use
Avoid these medications for tension-type headache:
- Triptans - These are migraine-specific agents with no role in TTH 3
- Opioids (meperidine, butorphanol) - Ineffective and risk dependency 1, 3, 7
- Muscle relaxants - Not recommended 3
The 2014 systematic review found that parenteral meperidine + promethazine was not more effective than placebo for tension-type headache 7.
Critical Medication Overuse Warning
Limit NSAID use to fewer than 15 days per month to prevent medication-overuse headache 8. If you're using acute medications more than twice weekly, prophylactic therapy should be initiated rather than continuing frequent acute treatment 5.
When Acute Treatment Fails
If episodic TTH becomes frequent (≥2 attacks/month causing ≥3 days disability) or chronic (≥15 headache days/month):
Start prophylactic treatment with amitriptyline 30-150 mg/day - this is the first-line preventive agent for chronic TTH 5, 3. Mirtazapine and venlafaxine are second-line options 3.
Adjunctive Non-Pharmacologic Considerations
While the question asks specifically about medication, the evidence strongly supports combining pharmacologic treatment with:
- Physical therapy targeting the cranio-cervical-mandibular region - reduces pain intensity and frequency in short to medium term 9, 10
- Manual therapy - significant improvements in pain, frequency, duration, and disability scores 10
These interventions address the myofascial trigger points and increased muscle tenderness that characterize TTH 4.
Practical Dosing Algorithm
- Start: Ibuprofen 400 mg at headache onset
- If inadequate response after 2 hours: Add caffeine-containing combination or switch to aspirin 1000 mg
- If using medication >2 days/week: Initiate amitriptyline prophylaxis
- Monitor: Track frequency to ensure <15 days/month NSAID use
The key distinction from migraine treatment is that tension-type headache does NOT respond to migraine-specific agents (triptans, ergots, gepants) and requires a fundamentally different pharmacologic approach centered on NSAIDs and combination analgesics 8, 3.