What are the treatment options for tension headaches (HA)?

Treatment Options for Tension Headaches

For the short-term treatment of tension-type headaches, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as first-line options. 1

Pharmacologic Treatment Options

Abortive Therapy for Tension-Type Headache

1. First-line options:

   • Ibuprofen 400 mg - Provides effective pain relief for acute tension headaches 1
   • Acetaminophen 1000 mg - Equally effective for tension headache relief 1

   Important note: Lower doses of acetaminophen (500-650 mg) have not shown statistically significant improvement compared to placebo 2, so the full 1000 mg dose is necessary for effectiveness.

2. Other NSAID options:

   • Naproxen sodium 550-825 mg
   • Aspirin 650-1000 mg

   Caution: NSAIDs carry risks including GI bleeding, cardiovascular events, and kidney damage. Review the FDA warnings before prescribing 3.

3. Combination analgesics:

   • Aspirin-acetaminophen-caffeine combinations can be slightly more effective than single agents 4
   • Isometheptene combinations (e.g., Midrin) for milder tension headaches 1

   Warning: Limit use of caffeine-containing preparations to avoid medication overuse headache and chronification of tension headaches 4.

Preventive Therapy for Chronic Tension-Type Headache

1. First-line preventive option:

   • Amitriptyline - Recommended for prevention of chronic tension-type headache 1
   • Typical dosing: Start low (10 mg at bedtime for elderly/adolescents; 25 mg for others) and gradually increase as needed and tolerated 5
   • May take up to 30 days to develop full therapeutic effect 5

2. NOT recommended:

   • Botulinum/neurotoxin injection is specifically not recommended for prevention of chronic tension-type headache 1
   • Gabapentin is not recommended (evidence suggests against its use) 1

Non-Pharmacologic Treatment Options

1. Physical therapy:

   • Recommended for management of tension-type headaches 1
   • May include thermal methods, trigger point massage, and mobilization/manipulation techniques

2. Exercise therapy:

   • Aerobic exercise or progressive strength training is recommended for prevention of tension-type headaches 1
   • Typical regimen: 2-3 times weekly for 30-60 minutes of aerobic exercise or 3 times weekly for 30 minutes of supervised upper-body progressive strength training

3. Other behavioral interventions (insufficient evidence to recommend for or against):

   • Biofeedback
   • Cognitive behavioral therapy
   • Mindfulness-based therapies
   • Progressive muscle relaxation
   • Acupuncture or dry needling
   • Yoga

Treatment Algorithm for Tension Headaches

For Acute Episodes:

1. Start with:

   • Ibuprofen 400 mg OR
   • Acetaminophen 1000 mg

2. If inadequate response:

   • Try an alternative NSAID (naproxen 550 mg)
   • Consider combination with caffeine (but limit frequency)

3. Important limitations:

   • Limit use of pain relievers to fewer than 2 days per week to prevent medication overuse headache 6
   • For patients with frequent headaches (>2 per week), consider preventive therapy

For Chronic Tension Headaches (≥15 days/month):

1. Initiate preventive therapy:

   • Amitriptyline: Start at 10-25 mg at bedtime, gradually increase to 50-100 mg daily as needed and tolerated
   • Continue for at least 3 months once effective to reduce relapse risk 5

2. Add non-pharmacologic approaches:

   • Physical therapy
   • Regular aerobic exercise or strength training program
   • Stress management techniques

Important Clinical Considerations

• Medication overuse risk: Using analgesics more than twice weekly increases risk of progression to chronic daily headache 6
• Efficacy rates: Even with optimal therapy, efficacy rates for chronic tension headache treatment are only around 40-50% 4
• Diagnostic considerations: Ensure proper diagnosis of tension-type headache (typically bilateral, band-like pressure or tightness) and exclude secondary causes of headache
• Avoid opioids and butalbital-containing medications as they have increased risk of causing chronic daily headache 6

By following this evidence-based approach to tension headache management, clinicians can effectively address both acute episodes and implement preventive strategies for patients with frequent tension headaches.