Best Treatment for Tension Headache
For acute tension headache treatment, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as first-line options. 1
Acute Treatment Algorithm
First-Line Options
- Ibuprofen 400 mg: Provides effective pain relief for tension-type headache with a favorable efficacy profile
- Acetaminophen 1000 mg: Equally effective as ibuprofen at this specific dosage
It's important to note that the dosage matters significantly. The evidence specifically supports acetaminophen at 1000 mg, as lower doses (500-650 mg) have not shown statistically significant improvement compared to placebo 2. Similarly, for NSAIDs like ibuprofen, the 400 mg dose has been specifically studied and recommended 1.
Second-Line Options
If first-line treatments are ineffective or contraindicated:
- Aspirin 1000 mg: Has demonstrated efficacy in tension headache treatment 3
- Aspirin-acetaminophen-caffeine combination: While primarily studied for migraine, can be considered for tension headaches that are unresponsive to single agents 1
Preventive Treatment for Chronic Tension Headache
For patients experiencing chronic tension-type headaches (≥15 headache days per month):
- Amitriptyline: Recommended for prevention of chronic tension-type headache 1
- Starting dose: 10-25 mg at bedtime
- Gradually titrate up to effective dose (typically 25-75 mg)
- Monitor for anticholinergic side effects, especially in older adults
The guidelines specifically recommend against botulinum toxin injections for chronic tension-type headache prevention 1.
Non-Pharmacological Approaches
Several non-pharmacological interventions can be effective either alone or as adjuncts to medication:
- Physical therapy: Recommended for management of tension-type headache 1
- Aerobic exercise: Regular physical activity can help reduce headache frequency 1
- Stress management techniques: Can address underlying triggers
Important Clinical Considerations
Medication Overuse Risk: Limit acute therapy to no more than 2-3 days per week to prevent medication overuse headache
Dosage Precision: The evidence specifically supports acetaminophen at 1000 mg, not lower doses 2
Combination Therapy: For patients with inadequate response to monotherapy, combining physical therapy with pharmacological treatment may provide better outcomes
Treatment Timing: Early intervention when headache is still mild may improve outcomes, similar to what has been observed with migraine treatment 1
Avoid Unnecessary Imaging: For typical tension-type headache with normal neurological examination, imaging studies are not indicated 4
By following this evidence-based approach to tension headache management, clinicians can effectively reduce pain, improve quality of life, and minimize the risk of medication overuse headache in their patients.