What is the best management for tension headaches?

Management of Tension Headache

For the treatment of tension-type headache, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as first-line abortive therapies, while amitriptyline is suggested for prevention of chronic tension-type headache. 1

Abortive Treatment

First-line Medications

• Ibuprofen 400 mg: Recommended as a first-line treatment with favorable efficacy and side-effect profile 1, 2
• Acetaminophen 1000 mg: Equally effective for pain relief 1, 3

Important considerations:

• Lower doses of acetaminophen (500-650 mg) have not shown statistically significant improvement 1
• Both medications demonstrate statistically significant improvement in pain-free response at 2 hours 1
• Ibuprofen may have a slightly faster onset of action, with greater pain reduction at 1 hour compared to other NSAIDs 3

Alternative NSAIDs

• Naproxen 550-825 mg
• Ketoprofen 50-75 mg 4

Caution: Using pain relievers more than twice weekly increases risk of progression to chronic daily headache 5

Preventive Treatment for Chronic Tension-Type Headache

First-line Prevention

• Amitriptyline: Recommended for prevention of chronic tension-type headache 1
  • Effective doses: 50-100 mg daily
  • Significantly reduces monthly headache days 1

Important considerations:

• Monitor for anticholinergic adverse effects, especially in:
  • Older patients
  • Patients with cardiac comorbidities
  • Risk of overdose 1

Treatments NOT Recommended

• Botulinum toxin injections: Evidence shows no significant improvement in chronic tension-type headache outcomes 1
  • The VA/DoD Clinical Practice Guideline specifically recommends against botulinum/neurotoxin injection for chronic tension-type headache prevention 1

Non-pharmacological Approaches

Recommended Approaches

• Physical therapy: Suggested for management of tension-type headache 1
• Aerobic exercise or progressive strength training: Recommended for prevention 1

Other Approaches (Limited Evidence)

• Relaxation therapies with EMG biofeedback (40-50% efficacy rate) 4
• Cognitive therapy 5

Clinical Algorithm

1. For acute tension headache episodes:

   • Start with ibuprofen 400 mg OR acetaminophen 1000 mg
   • Limit use to less than twice weekly to prevent medication overuse headache

2. For patients with chronic tension-type headache (≥15 headache days/month for >3 months):

   • Consider amitriptyline starting at lower doses and titrating up to 50-100 mg daily
   • Add physical therapy or aerobic exercise program

3. For inadequate response:

   • Consider combination of pharmacological and non-pharmacological approaches
   • Evaluate for medication overuse headache if frequent analgesic use
   • Consider referral to headache specialist if poor response to treatment

Common Pitfalls to Avoid

• Using inadequate doses of acetaminophen (doses <1000 mg are less effective)
• Prescribing botulinum toxin injections for tension-type headache (not recommended)
• Failing to address medication overuse, which can perpetuate headaches
• Neglecting non-pharmacological approaches, which can be effective adjuncts

By following this evidence-based approach, most patients with tension-type headache can achieve significant improvement in symptoms and quality of life.