What are the treatment options for tension headaches?

Treatment Options for Tension Headaches

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

Acute Treatment Options

First-Line Medications

• Ibuprofen (400 mg): Provides statistically significant improvement in pain-free response at 2 hours 1
• Acetaminophen (1000 mg): Equally effective for pain relief as ibuprofen 1
  • Note: Lower doses of acetaminophen (500-650 mg) have not shown statistically significant improvement 1, 2
• NSAIDs: Other options include naproxen (550-825 mg) and ketoprofen (50-75 mg) 3

Important Considerations for Acute Treatment

• Caffeine-containing preparations of NSAIDs may be slightly more effective but should be used cautiously to avoid headache chronification 3
• Using pain relievers more than twice weekly increases risk of progression to chronic daily headache 1, 4
• Sedating antihistamines or antiemetics can potentiate the pain-relieving effects of standard analgesics 4

Preventive Treatment Options

For Chronic Tension-Type Headache

• Amitriptyline: Most widely researched prophylactic agent 4
  • Effective doses range from 50-100 mg daily 1
  • Significantly reduces monthly headache days 1
  • Consider prophylaxis if tension headaches occur more than twice a week or last more than 2 days 5

Dosing Considerations for Amitriptyline

• Initial dosage should be low and increased gradually 6
• For elderly patients: Start with 10 mg 3 times a day with 20 mg at bedtime 6
• Monitor for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1

Other Preventive Medications

• Evidence supports the use of mirtazapine and venlafaxine 7
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 7
• Not recommended: Botulinum/neurotoxin injection for chronic tension-type headache prevention 1

Non-Pharmacological Approaches

Evidence-Based Options

• Physical therapy: Suggested for management of tension-type headache 1
• Aerobic exercise or progressive strength training: Recommended for prevention 1
• Relaxation therapies with EMG biofeedback: Efficacy rate of 40-50% (similar to tricyclics) 3
• Other options with some evidence include psychotherapy and acupuncture 7

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg
   • If inadequate relief, consider adding a sedating antihistamine or antiemetic
   • Limit use to fewer than twice weekly to prevent medication overuse headache

2. For frequent episodes (more than twice weekly):

   • Initiate preventive therapy with amitriptyline
   • Start at low dose (10-25 mg at bedtime) and gradually increase to 50-100 mg daily as needed
   • Allow 30 days for therapeutic effect to develop 6
   • Incorporate non-pharmacological approaches (physical therapy, exercise, relaxation techniques)

3. For treatment-resistant cases:

   • Consider alternative preventive medications (mirtazapine, venlafaxine)
   • Evaluate for medication overuse headache if frequent analgesic use is present 1
   • Intensify non-pharmacological interventions

Pitfalls to Avoid

• Using analgesics too frequently (>2 days/week), which can lead to medication overuse headache 1, 4
• Starting amitriptyline at too high a dose, which may cause intolerable side effects 6
• Expecting immediate results from preventive medications (may take up to 30 days) 6
• Neglecting non-pharmacological approaches, which can be effective adjuncts to medication therapy 1