What is the recommended abortive therapy for a 30-year-old patient with tension headaches and Bipolar I disorder, currently on Quetiapine (quetiapine) 250 mg daily?

Abortive Therapy for Tension Headaches in a Patient with Bipolar I on Quetiapine

For abortive therapy of tension headaches in a 30-year-old with Bipolar I on quetiapine 250 mg daily, ibuprofen 400 mg or acetaminophen 1000 mg is recommended as first-line treatment. 1

First-Line Abortive Treatment Options

The 2024 VA/DoD Clinical Practice Guideline for Headache Management specifically recommends:

• Ibuprofen (400 mg) - First-line option with good evidence for tension headache relief 1
• Acetaminophen (1000 mg) - Alternative first-line option with similar efficacy 1

These recommendations are supported by a "weak for" level of evidence, but represent the most current clinical guidance for tension-type headache abortive therapy.

Medication Considerations in Bipolar Disorder

When treating tension headaches in patients with Bipolar I disorder, several important considerations must be addressed:

1. Avoid medications that may trigger mood episodes

   • Certain medications used for headaches could potentially destabilize mood in bipolar patients
   • Quetiapine (250 mg daily) is an established mood stabilizer for Bipolar I disorder 2, 3

2. Medication interactions

   • NSAIDs like ibuprofen and acetaminophen generally have minimal interaction with quetiapine
   • These options are less likely to interfere with the mood-stabilizing effects of quetiapine 3

Treatment Algorithm

1. First attempt: Ibuprofen 400 mg at onset of headache

   • Take with food to minimize GI side effects
   • May repeat after 6 hours if needed (not exceeding 1200 mg/day)

2. Alternative: Acetaminophen 1000 mg at onset of headache

   • May repeat after 6 hours if needed (not exceeding 3000 mg/day)
   • Better option if patient has GI sensitivity or contraindications to NSAIDs

3. For inadequate response: Consider combination therapy

   • Aspirin-acetaminophen-caffeine combination may be effective
   • Note that while this combination is strongly recommended for migraines 1, it may also help with tension headaches

Important Cautions

• Avoid opioid analgesics - Can lead to dependency, rebound headaches, and eventual loss of efficacy 1
• Monitor for medication overuse headache - Regular use of analgesics more than 2-3 days per week can lead to medication overuse headaches 1
• Avoid sedatives containing barbiturates - These have limited evidence and may interfere with bipolar management 1
• Avoid triptans for tension headaches - These are indicated for migraines but not tension-type headaches 1

Preventive Considerations

If the patient experiences frequent tension headaches (more than twice weekly), consider:

• Amitriptyline - Recommended for prevention of chronic tension-type headache 1

  • However, use cautiously with bipolar disorder as antidepressants may potentially trigger manic episodes 1
  • Start at low doses (10-25 mg at bedtime) and monitor mood closely

• Avoid botulinum toxin injections - Evidence suggests against their use for tension-type headache prevention 1

By following this approach, you can effectively manage tension headaches while maintaining mood stability in this patient with Bipolar I disorder on quetiapine therapy.