What is a good treatment and plan for tension headaches?

Treatment of Tension-Type Headache

For tension-type headaches, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as first-line abortive therapies, with amitriptyline (50-100 mg daily) recommended for prevention of chronic tension-type headache. 1

Abortive Treatment

First-Line Medications:

• Ibuprofen 400 mg: Provides effective pain relief with favorable efficacy and side-effect profile 1
• Acetaminophen 1000 mg: Equally effective for pain relief, though lower doses (500-650 mg) have not shown statistically significant improvement 1, 2
  • Both medications demonstrate statistically significant improvement in pain-free response at 2 hours 1
  • In comparative studies, acetaminophen 1000 mg showed a significantly larger mean pain intensity difference from baseline at one hour compared to naproxen 375 mg 3

Other NSAIDs:

• Naproxen and other NSAIDs can be effective but carry risks of gastrointestinal side effects 4
• Aspirin has also shown efficacy but may have higher bleeding risk 5

Preventive Treatment for Chronic Tension-Type Headache

First-Line Prevention:

• Amitriptyline: Recommended for prevention of chronic tension-type headache 1, 6
  • Effective doses range from 50-100 mg daily 1
  • Start at lower doses (10 mg three times daily with 20 mg at bedtime) for adolescent and elderly patients 7
  • Significantly reduces monthly headache days 1
  • Multiple double-blind, placebo-controlled studies support its efficacy 6

Alternative Preventive Medications:

• Mirtazapine and venlafaxine have documented efficacy 6
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 6

Non-Pharmacological Approaches

• Physical therapy is suggested for management of tension-type headache 1
• Aerobic exercise or progressive strength training is recommended for prevention 1
• Biofeedback, relaxation training, self-hypnosis, and cognitive therapy are commonly employed, though large trials with rigorous methodologies are lacking 8
• Acupuncture has documented efficacy 6

Important Cautions and Monitoring

• Medication overuse risk: Using pain relievers more than twice weekly increases risk of progression to chronic daily headache 1, 8
• Monitor for anticholinergic adverse effects with amitriptyline, especially in older patients and those with cardiac comorbidities 1
• NSAIDs carry risks of gastrointestinal bleeding, ulcers, and cardiovascular events, particularly with prolonged use 4
• Amitriptyline may require up to 30 days to develop full therapeutic effect 7

Treatment Algorithm

1. For acute attacks:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg
   • Take at onset of headache for best results
   • Limit use to no more than twice weekly to prevent medication overuse headache

2. For frequent tension headaches (occurring more than twice weekly):

   • Initiate preventive therapy with amitriptyline
   • Start at low dose (10-25 mg at bedtime) and gradually increase
   • Target dose: 50-100 mg daily for optimal prevention
   • Allow 4-6 weeks to assess efficacy

3. Add non-pharmacological approaches:

   • Physical therapy
   • Regular exercise program
   • Stress management techniques

By following this evidence-based approach, most patients with tension-type headaches can achieve effective symptom control while minimizing medication overuse and adverse effects.