What are the treatment options for tension type headaches?

Treatment Options for Tension-Type Headache

For tension-type headaches, ibuprofen (400 mg) and acetaminophen (1000 mg) are recommended as first-line abortive treatments, while amitriptyline is the first-line preventive therapy for chronic tension-type headache. 1

Abortive Treatments

First-Line Options:

• Acetaminophen (1000 mg) - Effective for acute treatment with high-quality evidence supporting its use 1, 2

  • Can be repeated every 6 hours as needed (maximum daily dose: 4000 mg) 2
  • NNT of 10 for pain-free or mild pain at two hours 3
  • Well-tolerated with minimal side effects compared to other options 3

• Ibuprofen (400 mg) - Recommended by VA/DoD guidelines for acute treatment 1

  • Comparable efficacy to acetaminophen 1000 mg 4
  • May have slightly faster onset of action than acetaminophen 4

Second-Line Options:

• Acetaminophen-caffeine combination - Useful for patients who don't respond to acetaminophen alone 2
  • Caffeine enhances analgesic effects
  • Use with caution in patients with hypertension 2

Preventive Treatments

For Chronic Tension-Type Headache:

• Amitriptyline - First-line preventive therapy 1, 2, 5, 6
  • Recommended dosage: 50-100 mg daily 2
  • Significantly reduces monthly headache days 2
  • Multiple double-blind, placebo-controlled studies support its efficacy 5
  • Important safety considerations: Monitor for anticholinergic side effects, especially in older patients or those with cardiac comorbidities 2, 7
  • ECG monitoring may be needed due to potential QT prolongation and other cardiac effects 7

Other Preventive Options with Less Evidence:

• Mirtazapine and venlafaxine (antidepressants) 5
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 5

Non-Pharmacological Approaches

Evidence-Based Options:

• Physical therapy - Recommended by guidelines for TTH management 1, 2
• Aerobic exercise or progressive strength training - Effective for prevention 2, 6
• Behavioral interventions:
  • Electromyography biofeedback 6
  • Cognitive behavioral therapy 8, 6
  • Stress management techniques 2

Supportive Measures:

• Resting in a dark, quiet room 2
• Adequate hydration 2
• Sleep hygiene optimization 2
• Massage therapy 6

Monitoring and Prevention of Complications

• Track frequency of headaches and medication use 2
• Evaluate for medication overuse headache if analgesics are used more than twice weekly 2
• Consider preventive therapy if headaches occur more than twice weekly 2
• Avoid opioids due to risk of dependency and medication overuse headache 2

Clinical Pearls and Pitfalls

• Medication overuse risk: Despite the effectiveness of over-the-counter analgesics, their frequent use can lead to medication overuse headache 8
• Underestimated impact: TTH is often considered simple to treat, but it causes significant disability and accounts for more missed workdays than migraine 6
• Treatment resistance: Many patients with TTH do not achieve adequate relief with standard treatments, necessitating a multimodal approach 8
• Amitriptyline monitoring: When using amitriptyline for prevention, monitor for cardiac effects including QRS axis changes and QT prolongation, especially at higher doses 7

The most recent and highest quality evidence from the VA/DoD guidelines clearly supports the use of ibuprofen and acetaminophen for acute treatment, with amitriptyline as the preventive treatment of choice for chronic tension-type headache 1.