What is the recommended treatment regimen for tension headaches?

Tension Headache Treatment Regimen

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

Abortive Treatment Algorithm

First-Line Options:

• Ibuprofen 400 mg or Acetaminophen 1000 mg 1, 2
  • Both medications have demonstrated similar efficacy in treating tension headaches
  • Acetaminophen can be repeated every 6 hours as needed (maximum daily dose: 4000 mg)
  • Ibuprofen can be taken up to 3 times daily (maximum daily dose: 1200 mg)

Second-Line Options (if first-line treatment is inadequate):

• Combination of acetaminophen with caffeine 1
  • The caffeine component can enhance analgesic effects
  • Use with caution in patients with hypertension

For Severe or Refractory Cases:

• NSAIDs such as naproxen (550-825 mg) or ketoprofen (50-75 mg) 3
• Aspirin-acetaminophen-caffeine combination may be effective 4

CAUTION: Limit use of acute medications to no more than twice weekly to prevent medication overuse headache 4, 1

Preventive Treatment

When to Consider Prevention:

• Headaches occurring more than twice weekly 1, 5
• Headaches producing disability for three or more days per month 4
• Use of rescue medication more than twice a week 4
• Failure of acute treatments 4

First-Line Preventive Therapy:

• Amitriptyline (50-100 mg daily) 1, 5
  • Most widely researched prophylactic agent for frequent tension headaches
  • Monitor for anticholinergic side effects, especially in older patients or those with cardiac comorbidities

Non-Pharmacological Approaches:

• Relaxation techniques with EMG biofeedback (40-50% efficacy rate) 3
• Physical therapy 1
• Stress management techniques 1
• Sleep hygiene optimization 1
• Aerobic exercise or progressive strength training 1

Important Considerations and Pitfalls

1. Avoid opioids and butalbital-containing medications due to high risk of dependency and medication overuse headache 1

2. Monitor for medication overuse headache

   • Can occur when analgesics are used more than twice weekly 1
   • May require withdrawal of overused medication and initiation of preventive therapy

3. Track headache patterns

   • Consider using a headache diary to document frequency, severity, duration, and response to treatment 4
   • Identify and avoid potential triggers (alcohol, caffeine, certain foods, stress, fatigue, etc.) 4

4. Consider neuroimaging only if:

   • Headaches have atypical features
   • Accompanied by new neurological symptoms
   • There are worrisome findings on examination 6

5. Combination therapy

   • For patients with inadequate response to single agents, combining pharmacological and non-pharmacological approaches may be more effective 3

The VA/DoD guidelines specifically recommend ibuprofen and acetaminophen as first-line treatments for tension headaches 4, which is consistent with findings from comparative studies showing both medications are effective and well-tolerated 7. For chronic tension headaches, amitriptyline has demonstrated the most consistent evidence for prevention 1, 5.