What are the treatment options for tension headaches?

Treatment for Tension Headaches

For tension headaches, a combination of acetaminophen with caffeine is recommended as first-line treatment, with ibuprofen as an effective alternative. 1

Acute Treatment Options

First-Line Medications

• Acetaminophen with caffeine - Recommended by the American Academy of Family Physicians as first-line therapy due to caffeine's enhancement of analgesic effects 1
• Acetaminophen 1000 mg - Effective and safe option, can be repeated every 6 hours (maximum 4000 mg daily) 1
• Ibuprofen - Recommended by VA/DoD guidelines as an equally effective first-line option 1

Important Medication Considerations

• Limit acute medications to no more than twice weekly to prevent medication overuse headache 1
• For patients with cardiovascular history, acetaminophen is the safest first-line option 1
• Avoid opioids due to dependency risk and potential for medication overuse headache 1
• Contraindications: Triptans, ergotamine derivatives, and NSAIDs are contraindicated in patients with history of CVA due to vasoconstrictive effects or bleeding risk 1

Preventive Treatment

Amitriptyline (50-100 mg daily) is recommended for prevention of chronic tension-type headache when headaches occur more than twice weekly 1

Amitriptyline Dosing Considerations:

• Initial dosing: Start with low doses (10 mg three times daily with 20 mg at bedtime) for adolescent and elderly patients 2
• Maintenance: 50-100 mg daily (in some patients, 40 mg is sufficient) 2
• Administration: For maintenance, total daily dose may be given as a single bedtime dose 2
• Duration: Continue maintenance therapy for 3 months or longer to reduce relapse risk 2
• Monitor for: Anticholinergic side effects, especially in older patients or those with cardiac comorbidities 1

Non-Pharmacological Approaches

• Headache tracking: Monitor patterns, frequency, severity, duration, and response to treatment 1
• Trigger identification and avoidance: Common triggers include alcohol, caffeine, certain foods, stress, and fatigue 1
• Rest in dark, quiet room with adequate hydration 1
• Physical therapy is recommended for management of tension-type headaches 1
• Aerobic exercise or progressive strength training for prevention 1
• Stress management techniques and sleep hygiene optimization 1

When to Consider Neuroimaging

• Only if headaches have atypical features
• When accompanied by new neurological symptoms
• If there are worrisome findings on examination 1

Common Pitfalls to Avoid

1. Medication overuse: Using analgesics more than twice weekly can lead to medication overuse headache 1, 3
2. Inadequate dosing: Ensure proper dosing of medications (e.g., acetaminophen 1000 mg) for optimal effect 4, 5
3. Failure to identify triggers: Not addressing underlying triggers can lead to continued headaches 1
4. Delayed preventive therapy: Consider preventive therapy if headaches occur more than twice weekly 1, 6
5. Unnecessary neuroimaging: Not indicated unless atypical features or neurological symptoms are present 1, 3

Treatment Algorithm

1. Start with acute treatment:

   • Acetaminophen with caffeine OR
   • Acetaminophen 1000 mg OR
   • Ibuprofen (400-800 mg)

2. If headaches occur >2 times per week:

   • Add preventive therapy with amitriptyline (start low, increase gradually)
   • Continue to optimize non-pharmacological approaches

3. For inadequate response:

   • Ensure adequate dosing of first-line medications
   • Consider combination therapy (acetaminophen with caffeine)
   • Evaluate for medication overuse headache if using analgesics >2 times weekly

4. Implement non-pharmacological approaches throughout treatment course