What are the treatment options for tension headaches?

Treatment Options for Tension Headaches

For tension headaches, a combination of acetaminophen with caffeine is recommended as first-line treatment, with ibuprofen and acetaminophen alone also being effective first-line options. 1

Acute Treatment Options

First-Line Medications

• Acetaminophen with caffeine: Recommended by the American Academy of Family Physicians as first-line treatment due to caffeine's enhancement of analgesic effects 1
• Acetaminophen 1000 mg: Effective and can be repeated every 6 hours (maximum 4000 mg daily) 1
• Ibuprofen 400-800 mg: Recommended by VA/DoD guidelines as a first-line treatment 1, 2

Important Medication Considerations

• Limit use of 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
• NSAIDs like ibuprofen carry risks including GI side effects, cardiovascular thrombotic events, and renal effects 2
• Avoid opioids due to risk of dependency and medication overuse headache 1

Preventive Treatment

When to Consider Prevention

• If headaches occur more than twice weekly 1
• If acute treatments are ineffective or contraindicated

Preventive Medication

• Amitriptyline 50-100 mg daily: First-line preventive therapy for chronic tension-type headache 1, 3
  • Start with lower doses (10 mg three times daily with 20 mg at bedtime) for adolescents and elderly patients 3
  • Monitor for anticholinergic side effects, especially in older patients or those with cardiac comorbidities 1
  • May take up to 30 days to develop full therapeutic effect 3

Non-Pharmacological Approaches

Recommended Non-Drug Treatments

• Rest in a dark, quiet room 1
• Ensure adequate hydration 1
• Physical therapy 1
• Aerobic exercise or progressive strength training for prevention 1
• Stress management techniques 1
• Sleep hygiene optimization 1

Headache Monitoring

• Track headache patterns (frequency, severity, duration, response to treatment) 1
• Identify and avoid potential triggers (alcohol, caffeine, certain foods, stress, fatigue) 1

When to Consider Further Evaluation

• If headaches have atypical features
• If accompanied by new neurological symptoms
• If there are worrisome findings on examination
• In these cases, neuroimaging should be considered 1

Treatment Algorithm

1. Start with acute treatment:

   • Acetaminophen with caffeine as first choice
   • Alternative first-line options: acetaminophen 1000 mg or ibuprofen 400-800 mg
   • For cardiovascular patients: use acetaminophen alone

2. If acute treatments fail or headaches occur >2 times/week:

   • Consider preventive therapy with amitriptyline
   • Start low (10-25 mg) and gradually increase to 50-100 mg daily

3. Implement non-pharmacological approaches alongside medication therapy

4. Monitor medication use to prevent medication overuse headache (limit to <2 days/week)

Common Pitfalls to Avoid

• Using acute medications more than twice weekly, which can lead to medication overuse headache
• Failing to identify and address headache triggers
• Overlooking the need for preventive therapy in patients with frequent headaches
• Starting amitriptyline at too high a dose, especially in elderly patients
• Using opioids for tension headache management

Remember that tension headaches typically present with bilateral, band-like pressure or tightness around the head, often extending to the neck muscles. Proper diagnosis is essential before initiating treatment.