What are the treatment options for tension headaches?

Treatment Options for Tension Headache

For tension-type headache, a combination of acetaminophen with caffeine is recommended as first-line treatment, with ibuprofen or acetaminophen alone as effective alternatives. 1

First-Line Pharmacologic Treatment

• 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 safe option, can be repeated every 6 hours (maximum 4000 mg daily) 1, 2
• Ibuprofen: Recommended by VA/DoD guidelines as equally effective first-line treatment 1, 2
• NSAIDs: Various options (aspirin, diclofenac, naproxen) are effective for tension headache 3

Important Dosing Considerations

• Begin treatment as soon as possible after headache onset
• Limit use of acute medications to no more than twice weekly to prevent medication overuse headache 1
• For patients who don't achieve sufficient pain relief, consider increasing dosage without exceeding maximum daily dose 3

Second-Line Treatment Options

For patients who don't respond to first-line treatments:

• Try a different NSAID or acetaminophen formulation 3
• Consider combination therapy (NSAID plus acetaminophen) for enhanced efficacy 3, 1

Preventive Treatment

Amitriptyline is the most widely researched and recommended prophylactic medication for frequent tension-type headaches:

• Indicated when: Headaches occur more than twice weekly or last more than 2 days 4, 5
• Dosing: Start at low doses (10 mg three times daily with 20 mg at bedtime for elderly/adolescents) 6
• Maintenance: 50-100 mg daily (some patients respond to 40 mg daily) 6
• Monitoring: Watch for anticholinergic side effects, especially in older patients 1
• Duration: Continue maintenance therapy for at least 3 months to reduce relapse risk 6

Non-Pharmacological Approaches

Several evidence-based non-medication options:

• Resting in a dark, quiet room 1
• Adequate hydration 1
• Stress management techniques 1
• Sleep hygiene optimization 1
• Physical therapy and trigger point therapy 1, 7
• Aerobic exercise or progressive strength training 1

Treatment Pitfalls to Avoid

• Medication overuse headache: Occurs when analgesics are used more than twice weekly; monitor frequency of use carefully 1
• Opioids and butalbital: Avoid these medications due to risk of dependency and medication overuse headache 3, 1
• Triptans and ergotamine derivatives: Not first-line for tension headache; contraindicated in patients with CVA history 1
• Neuroimaging: Generally not needed unless headaches have atypical features or are accompanied by new neurological symptoms 1

Headache Monitoring

• Track headache patterns (frequency, severity, duration, response to treatment)
• Identify and avoid potential triggers (alcohol, caffeine, certain foods, stress, fatigue)
• Consider preventive therapy if headaches occur more than twice weekly 1

By following this structured approach to tension headache management, most patients can achieve significant relief while minimizing the risk of medication overuse and other complications.