What are the treatment options for tension headaches?

Treatment Options for Tension Headaches

For tension-type headaches, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as first-line abortive treatments. 1, 2

Abortive Treatment Options

First-Line Medications

• NSAIDs:

  • Ibuprofen 400 mg (weak recommendation) 1
  • Naproxen (effective but with caution in patients with cardiovascular risk) 2, 3
  • Aspirin (effective but with bleeding risk considerations) 2

• Acetaminophen:

  • 1000 mg dose (weak recommendation) 1, 2
  • Safest option for patients with cardiovascular history 2
  • Maximum daily dose: 4000 mg 2

• Combination therapy:

  • Acetaminophen with caffeine (recommended as first or second-line) 2
  • Caution with caffeine in hypertensive patients 2

Medications to Avoid

• Opioids and butalbital-containing medications:

  • Increase risk of dependency 2
  • Can lead to medication overuse headache 2

• Triptans and ergotamine derivatives:

  • Not indicated for tension-type headaches 2
  • Contraindicated in patients with cardiovascular disease 2, 4

Preventive Treatment

Pharmacological Prevention

• Amitriptyline:
  • Recommended for chronic tension-type headache (weak recommendation) 1, 2
  • Typical dosage: 50-100 mg daily 2
  • Monitor for anticholinergic side effects, especially in older patients 2

Non-Pharmacological Prevention

• Physical therapy and exercise:

  • Aerobic exercise or progressive strength training 2
  • Trigger point therapy (shown to reduce duration, intensity, and frequency) 5

• Other techniques:

  • Biofeedback and relaxation training 6
  • Stress management techniques 2
  • Sleep hygiene optimization 2

Managing Medication Overuse

• Limit use of acute medications to no more than twice weekly 2
• Consider preventive therapy if headaches occur more than twice weekly 2
• Monitor for medication overuse headache if analgesics are used frequently 2

Important Considerations and Cautions

NSAID Safety Concerns

• Cardiovascular risks:

  • Increased risk of thrombotic events, including MI and stroke 4
  • Use lowest effective dose for shortest duration 4
  • Particular caution in patients with history of MI or heart failure 4

• Gastrointestinal risks:

  • Can cause serious GI adverse events including bleeding and ulceration 4
  • Risk increases with duration of use 4
  • Use with extreme caution in those with prior history of ulcer disease 4

Practical Management Tips

• Track headache patterns (frequency, severity, duration, triggers) 2
• Identify and avoid potential triggers (alcohol, caffeine, stress, fatigue) 2
• Rest in dark, quiet room and ensure adequate hydration during attacks 2
• Consider neuroimaging only if headaches have atypical features or new neurological symptoms 2

By following these evidence-based recommendations, most tension headaches can be effectively managed. Start with the safest, most effective abortive treatments (ibuprofen or acetaminophen) and consider preventive therapy with amitriptyline if headaches are frequent or chronic.