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, with amitriptyline considered for prevention in frequent or chronic cases. 1

Abortive Treatment Options

First-Line Medications

• Ibuprofen 400 mg: Recommended as first-line therapy by the American College of Physicians and VA/DoD guidelines 1
• Acetaminophen 1000 mg: Equally effective first-line option, particularly safer in patients with cardiovascular concerns 1, 2
• Combination of acetaminophen with caffeine: Recommended by the American Academy of Family Physicians as first-line or for those who don't respond to acetaminophen alone 1

Second-Line Options

• Other NSAIDs: Aspirin, diclofenac, and naproxen are effective alternatives 1, 3
  • Aspirin 1000 mg has demonstrated superior efficacy compared to placebo (75.7% response rate vs 54.5%) 3
  • Naproxen 375 mg has shown comparable efficacy to acetaminophen 1000 mg 4

Important Cautions

• Avoid opioids and butalbital-containing medications: These carry significant risk of dependency and medication overuse headache 1
• Limit use of acute medications to no more than twice weekly: More frequent use increases risk of medication overuse headache 1
• NSAIDs contraindications: Avoid in patients with history of CVA, cardiovascular disease, or high bleeding risk 1, 5
• Monitor for side effects: While generally well-tolerated, NSAIDs can cause GI discomfort, cardiovascular events, and renal effects 5

Preventive Treatment

When to Consider Prevention

• For frequent headaches (occurring more than twice weekly) 1
• For chronic tension-type headache 1, 6
• When acute medications are ineffective or overused 1

First-Line Preventive Medication

• Amitriptyline: Most extensively researched preventive medication 1, 6, 7
  • Dosing: Start low (10 mg in elderly/adolescents) and gradually increase 8
  • Maintenance dose: 50-100 mg daily, often given as a single bedtime dose 1, 8
  • Duration: Continue for at least 3 months to prevent relapse 8
  • Monitoring: Watch for anticholinergic side effects, especially in older patients or those with cardiac comorbidities 1

Alternative Preventive Options

• Other antidepressants: Mirtazapine and venlafaxine have documented efficacy 6
• Anticonvulsants: Some evidence supports gabapentin and topiramate 6
• Muscle relaxants: Limited evidence for tizanidine 6

Non-Pharmacological Approaches

Acute Management

• Rest in a dark, quiet room 1
• Ensure adequate hydration 1
• Apply cold or warm compresses (based on patient preference)

Preventive Strategies

• Physical therapy: Recommended by guidelines for tension-type headache management 1
• Exercise: Aerobic exercise or progressive strength training 1
• Stress management: Relaxation techniques, biofeedback, cognitive therapy 1, 7
• Sleep hygiene optimization 1
• Headache tracking: Identify and avoid triggers (alcohol, caffeine, certain foods, stress, fatigue) 1

Common Pitfalls to Avoid

1. Medication overuse: Using analgesics more than twice weekly can lead to medication overuse headache 1
2. Unnecessary imaging: Neuroimaging only needed if headaches have atypical features, new neurological symptoms, or worrisome examination findings 1
3. Inadequate trial of preventive medications: Amitriptyline may take up to 30 days to show full therapeutic effect 8
4. Overlooking non-pharmacological approaches: These can be effective adjuncts to medication therapy 1, 6
5. Inappropriate use of triptans: These are not indicated for tension-type headache and are contraindicated in patients with cardiovascular disease 1

By following this evidence-based approach to tension headache management, most patients can achieve significant relief while minimizing medication-related risks.