What is the first line treatment for chronic tension-type headache?

First-Line Treatment for Chronic Tension-Type Headache

The first-line treatment for chronic tension-type headache is ibuprofen (400 mg) or acetaminophen (1000 mg) for acute management, with amitriptyline (50-100 mg daily) as the first-line preventive therapy for patients with frequent headaches. 1, 2

Acute Treatment Options

First-Line Medications

• Ibuprofen (400 mg) - Recommended as first-line therapy with strong evidence for effectiveness in providing pain relief at 2 hours 1, 2
• Acetaminophen (1000 mg) - Equally effective first-line option with demonstrated statistically significant improvement in pain-free response at 2 hours 1, 2
  • Important note: Lower doses of acetaminophen (500-650 mg) do not show statistically significant improvement 1

Key Considerations for Acute Treatment

• Maximum daily acetaminophen dose should not exceed 4000 mg 2
• Limit use of acute medications to no more than twice weekly to prevent medication overuse headache 2
• Avoid opioids and butalbital-containing medications due to high risk of dependency and medication overuse headache 2

Preventive Treatment

First-Line Preventive Therapy

• Amitriptyline (50-100 mg daily) - Recommended as first-line preventive therapy for chronic tension-type headache 1, 2, 3
  • Significantly reduces monthly headache days 1
  • Produces clinically significant improvements in headache index scores in approximately 38% of patients 3

Cautions with Amitriptyline

• Monitor for anticholinergic adverse effects, especially in:
  • Older patients
  • Patients with multiple cardiac comorbidities
  • Risk of overdose 1

Alternative Preventive Options

• If amitriptyline is ineffective or not tolerated, consider:
  • Nortriptyline (up to 75 mg/day) 3
  • Mirtazapine 4
  • Venlafaxine 4

Non-Pharmacological Approaches

Evidence-Based Non-Pharmacological Therapies

• Physical therapy - Recommended for management of tension-type headache (weak for recommendation) 1, 2
• Aerobic exercise or progressive strength training - Recommended for prevention (weak for recommendation) 1, 2
• Stress management therapy - Demonstrated efficacy similar to tricyclic antidepressants 3
  • Combined therapy (stress management + tricyclic antidepressants) produces clinically significant reductions in headache index scores in 64% of patients compared to 38% with medication alone 3

Additional Non-Pharmacological Approaches

• Resting in a dark, quiet room
• Adequate hydration
• Sleep hygiene optimization
• Tracking headache patterns and identifying triggers 2

Treatment Algorithm

1. For acute headache episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg
   • Limit use to no more than twice weekly

2. For patients with frequent headaches (>2 per week):

   • Initiate preventive therapy with amitriptyline, starting at low dose (10-25 mg) and titrating up to 50-100 mg daily as tolerated
   • Add non-pharmacological approaches (physical therapy, aerobic exercise, stress management)

3. For patients not responding to amitriptyline:

   • Consider alternative preventive medications (mirtazapine, venlafaxine)
   • Intensify non-pharmacological approaches

4. For optimal results in patients with chronic tension-type headache:

   • Consider combination therapy with both medication and non-pharmacological approaches, which has shown superior results to either approach alone 3

Common Pitfalls to Avoid

• Using acetaminophen at doses lower than 1000 mg, which lacks evidence for efficacy 1
• Overuse of acute medications leading to medication overuse headache 2
• Using onabotulinumtoxinA for chronic tension-type headache, which is not recommended (weak against recommendation) 1
• Failure to monitor for anticholinergic side effects with amitriptyline, particularly in vulnerable populations 1
• Relying solely on pharmacological or non-pharmacological approaches when combination therapy shows superior results 3