What is the recommended treatment for a tension headache?

Treatment of Tension Headache

For acute tension headache treatment, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as first-line options. 1, 2

Acute Treatment Options

First-line Medications:

• Ibuprofen 400 mg: Effective for short-term treatment of tension headache with significant improvement in pain-free response at 2 hours 1
• Acetaminophen 1000 mg: Equally effective for short-term treatment 1
  • Important: Lower doses of acetaminophen (500-650 mg) do not show statistically significant improvement 1

Alternative Options:

• Aspirin-acetaminophen-caffeine combination: Effective for mild to moderate headaches 2
  • Caution: Avoid in patients with peptic ulcer disease or bleeding disorders

Medication Administration Tips:

• Take at the onset of headache
• Take NSAIDs with food to minimize gastrointestinal side effects 2
• Treat headaches as early as possible during an attack for improved efficacy 2

Preventive Treatment for Chronic Tension Headache

For patients with frequent tension headaches requiring preventive therapy:

• Amitriptyline: Recommended for prevention of chronic tension-type headache (50-100 mg) 1
  • Both doses significantly reduce monthly headache days
  • Caution: Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1

Not Recommended:

• Botulinum toxin injections: Evidence does not support use for chronic tension-type headache prevention 1

Non-Pharmacological Approaches

These approaches can complement medication therapy:

• Maintain adequate hydration
• Regular sleep schedule
• Identify and avoid potential triggers
• Stress reduction techniques 2
• Physical therapy for tension-type headache 2
• Aerobic exercise or progressive strength training 2

Important Limitations and Precautions

• Limit medication use to prevent medication overuse headache:
  • NSAIDs: No more than 15 days per month 2
  • OTC medications: No more than 14 days per month 2

Treatment Algorithm

1. Acute episode:

   • Start with ibuprofen 400 mg OR acetaminophen 1000 mg
   • If inadequate relief, consider aspirin-acetaminophen-caffeine combination

2. For chronic/frequent tension headaches (occurring >15 days/month for >3 months):

   • Consider amitriptyline (starting at lower doses and titrating up to 50-100 mg)
   • Implement non-pharmacological approaches

3. Follow-up:

   • Evaluate effectiveness after 4-6 weeks
   • Adjust treatment as needed 2
   • Allow 2-3 months for preventive medications to demonstrate full benefit 2

Common Pitfalls to Avoid

• Using inadequate doses of acetaminophen (doses <1000 mg are not effective) 1
• Overuse of acute medications leading to medication overuse headache
• Failing to address lifestyle factors that may trigger headaches
• Not allowing sufficient time for preventive medications to take effect
• Ignoring comorbid conditions like anxiety and depression that may exacerbate headaches 2