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 treatment options. 1, 2

Acute Treatment

First-Line Medications

• Ibuprofen (400 mg): Recommended by both the VA/DoD and American College of Physicians guidelines for acute tension headache treatment 2, 1
• Acetaminophen (1000 mg): Equally effective first-line option 2, 1
  • Note: Using inadequate doses of acetaminophen (<1000 mg) is not effective 1
  • The NNT for paracetamol 1000 mg compared with placebo was 22 for being pain-free at two hours 3

Alternative Acute Options

• Aspirin-acetaminophen-caffeine combinations: Effective for mild to moderate headaches 1
  • Caution: Avoid in patients with peptic ulcer disease or bleeding disorders

Preventive Treatment

First-Line for Chronic Tension Headache Prevention

• Amitriptyline: Recommended for prevention of chronic tension-type headache 2, 1
  • Dosing: Start low (10 mg three times daily with 20 mg at bedtime for elderly/adolescents) 4
  • Can be increased gradually to 50-100 mg per day 4
  • Most widely researched prophylactic agent for frequent headaches 5
  • Efficacy rate of approximately 40-50% 6
  • Consider maintenance therapy for 3+ months to prevent relapse 4

Second-Line Preventive Options

• Beta-blockers: Propranolol (80-240 mg/day) or timolol (20-30 mg/day) for frequent and disabling headaches 1
• Anticonvulsants: Divalproex sodium (500-1500 mg/day) for refractory cases 1
  • Requires monitoring for weight gain, hair loss, and tremor

Non-Pharmacological Approaches

Physical Interventions

• Physical therapy: Recommended for tension-type headache 1
• Greater occipital nerve block: Can be used for short-term treatment 1
• Aerobic exercise or progressive strength training: Recommended for tension-type headache 1

Behavioral Interventions

• Relaxation therapies with EMG biofeedback: Efficacy rate of 40-50% 6
• Stress reduction techniques: Regular practice of relaxation techniques or mindfulness 1
• Cognitive therapy: May be helpful though large rigorous trials are lacking 5

Important Considerations and Precautions

Medication Overuse Prevention

• Limit medication use: Using pain relievers more than twice weekly increases risk for chronic daily headache 5
• Maximum frequency guidelines:
  • NSAIDs: No more than 15 days per month 1
  • OTC medications: No more than 14 days per month 1

Lifestyle Modifications

• Maintain regular sleep schedule
• Ensure adequate hydration
• Identify and avoid potential triggers
• Practice stress reduction techniques 1

Treatment Monitoring

• Schedule follow-up in 4-6 weeks to assess effectiveness 1
• Allow 2-3 months for full benefit of preventive medications 1
• For amitriptyline, therapeutic effect may take up to 30 days to develop 4

Treatment Algorithm

1. Start with acute treatment:

   • Ibuprofen 400 mg OR acetaminophen 1000 mg at onset of headache

2. If headaches occur >2 times per week or last >2 days:

   • Consider preventive therapy with amitriptyline
   • Start at low dose (10-25 mg) and titrate up gradually

3. For inadequate response to first-line treatments:

   • Consider combination therapies
   • Evaluate for medication overuse headache
   • Consider non-pharmacological approaches

4. For refractory cases:

   • Consider referral to headache specialist
   • Evaluate for comorbid conditions (anxiety, depression)

Common Pitfalls to Avoid

• Using inadequate doses of acetaminophen (<1000 mg)
• Overuse of acute medications leading to medication overuse headache
• Expecting immediate results from preventive medications
• Failing to address lifestyle factors and triggers
• Not allowing sufficient trial period for preventive medications