What are the treatments for tension-type headaches?

Treatments for Tension-Type Headaches

For tension-type headaches, first-line acute treatment is ibuprofen (400 mg) or acetaminophen (1000 mg), while amitriptyline (50-100 mg daily) is recommended for prevention in chronic or frequent cases. 1, 2

Acute Treatment Options

First-Line Medications

• Ibuprofen (400 mg): Provides significant pain relief at 2 hours 1, 2
• Acetaminophen (1000 mg): Equally effective as ibuprofen for pain relief at 2 hours 1, 2
  • Note: Lower doses (500-650 mg) are not significantly effective 1
• NSAIDs: Other options include aspirin, diclofenac, and naproxen 2

Second-Line Options

• Combination therapy: Acetaminophen with caffeine can be more effective than either agent alone 2
• Caffeine-containing NSAID preparations: Slightly superior to NSAIDs alone but should be used cautiously to avoid headache chronification 3

Important Cautions

• Avoid opioids and butalbital: High risk of dependency and medication overuse headache 2
• Limit acute medications: Use no more than twice weekly to prevent medication overuse headache 2
• Special populations: For patients with history of CVA, acetaminophen 1000 mg is the safest option 2

Preventive Treatment

When to Consider Prevention

• Two or more attacks per month causing disability for 3+ days per month
• Failure of or contraindication to acute treatments
• Use of abortive medication more than twice per week
• Chronic tension-type headache 1, 2

First-Line Preventive Medication

• Amitriptyline (50-100 mg daily): Significantly reduces monthly headache days 1, 2, 4
  • Monitor for anticholinergic side effects, especially in older patients or those with cardiac conditions
  • Start at lower doses (10-25 mg) and gradually increase

Alternative Preventive Medications

• Mirtazapine and venlafaxine: Second-line options with documented efficacy 4, 5
• Limited evidence supports gabapentin, topiramate, and tizanidine 4

Non-Pharmacological Approaches

Evidence-Based Options

• EMG biofeedback: Has documented effect in tension-type headache 5
• Cognitive-behavioral therapy: Effective for selected patients 6, 5
• Relaxation training: Likely effective for tension-type headache 2, 5
• Physical therapy: Recommended though evidence is limited 2, 5
• Exercise: Aerobic exercise or progressive strength training recommended for prevention 2

Lifestyle Modifications

• Trigger identification and avoidance: Track headache patterns to identify triggers (alcohol, caffeine, certain foods, stress, fatigue) 2
• Sleep hygiene optimization: Establish regular sleep patterns 2
• Stress management techniques: Implement yoga, mindfulness 1
• Regular meals and adequate hydration: Maintain consistent eating schedule and hydration 1

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg
   • If inadequate response, try combination with caffeine
   • Avoid using acute medications more than twice weekly

2. For frequent or chronic tension-type headaches:

   • Initiate amitriptyline starting at 10-25 mg at bedtime
   • Gradually increase to 50-100 mg daily as tolerated
   • Allow 3-4 months for maximum efficacy 1
   • If ineffective or not tolerated, consider mirtazapine or venlafaxine

3. Concurrent non-pharmacological approaches:

   • Implement EMG biofeedback and/or cognitive-behavioral therapy
   • Incorporate regular exercise program
   • Optimize sleep hygiene and stress management

Common Pitfalls to Avoid

• Using inadequate doses of acetaminophen (doses below 1000 mg are not effective) 1
• Relying solely on pharmacological or non-pharmacological approaches when combination therapy shows superior results 2
• Overusing acute medications leading to medication overuse headache 2, 5
• Failing to monitor for anticholinergic side effects with amitriptyline, especially in older patients 2
• Not allowing sufficient time (3-4 months) for preventive medications to reach maximum efficacy 1