What is the treatment for tension headache?

Treatment of Tension Headache

For most patients with tension headache, over-the-counter NSAIDs such as ibuprofen (400-600mg) or naproxen sodium (500-550mg) are the first-line treatment, with non-pharmacological approaches including stress management and lifestyle modifications as important adjuncts. 1, 2

Pharmacological Management

Acute Treatment

1. First-line therapy:

   • NSAIDs 2
     • Ibuprofen 400-600mg
     • Naproxen sodium 500-550mg
     • Aspirin
   • Simple analgesics should be used with caution to avoid medication overuse headache (using pain relievers more than twice weekly increases risk) 3

2. Second-line therapy:

   • Combination analgesics containing caffeine 2
   • Sedating antihistamines or antiemetics can potentiate pain-relieving effects 3

3. NOT recommended:

   • Triptans
   • Muscle relaxants
   • Opioids 2
   • Butalbital-containing compounds (risk of medication overuse headache) 3

Preventive Treatment

For chronic tension-type headache (≥15 days/month for at least 6 months):

1. First-line preventive therapy:

   • Amitriptyline (tricyclic antidepressant) 2, 4
     • Starting dose: 10mg at bedtime for elderly/adolescents 5
     • Typical dose: 30-150mg daily 6, 4
     • May take 2-3 months to show full benefit 1

2. Second-line preventive options:

   • Mirtazapine
   • Venlafaxine 2

Non-Pharmacological Approaches

1. Evidence-based options:

   • EMG biofeedback (documented effectiveness) 2
   • Cognitive-behavioral therapy 2, 3
   • Relaxation training 2, 3
   • Self-hypnosis 3

2. Additional options with limited evidence:

   • Physical therapy 2
   • Acupuncture 2
   • Topical heat or cold packs 7
   • Regular exercise 1, 7

Lifestyle Modifications

• Identify and avoid trigger factors 6, 1
• Maintain regular sleep schedule 1
• Ensure adequate hydration 6, 1
• Limit caffeine intake 6
• Regular meals 6
• Stress management techniques 6, 1

Treatment Algorithm

1. For episodic tension headache (< 15 days/month):

   • Start with NSAIDs or simple analgesics
   • Add non-pharmacological approaches
   • Limit medication use to avoid medication overuse headache

2. For chronic tension headache (≥ 15 days/month):

   • Consider prophylactic treatment with amitriptyline
   • Continue appropriate acute treatment for breakthrough headaches
   • Implement comprehensive non-pharmacological approaches

Important Cautions

• Avoid using analgesics more than twice weekly to prevent medication overuse headache 3
• Monitor for side effects of amitriptyline including drowsiness, weight gain, and anticholinergic symptoms 6
• NSAIDs carry cardiovascular and gastrointestinal risks, particularly with prolonged use 8
• Combined therapy (medication plus stress management) is more effective than either approach alone, with 64% of patients achieving significant reduction in headache severity compared to 38% with medication alone 4

Special Considerations

• For patients with mixed tension and migraine headaches, amitriptyline may be particularly effective 6
• Patients with chronic tension headache often experience moderate to high severity pain (mean score 6.62/10), with headaches occurring approximately 5 days per week and lasting about 8.7 hours per day 9
• Married patients, those with illness duration less than two years, and those treated with only analgesics tend to report higher headache severity 9

The combination of appropriate pharmacological treatment and non-pharmacological approaches offers the best chance for successful management of tension headaches.