What are the treatment options for tension headaches?

Treatment Options for Tension Headaches

NSAIDs are the first-line treatment for tension headaches, with ibuprofen 400-600mg or naproxen 500-550mg being the most effective options. 1

First-Line Treatments

Non-Pharmacological Approaches

• Regular aerobic exercise and strength training
• Maintaining a regular sleep schedule
• Adequate hydration
• Identification and avoidance of triggers
• Relaxation techniques or mindfulness meditation 1
• Cognitive-behavioral therapy (CBT) and biofeedback have shown efficacy rates of 40-50% for chronic tension headaches 2

Pharmacological Approaches (Acute Treatment)

• NSAIDs (first-line):
  • Ibuprofen: 400-600mg
  • Naproxen sodium: 500-550mg
  • Aspirin: 800-1000mg 1
• Acetaminophen: 1000mg (provides a small benefit in terms of being pain free at two hours) 3

Second-Line Treatments

For patients who don't respond adequately to first-line treatments:

• Combination therapy: Adding a triptan to an NSAID or acetaminophen 4
• Tricyclic antidepressants: Amitriptyline is the most widely researched prophylactic agent for frequent headaches 5

Preventive Therapy

Consider preventive therapy if tension headaches occur more than twice per week or last more than 2 days 6:

• First-line preventive options include:
  • Beta blockers
  • Topiramate
  • Candesartan
  • Amitriptyline
  • Divalproex sodium 1

Important Considerations and Pitfalls

Medication Overuse Headache

• Limit NSAIDs to no more than 15 days per month 1
• Limit OTC medications to no more than 14 days per month 1
• Avoid using pain relievers more than twice weekly to prevent progression to chronic daily headache 5

Medications to Avoid

• Do not use opioids or butalbital for treatment of tension headaches due to risk of medication overuse headache and worsening sleep 1
• Caffeine-containing preparations should be used cautiously to avoid headache chronification 2

Treatment Approach

1. Start with non-pharmacological interventions and over-the-counter analgesics
2. Begin treatment as soon as possible after headache onset
3. If headaches occur frequently or treatment doesn't provide adequate response, consider preventive medications 4
4. Track headache frequency, severity, duration, and response to treatment using a headache diary 1

Special Situations

• For patients with significant nausea/vomiting, consider adding an antiemetic to potentiate pain-relieving effects 5
• For chronic tension headaches (≥15 headache days per month for at least 3 months), consider combination of pharmacological and non-pharmacological approaches 4

The evidence strongly supports starting with NSAIDs for acute treatment of tension headaches, with ibuprofen 400mg showing an NNT of 14 for being pain-free at 2 hours compared to placebo 7. For frequent tension headaches, adding preventive therapy with amitriptyline has demonstrated good efficacy 5.