What are the treatment options for tension-type headaches?

Treatment Options for Tension-Type Headaches

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

Non-Pharmacological Interventions

Non-pharmacological approaches are essential components of tension headache management:

• Physical therapy - Recommended as an effective treatment by CDC and VA/DoD guidelines 1
• Regular aerobic exercise or strength training - Helps prevent tension headaches 1
• Stress management techniques - Yoga and mindfulness meditation 1
• Sleep hygiene optimization - Establishing regular sleep patterns 1
• Trigger avoidance - Tracking and avoiding potential triggers such as alcohol, caffeine, certain foods, stress, and fatigue 1
• Lifestyle modifications - Regular meals, adequate hydration, and resting in a dark, quiet room during attacks 1

Evidence suggests that EMG biofeedback has documented efficacy for tension-type headaches, while cognitive-behavioral therapy and relaxation training are likely effective 2. Though acupuncture may be valuable, robust scientific evidence for its efficacy is limited 2.

Pharmacological Management

Acute Treatment

For episodic tension-type headaches, the following medications are recommended:

1. First-line options:

   • Acetaminophen (1000 mg) - Provides significant pain relief at 2 hours 1, 3
   • Ibuprofen (400 mg) - Also provides significant pain relief at 2 hours 1
   • Other NSAIDs - Aspirin, diclofenac, and naproxen are effective options 1, 4

2. Second-line options:

   • Combination analgesics containing caffeine - Slightly superior to single agents but should be used cautiously 1, 4

Prophylactic Treatment

For chronic or frequent tension-type headaches (occurring more than twice weekly):

1. First-line prophylaxis:

   • Amitriptyline (50-100 mg daily) - Most widely researched prophylactic agent, significantly reduces monthly headache days 1, 5, 2, 6
   • Initial dosage should be low (10 mg 3 times daily with 20 mg at bedtime for elderly patients) and gradually increased 7
   • Maintenance dosage is typically 50-100 mg per day 7

2. Second-line prophylaxis:

   • Mirtazapine - Documented efficacy as alternative to amitriptyline 5, 2
   • Venlafaxine - Another second-choice option 5, 2
   • Other options with weaker evidence - Gabapentin, topiramate, and tizanidine 5

Important Considerations and Pitfalls

Medication Overuse Headache Prevention

• Limit analgesic use to no more than twice weekly to prevent medication overuse headache 1, 6
• Monitor frequency carefully - Medication overuse headache occurs when analgesics are used too frequently 1
• Consider prophylactic therapy if headaches occur more than twice weekly 1

Medications to Avoid

• Opioid analgesics (e.g., tilidine) - Risk of medication-induced headaches and addiction 1
• Triptans, ergotamine derivatives - Contraindicated in patients with history of CVA due to vasoconstrictive effects 1
• Muscle relaxants and opioids - Should not be used routinely due to limited evidence and risk of dependence 2, 6

Special Populations

• Elderly patients - Lower dosages are recommended; monitor carefully and adjust dosage according to clinical response rather than plasma levels 7
• Pediatric patients - Amitriptyline is not recommended for patients under 12 years of age due to lack of experience 7

When to Consider Neuroimaging

• Only if headaches have atypical features
• If accompanied by new neurological symptoms
• If there are worrisome findings on examination 1

Treatment Algorithm

1. For acute episodes:

   • Start with acetaminophen 1000 mg or ibuprofen 400 mg
   • If ineffective, consider combination analgesics with caffeine (with caution)

2. For frequent episodes (>2 per week):

   • Implement non-pharmacological interventions
   • Start amitriptyline at low dose (10-25 mg at bedtime)
   • Gradually increase to 50-100 mg daily as needed and tolerated
   • If ineffective or not tolerated, consider mirtazapine or venlafaxine

3. For all patients:

   • Educate about trigger avoidance
   • Emphasize importance of regular exercise, stress management, and sleep hygiene
   • Monitor medication use to prevent overuse headache

The efficacy of prophylactic medications is often limited, and treatment may be hampered by side effects 2. Therefore, a combination of pharmacological and non-pharmacological approaches is often necessary for optimal management.