What are the treatment options for tension headaches?

Treatment Options for Tension Headaches

NSAIDs and acetaminophen are the first-line treatments for acute tension headaches, while amitriptyline (25-100 mg daily) is the most effective preventive medication for frequent or chronic tension headaches. 1

Acute Treatment Options

First-line Medications

• NSAIDs:
  • Ibuprofen 400-600 mg 1, 2
  • Naproxen sodium 500-550 mg 1
  • Diclofenac potassium 1
  • Acetaminophen 1000 mg 3

NSAIDs and acetaminophen have demonstrated similar efficacy in treating tension headaches. A randomized, double-blind study showed both acetaminophen 1000 mg and naproxen 375 mg were significantly superior to placebo for pain relief, with acetaminophen showing slightly faster onset of action at one hour 3.

Important Safety Considerations with NSAIDs

• Limit use to less than 15 days per month to prevent medication overuse headache 1
• Monitor for gastrointestinal side effects, including ulceration and bleeding 2
• Use caution in patients with cardiovascular risk factors, as NSAIDs may increase risk of thrombotic events 2
• Avoid in patients with recent CABG surgery or recent myocardial infarction 2

Preventive Treatment for Frequent or Chronic Tension Headaches

First-line Preventive Medication

• Amitriptyline:
  • Starting dose: 10 mg three times daily with 20 mg at bedtime for elderly or adolescent patients 4
  • Target dose: 50-100 mg daily 1, 4, 5
  • Efficacy: Significantly reduces monthly headache days in chronic tension-type headache 1
  • Onset of effect: May take up to 30 days to develop therapeutic effect 4

Dosing Considerations for Amitriptyline

• Start at low doses and increase gradually 4
• Sedative effects may appear before analgesic effects 4
• For maintenance, the total daily dose may be given as a single dose at bedtime 4
• Continue maintenance therapy for at least 3 months to prevent relapse 4

Alternative Preventive Medications

• Mirtazapine 5
• Venlafaxine 5
• Weaker evidence for: gabapentin, topiramate, and tizanidine 5

Non-Pharmacological Approaches

Evidence-Based Non-Pharmacological Treatments

1. Trigger Point Therapy:

   • Dry needling
   • Ischemic compression
   • Positional relaxation techniques
   • Massage protocols targeting trigger points

   These techniques have been shown to reduce duration, intensity, and frequency of tension headaches 6.

2. Manual Therapies:

   • May reduce headache frequency by 1.5 to 4.2 headaches per week 7

3. Mind-Body Approaches:

   • Relaxation training
   • Biofeedback (especially thermal biofeedback combined with relaxation)
   • Cognitive-behavioral therapy 1, 8
   • Self-hypnosis 8

4. Lifestyle Modifications:

   • Regular aerobic exercise and strength training 1
   • Maintaining regular sleep schedule 1
   • Adequate hydration 1
   • Identification and avoidance of triggers 1
   • Sleep hygiene education 1

Treatment Algorithm for Tension Headaches

1. For infrequent tension headaches (less than 2 per week):

   • Use NSAIDs (ibuprofen 400-600 mg) or acetaminophen (1000 mg) as needed
   • Limit use to fewer than 15 days per month to prevent medication overuse headache
   • Consider combining with non-pharmacological approaches

2. For frequent tension headaches (2 or more per week):

   • Start amitriptyline at low dose (10-25 mg at bedtime)
   • Gradually increase to 50-100 mg daily as needed and tolerated
   • Continue for at least 3 months once effective
   • Implement non-pharmacological approaches concurrently

3. For treatment-resistant cases:

   • Consider alternative preventive medications (mirtazapine, venlafaxine)
   • Intensify non-pharmacological approaches
   • Refer to headache specialist if inadequate response to first-line treatments

Important Caveats and Pitfalls

• Avoid opioids and butalbital-containing medications due to high risk of medication overuse headache 1
• Limit analgesic use to prevent progression to chronic daily headache 8
• Monitor for side effects of amitriptyline, including sedation, dry mouth, constipation, and urinary retention
• Neuroimaging is not needed in patients without concerning findings on examination 8
• Consider referral for patients with inadequate response to first-line treatments or presence of red flags 1