What are the treatment options for tension headaches?

Treatment Options for Tension Headaches

For tension headaches, over-the-counter NSAIDs such as ibuprofen (400-800mg) or naproxen (550-825mg) are the first-line treatment, while amitriptyline (50-100mg) is recommended for prophylaxis in chronic cases. 1, 2

Acute Treatment

First-Line Medications

• NSAIDs are more effective than aspirin or acetaminophen for acute tension headache episodes:

  • Ibuprofen: 400-800mg
  • Naproxen: 550-825mg
  • Ketoprofen: 50-75mg 2

• Acetaminophen (Paracetamol): 1000mg has been shown to be effective and comparable to naproxen 375mg in treating moderate-to-severe tension headaches 3

Important Considerations

• Use pain relievers no more than twice weekly to avoid progression to chronic daily headache 4
• Caffeine-containing preparations of NSAIDs may be slightly more effective but should be limited to prevent headache chronification 2
• Sedating antihistamines or antiemetics can enhance the pain-relieving effects of standard analgesics 4

Second-Line Medications

• Analgesics combined with butalbital or opiates may be useful but carry an increased risk of causing chronic daily headache 4
• Caution: The American College of Physicians recommends avoiding opioids due to risk of dependence and lack of efficacy 5

Prophylactic Treatment

Prophylactic treatment is indicated when tension headaches are frequent and/or difficult to treat:

First-Line Prophylactic Medications

• Tricyclic antidepressants, particularly amitriptyline (50-100mg), have the strongest evidence for efficacy in preventing chronic tension-type headache 5, 1

Alternative Prophylactic Options

• Other antidepressants with documented efficacy:
  • Mirtazapine
  • Venlafaxine 1
• Medications with weaker evidence:
  • Gabapentin
  • Topiramate
  • Tizanidine 1

Non-Pharmacological Approaches

Evidence-Based Non-Pharmacological Treatments

• Relaxation therapies with EMG biofeedback: 40-50% efficacy rate, comparable to tricyclic antidepressants 2
• Manual therapies may reduce headache frequency by 1.5 to 4.2 headaches or days with headache per week in chronic tension headache patients 6
• Other effective approaches:
  • Cognitive-behavioral therapy
  • Relaxation training
  • Self-hypnosis 4, 1
  • Acupuncture (though generally less effective than other options) 1, 2

Lifestyle Modifications

• Regular exercise
• Maintaining regular sleep schedule
• Adequate hydration
• Identification and avoidance of triggers 5

Treatment Algorithm

1. For acute episodes:

   • Start with NSAIDs (ibuprofen 400-800mg or naproxen 550-825mg) or acetaminophen 1000mg
   • If inadequate relief, consider adding a sedating antihistamine or antiemetic
   • Limit use to less than twice weekly to prevent medication overuse headache

2. For frequent or chronic tension headaches:

   • Initiate prophylactic treatment with amitriptyline (starting at lower doses and titrating up to 50-100mg)
   • Add non-pharmacological approaches (biofeedback, relaxation techniques, cognitive therapy)
   • Consider manual therapies as adjunctive treatment

3. If first-line treatments fail:

   • Try alternative antidepressants (mirtazapine, venlafaxine)
   • Consider medications with weaker evidence (gabapentin, topiramate, tizanidine)
   • Intensify non-pharmacological approaches

Common Pitfalls and Caveats

• Medication overuse: Using pain relievers more than twice weekly can lead to chronic daily headache 4
• Misdiagnosis: Ensure proper diagnosis by confirming bilateral, band-like pressure or tightness without migraine features (unilateral pain, throbbing, nausea, photophobia) 4
• Overlooking serious conditions: All patients with frequent or severe headaches need careful evaluation to exclude any occult serious condition 4
• Neuroimaging: Not needed in patients without worrisome findings on examination 4
• Overreliance on medications: Combining pharmacological and non-pharmacological approaches is often more effective than either alone