What is the recommended treatment for tension type headache?

Treatment of Tension Type Headache

For the treatment of tension type headache, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended for acute episodes, while amitriptyline is recommended for prevention of chronic tension-type headache. 1

Acute Treatment

First-Line Options:

• Ibuprofen 400 mg is suggested for short-term treatment of tension-type headache, demonstrating statistically significant improvement in pain-free response at 2 hours 1
• Acetaminophen 1000 mg is equally effective for acute treatment, also showing significant improvement in pain-free response at 2 hours 1
• Lower doses of acetaminophen (500-650 mg) have not shown statistically significant improvement and should be avoided 1, 2

Efficacy Considerations:

• Both ibuprofen and acetaminophen provide a small but meaningful benefit in terms of being pain-free at two hours for moderate to severe tension headaches 2, 3
• For the outcome of being pain-free at two hours, the number needed to treat (NNT) for acetaminophen 1000 mg compared with placebo is 22 2
• For the outcome of pain-free or mild pain at two hours, the NNT is 10 2

Important Cautions:

• Frequent use of acute medications (more than twice weekly) increases risk of medication overuse headache and progression to chronic daily headache 4
• Monitor for adverse effects, though studies show no significant difference in adverse events between acetaminophen 1000 mg and placebo 2

Preventive Treatment

First-Line Prevention:

• Amitriptyline at 50 mg and 100 mg is recommended for preventive treatment of chronic tension-type headache 1
• Amitriptyline has been shown to significantly reduce monthly headache days in patients with chronic tension-type headache 1, 5

Precautions with Amitriptyline:

• Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1
• Monitor for potential overdose risk 1
• Start at lower doses and titrate up as tolerated to minimize side effects 5

Treatments Not Recommended:

• OnabotulinumtoxinA (Botox) is not recommended for prevention of chronic tension-type headache as it did not show statistically significant improvement in critical outcomes in systematic reviews of 12 randomized controlled trials 1

Non-Pharmacological Approaches

Physical Therapies:

• Physical therapy and aerobic exercise can be used in the management of tension-type headache 1
• Evidence for non-pharmacological interventions is generally of lower quality than for medications 1

Behavioral Interventions:

• Evidence is insufficient to make strong recommendations for biofeedback, cognitive behavioral therapy, mindfulness-based therapies, and progressive muscle relaxation when used alone 1
• These approaches may be considered as adjuncts to pharmacological treatment, especially in patients with frequent headaches or those who prefer non-medication approaches 5, 4

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1
   • Limit use to no more than twice weekly to prevent medication overuse headache 4

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

   • Consider prophylactic treatment with amitriptyline starting at low doses and titrating up to 50-100 mg 1, 5
   • Monitor for anticholinergic side effects and adjust dosing accordingly 1

3. For patients with inadequate response:

   • Consider combination of pharmacological and non-pharmacological approaches 1, 4
   • Evaluate for possible medication overuse headache if headache frequency is increasing 1, 4