Best Medication for Tension Headaches

Ibuprofen (400 mg) or acetaminophen (1000 mg) are the recommended first-line medications for the short-term treatment of tension-type headache. 1

First-Line Treatment Options

Ibuprofen 400 mg provides effective pain relief for tension headaches and is supported by high-quality evidence as a first-line treatment 2
Acetaminophen 1000 mg is equally effective for tension headaches and may be preferred in patients who cannot tolerate NSAIDs 3
Both medications have shown similar efficacy in direct comparison studies, with no significant differences in their ability to relieve tension headache pain 4
The VA/DoD Clinical Practice Guideline specifically recommends these two medications with a "weak for" recommendation, indicating positive but moderate strength of evidence 1

In randomized controlled trials, both ibuprofen 400 mg and acetaminophen 1000 mg were significantly superior to placebo for relieving tension headache pain 4
Ibuprofen may provide slightly faster onset of pain relief, with one study showing a significantly larger mean pain intensity difference at one hour compared to naproxen 4
For the outcome of being pain-free at 2 hours, ibuprofen 400 mg has a Number Needed to Treat (NNT) of 14 compared to placebo 2
Acetaminophen 1000 mg has an NNT of 22 for being pain-free at 2 hours, and an NNT of 10 for achieving pain-free or mild pain at 2 hours 3

Ibuprofen has a similar adverse event profile to placebo in short-term use for tension headaches (RR 1.1,95% CI 0.64 to 1.7) 2
Acetaminophen also shows no significant difference in adverse events compared to placebo (RR 1.1,95% CI 0.94 to 1.3) 3
Ibuprofen may cause gastrointestinal side effects in some patients, though these are less common than with aspirin 5
For patients with gastrointestinal sensitivity, acetaminophen may be the preferred option 5

For patients with significant nausea accompanying their tension headache, adding an antiemetic may be beneficial 6
Limit acute therapy to no more than twice weekly to prevent medication-overuse headache 6
For patients with chronic tension-type headache (≥15 headache days per month), preventive treatment with amitriptyline should be considered rather than relying solely on abortive medications 1
Combination products containing caffeine (such as aspirin-acetaminophen-caffeine) have shown efficacy for migraine but have less evidence specifically for tension-type headache 6, 7

Start with either ibuprofen 400 mg or acetaminophen 1000 mg at the onset of tension headache 1
If one medication is ineffective, try the alternative medication for subsequent headaches 4
For patients with gastrointestinal sensitivity, prefer acetaminophen over ibuprofen 5
If simple analgesics provide inadequate relief after multiple attempts, consider evaluation for other headache types or underlying conditions 1
For patients experiencing frequent tension headaches (>2 per week), consider preventive therapy with amitriptyline rather than increasing acute medication use 1

Overuse of acute medications (>10-15 days per month) can lead to medication-overuse headache, which is difficult to treat 6
Lower doses of ibuprofen (200 mg) or acetaminophen (500-650 mg) may be less effective than the recommended doses 3
Tension-type headache can sometimes be difficult to distinguish from migraine; if standard tension headache treatments fail, reassessment of diagnosis may be warranted 1
Botulinum toxin injections are not recommended for tension-type headache and should be avoided 1