What are the recommended management strategies for tension headaches?

Management Strategies for Tension Headaches

For tension headache management, ibuprofen 400 mg or acetaminophen 1000 mg are recommended as first-line treatments for acute episodes, while amitriptyline is suggested for prevention of chronic tension-type headache. 1, 2

Acute Treatment Options

• Ibuprofen 400 mg is recommended for short-term treatment of tension-type headache, showing statistically significant improvement in pain-free response at 2 hours 1, 2, 3
• Acetaminophen 1000 mg is an equally effective alternative for acute treatment, also demonstrating significant improvement in pain-free response at 2 hours 1, 2, 4
• For patients with moderate to severe tension headache, ibuprofen 400 mg provides an NNT of 14 for being pain-free at 2 hours compared to placebo 3
• The use of rescue medication is lower with ibuprofen 400 mg than with placebo, with an NNTp of 8.9 3
• Caffeine-containing preparations may provide slightly superior relief but should be used cautiously to avoid headache chronification 5

Preventive Treatment

• Amitriptyline is suggested for the prevention of chronic tension-type headache (occurring 15 or more days per month) 1, 2
• Typical effective doses of amitriptyline range from 50-100 mg daily, which significantly reduces monthly headache days 2, 6
• When prescribing amitriptyline, be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 2
• Cognitive-behavioral therapy has shown comparable or even superior outcomes to amitriptyline in some studies, with a 56% reduction in headache index compared to 27% with amitriptyline 6
• Botulinum/neurotoxin injections are not recommended for the prevention of chronic tension-type headache 1

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as management options for tension-type headache 2
• Relaxation therapies with EMG biofeedback have shown efficacy rates of 40-50% for chronic tension-type headache 5, 7
• Cognitive-behavioral therapy, particularly when administered in a home-based treatment protocol, has demonstrated significant improvement in headache activity 6
• Non-pharmacological approaches should be considered particularly for patients who:
  • Have contraindications to medication use 2, 7
  • Experience inadequate relief from pharmacological treatments 7
  • Prefer non-drug approaches 7

Treatment Algorithm

1. For acute tension headache episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
   • If inadequate relief, consider combination therapy with caffeine-containing preparations, but use cautiously 5

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

   • Consider prophylactic treatment with amitriptyline, starting at lower doses and titrating as needed 1, 2
   • Monitor for anticholinergic side effects and adjust dosing accordingly 2
   • Incorporate non-pharmacological approaches such as physical therapy, aerobic exercise, or cognitive-behavioral therapy 2, 6

3. For all patients with frequent tension headaches:

   • Avoid medication overuse (>15 days/month for simple analgesics) to prevent medication overuse headache 5, 7
   • Consider combination of pharmacological and non-pharmacological approaches for optimal management 7, 6