What are the treatment options for tension headaches?

Treatment for Tension Headache

For tension-type headaches, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as first-line treatments for acute episodes, while amitriptyline is recommended 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
• Acetaminophen 1000 mg is an equally effective alternative for acute treatment, also demonstrating significant improvement in pain-free response at 2 hours 2, 3
• NSAIDs like ibuprofen are generally more effective than aspirin or acetaminophen alone for acute tension-type headache episodes 4
• Caffeine-containing preparations of NSAIDs may be slightly more effective, but should be used cautiously to avoid headache chronification 4
• Use of pain relievers more than twice weekly increases risk of progression to chronic daily headache 5

Safety Considerations for Acute Treatments

• When using ibuprofen, be aware of potential cardiovascular risks, especially in patients with cardiovascular disease or risk factors 6
• Monitor for gastrointestinal adverse effects with NSAIDs, including inflammation, bleeding, ulceration, and perforation 6
• Use the lowest effective dose for the shortest possible duration to minimize potential adverse effects 6
• Acetaminophen may be preferred in patients with contraindications to NSAIDs, such as those with gastrointestinal issues or cardiovascular disease 2, 3

Preventive Treatment

• Amitriptyline is recommended for prevention of chronic tension-type headache 1, 2
• The American College of Physicians recommends amitriptyline at doses of 50-100 mg for preventive treatment, which significantly reduces monthly headache days 2
• Amitriptyline has shown clinically significant improvements in headache activity, with studies showing 27-56% reduction in headache index 7
• Initial dosing should be low (10 mg three times daily with 20 mg at bedtime) for elderly patients and gradually increased as needed 8
• Be aware of anticholinergic adverse effects with amitriptyline, especially in older patients and those with cardiac comorbidities 2, 8

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are suggested as management options for tension-type headache 2
• Cognitive-behavioral therapy has shown efficacy comparable or superior to amitriptyline in some studies, with up to 56% reduction in headache index 7
• Relaxation therapies with EMG biofeedback have shown efficacy rates of 40-50% for chronic tension-type headache 4
• Other non-pharmacological options include biofeedback, relaxation training, self-hypnosis, and cognitive therapy, though large trials with rigorous methodologies are lacking 5

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
   • If inadequate relief, consider combination therapy or alternative analgesics 4
   • Limit use to less than twice weekly to prevent medication overuse headache 5

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

   • Consider prophylactic treatment with amitriptyline 1, 2
   • Start at low doses (10-25 mg) and gradually increase as needed up to 50-100 mg 8
   • Monitor for anticholinergic side effects and adjust dosing accordingly 2, 8
   • Consider non-pharmacological approaches such as cognitive-behavioral therapy, biofeedback, or physical therapy as adjuncts or alternatives 7, 5

3. For patients with frequent but not chronic headaches:

   • Implement non-pharmacological strategies first 2
   • If inadequate response, consider preventive medication 9

Remember that the goal of treatment is to reduce headache frequency and severity while minimizing medication use and improving quality of life 9, 5.