What is the recommended treatment for tension headaches?

Treatment of Tension Headache

For tension headache treatment, ibuprofen 400 mg or acetaminophen 1000 mg are recommended as first-line acute treatments, while amitriptyline is recommended for prevention of chronic tension headaches. 1

Acute Treatment Options

• Ibuprofen 400 mg is a first-line treatment for tension headaches, showing statistically significant improvement in pain-free response at 2 hours 1
• Acetaminophen 1000 mg is equally effective as a first-line option for acute treatment 1, 2
• NSAIDs (such as ibuprofen, naproxen, diclofenac) generally show superior efficacy compared to acetaminophen, though both are effective 3
• Medications should be taken early in the headache episode for maximum effectiveness 4
• Caution: Using pain relievers more than twice weekly increases risk of developing medication overuse headache (MOH) 5

Preventive Treatment for Chronic Tension Headache

• Amitriptyline at doses of 50-100 mg is the first-line preventive treatment for chronic tension headache, significantly reducing monthly headache days 1
• Tricyclic antidepressants have the strongest evidence base for prevention, with amitriptyline being the most extensively studied 6
• When prescribing amitriptyline, be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1
• Other antidepressants with documented efficacy include mirtazapine and venlafaxine, which may be considered as alternatives 6

Non-Pharmacological Approaches

• Cognitive-behavioral therapy has shown significant efficacy, with some studies suggesting it may be comparable or even superior to amitriptyline for chronic tension headache (56% vs 27% reduction in headache index) 7
• Physical therapy and aerobic exercise are recommended management options 1
• Relaxation therapies with EMG biofeedback have efficacy rates of approximately 40-50% for chronic tension headache 3
• Acupuncture has shown some benefit but generally less effectiveness than medication or behavioral therapies 6, 3

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at the onset of headache 1
   • If inadequate relief, consider combination analgesics, but use cautiously to avoid medication overuse headache 5

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

   • Initiate preventive treatment with amitriptyline, starting at a low dose (10-25 mg) and titrating up to 50-100 mg as tolerated 1, 6
   • Monitor for anticholinergic side effects and adjust dosing accordingly 1
   • Consider cognitive-behavioral therapy as an alternative or adjunct to medication 7

Common Pitfalls and Caveats

• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 4, 5
• Analgesics combined with butalbital or opiates should be avoided as first-line treatments due to increased risk of causing chronic daily headache 5
• Failure to distinguish tension-type headache from migraine can lead to suboptimal treatment (tension headache typically causes bilateral, band-like, pressing pain without migraine features like nausea or photophobia) 5
• Non-pharmacological interventions generally have lower quality evidence than medications but may be valuable for patients who cannot tolerate medications or prefer non-drug approaches 1