What is the treatment for tension headaches?

Treatment of Tension Headaches

For tension-type headaches, ibuprofen (400 mg) or acetaminophen (1000 mg) are the recommended first-line treatments for acute episodes, with both medications showing significant improvement in pain-free response at 2 hours. 1, 2

Acute Treatment Options

• Ibuprofen 400 mg is recommended as a first-line treatment for tension-type headaches, demonstrating statistically significant improvement in pain relief 1, 2
• Acetaminophen 1000 mg is an equally effective option for acute treatment of tension headaches 1, 2
• Medications should be taken early in the headache episode for maximum effectiveness 2
• In comparative studies, both acetaminophen 1000 mg and naproxen 375 mg were significantly superior to placebo for pain relief, with acetaminophen showing slightly faster onset of action at one hour 3
• Caffeine-containing preparations of NSAIDs may be slightly more effective but should be used cautiously to avoid headache chronification 4

Preventive Treatment

• Amitriptyline is recommended for the prevention of chronic tension-type headache 1, 2
• Amitriptyline at doses of 50-100 mg significantly reduces monthly headache days in patients with chronic tension-type headache 2
• 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 slightly better outcomes than amitriptyline in some studies, with 56% reduction in headache index compared to 27% with amitriptyline 5

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at the onset of headache 1, 2
   • Take medication early in the headache episode for maximum effectiveness 2
   • If inadequate relief, consider combination analgesics 4

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

   • Consider prophylactic treatment with amitriptyline 1, 2
   • Start at a low dose and titrate up as needed while monitoring for side effects 2, 6
   • Consider non-pharmacological approaches as adjunctive therapy 2

Important Cautions

• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 2, 7
• Regular use of analgesics combined with butalbital or opiates increases the risk of progression to chronic daily headache 7
• Monitor for anticholinergic side effects with amitriptyline, particularly in elderly patients or those with cardiac conditions 2, 6

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are suggested as management options for tension-type headache 2
• Biofeedback, relaxation training, and cognitive therapy may be beneficial, though evidence quality is generally lower than for medications 2, 7
• These non-pharmacological approaches may be particularly valuable for patients who cannot tolerate medications or prefer non-drug therapies 6