Treatment Options for Tension Headaches
For tension-type headaches, 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 headaches. 1, 2
Acute Treatment
- 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 1, 2, 3
- Medications should be taken early in the headache episode for maximum effectiveness 2
- Both ibuprofen and acetaminophen are superior to placebo but not significantly different from each other in efficacy for tension headache relief 3
- Ibuprofen may provide slightly faster onset of relief (within 1 hour) compared to other options 3
Preventive Treatment
- Amitriptyline is recommended for prevention of chronic tension-type headache, significantly reducing monthly headache days 1, 2, 4
- Typical dosing for amitriptyline starts low (10-25 mg) and can be gradually increased as needed, with most patients responding to 50-100 mg daily 2, 5
- For elderly or adolescent patients, lower dosages are recommended (10 mg three times daily with 20 mg at bedtime) 5
- Maintenance therapy should continue for at least 3 months to reduce the possibility of relapse 5
- Botulinum toxin injections are not recommended for prevention of chronic tension-type headache 1
Safety Considerations
For Ibuprofen:
- Monitor for cardiovascular risks, especially in patients with cardiovascular disease or risk factors 6
- Use the lowest effective dose for the shortest duration to minimize cardiovascular and gastrointestinal risks 6
- Caution in patients with hypertension, heart failure, or renal impairment 6
- Avoid in patients who have recently undergone coronary artery bypass graft surgery 6
For Amitriptyline:
- Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 2, 5
- Sedative effects may appear before therapeutic effects, which may take up to 30 days to develop 5
- When satisfactory improvement has been reached, dosage should be reduced to the lowest amount that maintains symptom relief 5
Common Pitfalls to Avoid
- Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 2, 7
- Using combined analgesics with butalbital or opiates increases the risk of developing chronic daily headache 7
- Failure to recognize that tension-type headache typically causes bilateral pain that radiates in a band-like fashion from the forehead to the occiput 7
- Not distinguishing tension-type headache from migraine (tension headache lacks unilateral throbbing pain, nausea, and photophobia) 7
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 to or better than amitriptyline in some studies, with 56% reduction in headache index compared to 27% with amitriptyline 8
- Relaxation therapies with EMG biofeedback have efficacy rates of 40-50% for chronic tension-type headache 9
- Evidence for non-pharmacological interventions is generally of lower quality than for medications 2