What is the recommended treatment for tension-type headache?

Treatment of Tension-Type Headache

For acute treatment of tension-type headache, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as first-line options. 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 2
• Acetaminophen 1000 mg is equally effective for acute treatment, also demonstrating significant improvement in pain-free response at 2 hours 2, 3
• Medications should be taken early in the headache episode for maximum effectiveness 2
• The number needed to treat (NNT) for paracetamol 1000 mg to be pain-free at two hours is 22 compared to placebo, while the NNT for pain-free or mild pain at two hours is 10 3
• Lower doses of acetaminophen (500-650 mg) have not shown superiority to placebo in clinical trials 3

Preventive Treatment

• Amitriptyline is recommended for the prevention of chronic tension-type headache 1, 2
• Amitriptyline at doses of 50 mg and 100 mg significantly reduces monthly headache days in patients with chronic tension-type headache 2
• Botulinum/neurotoxin injections are not recommended for the prevention of chronic tension-type headache 1
• Other antidepressants with documented efficacy include mirtazapine and venlafaxine, though evidence is less robust than for amitriptyline 4

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at the onset of headache 1, 2
   • NSAIDs (ibuprofen 400-800 mg, naproxen 550-825 mg, ketoprofen 50-75 mg) may be more effective than aspirin or acetaminophen according to some evidence 5

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

   • Consider prophylactic treatment with amitriptyline 1, 2
   • Monitor for anticholinergic side effects, especially in older patients and those with cardiac comorbidities 2
   • Start with lower doses and titrate up as needed and tolerated 4

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are suggested as management options 2
• Relaxation therapies with EMG biofeedback have shown efficacy rates of 40-50% in chronic tension-type headache 5
• Other non-pharmacological options include certain types of psychotherapy and acupuncture 4
• Evidence for non-pharmacological interventions is generally of lower quality than for medications 2

Important Considerations and Pitfalls

• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 2, 6
• Caffeine-containing preparations of NSAIDs may be slightly more effective but should be used cautiously to avoid headache chronification 5
• Analgesics combined with butalbital or opiates can be effective for tension-type pain but carry an increased risk of causing chronic daily headache 6
• Adverse events with paracetamol 1000 mg are not significantly different from placebo in clinical trials 3