What is the recommended acute treatment for tension-type headaches?

Acute Treatment of Tension-Type Headache

The first-line treatment for acute tension-type headache is ibuprofen 400 mg, which demonstrates statistically significant improvement in pain-free response at 2 hours. 1

First-Line Pharmacological Options

• Ibuprofen 400 mg is recommended as the initial treatment for tension-type headache, with a Number Needed to Treat (NNT) of 14 for being pain-free at 2 hours compared to placebo 2
• Acetaminophen (paracetamol) 1000 mg is an equally effective alternative first-line option, particularly for patients who cannot tolerate NSAIDs 1, 3
• Both medications should be taken early in the headache episode for maximum effectiveness 1

Comparative Efficacy

• Ibuprofen 400-800 mg has demonstrated superior efficacy compared to aspirin or acetaminophen alone for acute tension-type headache 4
• Acetaminophen 1000 mg provides a small but significant benefit in terms of being pain-free at 2 hours for moderate to severe tension-type headache (NNT = 22) 3
• Naproxen sodium 375-550 mg is also effective and comparable to acetaminophen 1000 mg for treating moderate-to-severe tension-type headache 5

Treatment Algorithm

1. First attack or infrequent episodes:

   • Start with ibuprofen 400 mg at onset of headache 1, 2
   • Alternative: acetaminophen 1000 mg if NSAIDs are contraindicated 1, 3

2. For inadequate response:

   • Consider combination therapy with caffeine-containing preparations (slightly superior efficacy) 4
   • Try alternative NSAID (naproxen sodium 550 mg) 5

3. For severe attacks with nausea:

   • Consider adding an antiemetic medication 6

Important Cautions

• Limit use of acute medications to no more than 2 days per week to prevent medication overuse headache 1
• Caffeine-containing preparations should be used cautiously to avoid headache chronification 4
• Opioids should be avoided for tension-type headache due to risk of dependence and medication overuse headache 6

Prevention for Frequent Episodes

• For patients experiencing frequent tension-type headaches (≥2 per week), consider prophylactic treatment with amitriptyline 1, 7
• Non-pharmacological approaches like relaxation techniques, physical therapy, and aerobic exercise may be beneficial as adjunctive treatments 1, 7

Monitoring

• Monitor frequency of medication use to prevent medication overuse headache 1
• Assess response to therapy and adjust treatment if inadequate pain relief is achieved 6
• Evaluate for development of chronic tension-type headache, which may require different management strategies 7