What are the treatment options for tension headaches?

Treatment Options for Tension Headaches

For tension headaches, ibuprofen 400 mg or acetaminophen 1000 mg are the first-line treatments for acute episodes, with amitriptyline recommended for prevention of chronic tension-type headache. 1

Acute Treatment

• Ibuprofen 400 mg is recommended as first-line treatment for acute tension-type headache episodes, showing statistically significant improvement in pain-free response at 2 hours 1
• Acetaminophen 1000 mg is an equally effective alternative for acute treatment, particularly when NSAIDs are contraindicated or not tolerated 1
• Medications should be taken early in the headache episode for maximum effectiveness 1
• For severe attacks with nausea, consider adding an antiemetic medication to improve treatment outcomes 1
• Caffeine-containing preparations of NSAIDs may provide slightly superior relief but should be used cautiously to avoid headache chronification 2
• Avoid opioids and butalbital-containing medications for tension headaches due to risk of dependence and medication overuse headache 1, 3

Preventive Treatment

• Amitriptyline at doses of 50-100 mg is recommended for preventive treatment of chronic tension-type headache (occurring frequently) 1, 4
• The FDA-approved dosing for amitriptyline typically starts at lower doses (10 mg three times daily with 20 mg at bedtime) for elderly patients and those who don't tolerate higher doses 4
• Be aware of anticholinergic adverse effects with amitriptyline, especially in older patients and those with cardiac comorbidities 1, 4
• Valproate may be considered as an alternative preventive option when first-line treatments fail 3
• Preventive treatment should be considered when tension headaches occur more than twice weekly or last more than 2 days 5

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as management options for tension-type headache 1
• Relaxation therapies with EMG biofeedback have shown efficacy rates of 40-50% for chronic tension-type headache, comparable to tricyclic antidepressants 2
• Osteopathic manipulative treatment may be beneficial for tension headaches that are non-responsive to medication 6
• Acupuncture has shown some evidence of efficacy but is generally considered less effective than medication or relaxation therapies 2, 7

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1
   • If inadequate relief, consider combination therapy with caffeine-containing preparations or try alternative NSAID, such as naproxen sodium 550-825 mg 1, 2
   • For severe attacks with nausea, add an antiemetic 1

2. For chronic tension-type headache:

   • Consider prophylactic treatment with amitriptyline, starting at lower doses and titrating up to 50-100 mg as tolerated 1, 4
   • Monitor for anticholinergic side effects and adjust dosing accordingly 1
   • If amitriptyline is ineffective or poorly tolerated, consider alternative preventives like mirtazapine, venlafaxine, or valproate 3, 7

3. Important precautions:

   • Limit use of acute medications to fewer than 2 days per week to prevent medication overuse headache 1, 8
   • Evaluate for comorbidities, including psychiatric disorders and sleep disturbances, which may affect treatment response 3
   • Consider non-pharmacological approaches as adjunctive therapy 1, 6

Common Pitfalls and Caveats

• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 1, 8
• Botulinum toxin injections are not recommended for chronic tension-type headache prevention 3
• Gabapentin is not recommended based on lack of efficacy evidence 3
• Patients with frequent or severe headaches need careful evaluation to exclude serious underlying conditions 8
• Neuroimaging is generally not needed in patients without concerning findings on examination 8