What are the recommended management strategies for tension headaches?

Management Strategies 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 the preferred preventive treatment for chronic tension-type headache. 1

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 1
• Acetaminophen 1000 mg is equally effective for acute treatment, also demonstrating significant improvement in pain-free response at 2 hours 1, 2
• Medications should be taken early in the headache episode for maximum effectiveness 1
• For severe attacks with nausea, adding an antiemetic medication may improve treatment outcomes 1
• Caffeine-containing preparations of NSAIDs show slightly superior efficacy but should be used cautiously to avoid headache chronification 3
• Avoid opioids for tension-type headache due to risk of dependence and medication overuse headache 1

Preventive Treatment Options

• Amitriptyline at doses of 50-100 mg is recommended for prevention of chronic tension-type headache, significantly reducing monthly headache days 1, 4
• When using amitriptyline, be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1
• Valproate may be considered as an alternative preventive option for patients who fail standard therapies 5
• Botulinum toxin injections (onabotulinumtoxinA or abobotulinumtoxinA) are not recommended for chronic tension-type headache prevention 5
• Gabapentin is not recommended based on lack of efficacy evidence and potential for misuse 5

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended management options for tension-type headache 1, 6
• Relaxation therapies with EMG biofeedback have shown efficacy rates of 40-50% for chronic tension-type headache, comparable to tricyclic antidepressants 3, 7
• Cognitive-behavioral therapy has demonstrated clinically significant improvements in headache activity, with some studies showing better outcomes than medication alone 4
• Greater occipital nerve blocks may be considered for short-term treatment of headache that doesn't respond to first-line therapies 5
• Osteopathic manipulative treatment may be beneficial as an adjunctive therapy for tension headaches unresponsive to medication 8

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1
   • If inadequate response, consider combination therapy with caffeine-containing preparations or try alternative NSAID, such as naproxen sodium 550 mg 1
   • Monitor for medication overuse (>2 days/week), which can lead to medication overuse headache 1

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

   • Consider preventive treatment with amitriptyline, starting at a low dose and titrating up to 50-100 mg as tolerated 1, 7
   • Monitor for anticholinergic side effects and adjust dosing accordingly 1
   • Incorporate non-pharmacological approaches such as physical therapy, aerobic exercise, or cognitive-behavioral therapy 1, 4
   • Evaluate for comorbidities, including psychiatric disorders and sleep disturbances, which may affect treatment response 5

Common Pitfalls and Caveats

• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 1
• Even with optimal treatment, complete elimination of headache problems may not be achievable 4
• The evidence for non-pharmacological interventions is generally of lower quality than for medications, but these approaches have fewer side effects 1
• Confirm diagnosis and rule out medication overuse headache before initiating preventive therapy 5
• Patients with frequent or daily tension-type headache may experience significant distress, requiring more aggressive management strategies 7