What is the treatment for tension headaches?

Treatment of Tension Headache

For tension-type headache, ibuprofen 400 mg or acetaminophen 1000 mg are the first-line treatments for acute episodes, while amitriptyline is recommended for prevention of chronic tension-type headache. 1, 2

Acute Treatment

• Ibuprofen 400 mg is recommended as first-line therapy for acute tension headache episodes, showing statistically significant improvement in pain-free response at 2 hours 2
• Acetaminophen 1000 mg is equally effective as an alternative first-line option for acute treatment 2, 3
• Medications should be taken early in the headache episode for maximum effectiveness 2
• Caffeine-containing preparations of NSAIDs may be slightly more effective but should be used cautiously to avoid headache chronification 4
• For severe attacks with nausea, adding an antiemetic medication can improve treatment outcomes 2
• If initial treatment provides inadequate relief, consider trying an alternative NSAID such as naproxen sodium 550-825 mg 2, 4

Preventive Treatment

• Amitriptyline at doses of 50-100 mg is recommended for prevention of chronic tension-type headache, significantly reducing monthly headache days 1, 2
• Be aware of anticholinergic adverse effects with amitriptyline, especially in older patients and those with cardiac comorbidities 2, 5
• Alternative preventive options with weaker evidence include:
  • Valproate (with appropriate monitoring) 6
  • Mirtazapine and venlafaxine 5
• Medications to avoid:
  • Botulinum toxin injections (onabotulinumtoxinA or abobotulinumtoxinA) are not recommended for chronic tension-type headache prevention 6
  • Gabapentin is not recommended due to lack of efficacy evidence and potential for misuse 6

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as management options for tension-type headache 1, 2
• Relaxation therapies with EMG biofeedback have shown efficacy rates of 40-50% in chronic tension-type headache 4
• Osteopathic manipulative treatment may be beneficial for patients who don't respond to medication 7
• Greater occipital nerve blocks may provide short-term relief for some patients 6

Important Considerations and Pitfalls

• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 2, 6
• Opioids should be avoided for tension-type headache due to risk of dependence and medication overuse headache 2
• Analgesics combined with butalbital or opiates have an increased risk of causing chronic daily headache 8
• Evaluate for comorbidities, including psychiatric disorders and sleep disturbances, which may affect treatment response 6
• Confirm diagnosis and rule out medication overuse headache before initiating preventive therapy 6

Treatment Algorithm

1. For acute episodes: Start with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
2. For inadequate response: Try alternative NSAID or consider combination therapy with caffeine-containing preparations 2, 4
3. For chronic tension-type headache (≥15 headache days/month): Consider prophylactic treatment with amitriptyline, monitoring for side effects 1, 2
4. Incorporate non-pharmacological approaches such as physical therapy, aerobic exercise, or relaxation techniques 1, 2
5. Avoid medication overuse by limiting acute medication use to <2 days/week 2, 6