What is the treatment for tension headaches?

Treatment of Tension Headaches

For acute treatment of tension headaches, ibuprofen 400 mg or acetaminophen 1000 mg are recommended as first-line options. 1, 2

Acute Treatment

• Ibuprofen 400 mg is recommended for the short-term treatment of tension-type headache, showing significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is an equally effective alternative for acute treatment of tension headaches 1, 2, 3
• Medications should be taken early in the headache episode for maximum effectiveness 2
• For severe attacks with nausea, consider adding an antiemetic medication to improve treatment outcomes 2
• If inadequate response to initial treatment, consider combination therapy with caffeine-containing preparations or try alternative NSAIDs such as naproxen sodium 2, 4

Preventive Treatment

• Amitriptyline is recommended for prevention of chronic tension-type headache 1, 2
• Starting doses of amitriptyline typically range from 10-25 mg at bedtime, with gradual titration up to 50-100 mg as needed and tolerated 2, 5
• Preventive treatment should be considered when:
  • Headaches occur frequently (more than 2 days per week)
  • Acute medications are being used more than twice weekly (risk of medication overuse headache) 2, 6
  • Headaches significantly impact quality of life 2

Medication Overuse Considerations

• Limit use of acute headache medications to no more than 2 days per week to prevent medication overuse headache 2, 6
• If medication overuse is present, gradual withdrawal of the overused medication is necessary 1
• Non-opioids and triptans may be stopped abruptly or weaned down within a month 1
• Opioid medications should be gradually removed over a longer period 1

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 2
• Lifestyle modifications should include:
  • Regular meals and adequate hydration
  • Sleep hygiene improvement
  • Stress management techniques 1
• Behavioral interventions such as biofeedback, relaxation training, and cognitive therapy may be beneficial 6
• Some evidence supports osteopathic manipulative treatment for tension headaches not responsive to medication 7

Treatment Algorithm

1. First step: For acute episodes, use ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
2. If inadequate relief: Consider combination analgesics with caffeine or try alternative NSAIDs 2
3. For chronic tension headaches (frequent episodes):
   • Start amitriptyline at low dose (10-25 mg) at bedtime 2
   • Gradually increase to effective dose (typically 50-100 mg) 2, 5
   • Monitor for anticholinergic side effects (dry mouth, constipation, urinary retention, blurred vision) 2
4. Incorporate non-pharmacological approaches alongside medication treatment 2, 7

Cautions and Monitoring

• Avoid opioids for tension-type headache due to risk of dependence and medication overuse headache 2
• Monitor for medication overuse (use of acute treatments >2 days/week) 2
• Be aware of anticholinergic adverse effects with amitriptyline, especially in older patients and those with cardiac comorbidities 2
• Regularly assess treatment effectiveness and adjust therapy as needed 2