What are the treatment guidelines for tension migraine?

Treatment Guidelines for Tension Migraine

First-line treatment for tension migraine should begin with non-steroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid, ibuprofen, or diclofenac potassium, which have the strongest evidence for efficacy. 1

Acute Treatment Algorithm

First-line Medications

• NSAIDs have the strongest evidence for efficacy and should be used as first-line treatment for mild to moderate tension migraine 1
• Specific options include acetylsalicylic acid (aspirin), ibuprofen, and diclofenac potassium 1
• Paracetamol (acetaminophen) has less efficacy and should only be used in patients who cannot tolerate NSAIDs 1
• The combination of acetaminophen-aspirin-caffeine has good evidence for efficacy 1

Second-line Medications

• Triptans should be offered to patients for whom over-the-counter analgesics provide inadequate relief 1
• Triptans are most effective when taken early in an attack while headache pain is still mild 1
• If one triptan is ineffective, others may still provide relief 1
• For patients who rapidly reach peak headache intensity or cannot take oral medications due to vomiting, sumatriptan by subcutaneous injection can be useful 1

Third-line Medications

• For patients who fail triptan therapy or have contraindications, consider CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant 1
• The ditan lasmiditan may be considered for patients who don't respond to or tolerate other treatments 1

Combination Therapy

• Combining a triptan with an NSAID or acetaminophen can improve efficacy 1
• For patients experiencing relapses (return of symptoms within 48 hours), combining a triptan with a fast-acting NSAID may be beneficial 1
• For nausea and vomiting, add an antiemetic with prokinetic properties 1

Important Considerations

Route of Administration

• For patients with significant nausea or vomiting, consider non-oral routes of administration 1
• Options include subcutaneous sumatriptan, nasal triptans, or adding an antiemetic 1

Medication Overuse

• Limit acute treatments to no more than twice a week to prevent medication overuse headache 1
• Medication overuse headache can occur with ≥15 days/month of NSAID use or ≥10 days/month of triptan use 1
• Advise patients to begin treatment as soon as possible after headache onset 1

Treatments to Avoid

• Do not use opioids or butalbital-containing medications for tension migraine treatment 1
• These medications carry significant risk of dependence and medication overuse headache 1

Non-Pharmacological Approaches

Physical Interventions

• Physical therapy can be beneficial for tension-type and migraine headaches 1
• Aerobic exercise and progressive strength training are recommended for prevention 1
• Greater occipital nerve block may provide short-term relief for migraine 1

Lifestyle Modifications

• Maintain regular sleep patterns and adequate hydration 1
• Ensure regular meals and consistent sleep schedule 1
• Implement stress management techniques 1
• Identify and manage trigger factors when possible 1, 2

When to Consider Preventive Treatment

• Consider preventive therapy if:
  • Headaches occur frequently (≥2 attacks per month) 1
  • Attacks produce disability for ≥3 days per month 1
  • Acute treatments are used more than twice a week 1
  • Patient experiences inadequate response to acute treatments 1

Preventive Options

• First-line preventive options include:
  • Beta-blockers (e.g., propranolol) 3, 4
  • Tricyclic antidepressants (e.g., amitriptyline) 3, 5
  • Anticonvulsants (e.g., topiramate) 3, 4
• For chronic migraine, consider botulinum toxin injections 3
• CGRP monoclonal antibodies are newer options specifically designed for migraine prevention 3

Special Populations

• For pregnant or breastfeeding women, discuss potential adverse effects of medications 1
• For women with menstrual-related migraines, consider hormonal factors in treatment planning 1
• In children and adolescents, treatment approaches may differ with greater emphasis on non-pharmacological strategies 1