What is the recommended treatment for tension headaches?

Treatment of Tension Headache

For tension headache treatment, ibuprofen 400 mg or acetaminophen 1000 mg are the first-line options for acute treatment, showing significant improvement in pain-free response at 2 hours. 1, 2

Acute Treatment

• Ibuprofen 400 mg is recommended as first-line therapy for short-term treatment of tension-type headache, demonstrating statistically 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 1
• For inadequate response to initial treatment, consider combination therapy with caffeine-containing preparations or try alternative NSAIDs, such as naproxen sodium 2, 3
• For severe attacks with nausea, consider adding an antiemetic medication to improve treatment outcomes 1

Preventive Treatment

• Amitriptyline is recommended for prevention of chronic tension-type headache 1, 2, 4
• 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 therapy should be considered when:
  • Headaches occur frequently (more than twice weekly) 2, 6
  • Acute treatments are ineffective or contraindicated 2
  • Medication overuse is present 2

Medication Overuse Considerations

• Limit use of acute headache medications to no more than 2 days per week to prevent medication overuse headache 1, 2
• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 1, 5
• If medication overuse is present, gradual withdrawal of the overused medication is necessary 2

Cautions and Monitoring

• When using NSAIDs like ibuprofen, be aware of potential cardiovascular risks:
  • Increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke 7
  • Use the lowest effective dose for the shortest duration possible 7
  • Monitor blood pressure during treatment 7
  • Use with caution in patients with cardiovascular disease, heart failure, or hypertension 7
• NSAIDs can cause serious gastrointestinal adverse events including inflammation, bleeding, ulceration, and perforation 7
• When using amitriptyline, be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2
• Opioids should be avoided for tension-type headache due to risk of dependence and medication overuse headache 1, 2

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 1, 2
• Other beneficial lifestyle modifications include:
  • Regular meals and adequate hydration 2
  • Improved sleep hygiene 2, 8
  • Stress management techniques 2, 8
• Alternative therapies with some evidence of efficacy include:
  • Biofeedback and relaxation training 5
  • Cognitive therapy 5
  • Osteopathic manipulative treatment in selected cases 8

Treatment Algorithm

1. For acute episodes, start with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
2. If inadequate relief, consider combination analgesics with caffeine or alternative NSAIDs 2
3. For chronic tension headaches (occurring more than twice weekly), consider prophylactic treatment with amitriptyline 2, 6
4. Start amitriptyline at a low dose (10-25 mg) at bedtime, gradually increase to an effective dose (typically 50-100 mg) 2
5. Monitor for medication overuse and anticholinergic adverse effects 1, 2
6. Incorporate non-pharmacological approaches as adjunctive therapy 1, 2