What is the recommended 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, with both medications showing significant improvement in pain-free response at 2 hours. 1, 2

Acute Treatment Options

• Ibuprofen 400 mg is recommended as a first-line treatment for 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 severe attacks with nausea, consider adding an antiemetic medication to improve treatment outcomes 1
• If inadequate response to initial treatment, consider combination therapy with caffeine-containing preparations or try alternative NSAIDs, such as naproxen sodium 550 mg 1, 4

Preventive Treatment

• Amitriptyline is recommended for prevention of chronic tension-type headache, with doses of 50-100 mg showing significant reduction in monthly headache days 1, 2, 5
• Starting doses of amitriptyline typically range from 10-25 mg at bedtime, with gradual titration up to effective doses as needed and tolerated 2
• Be aware of anticholinergic adverse effects when using amitriptyline, especially in older patients and those with cardiac comorbidities 1, 2
• Valproate may be considered as an alternative preventive option for patients who cannot tolerate amitriptyline 6

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
• If medication overuse is present, gradual withdrawal of the overused medication is necessary 2

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options for tension-type headache 1, 2
• Consider lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 2
• Osteopathic manipulative treatment may be beneficial for patients with tension headaches not responding to medication alone 7

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 is obtained, consider combination analgesics with caffeine or alternative NSAIDs 1, 2
3. For patients with frequent tension headaches (≥2 per month with disability lasting ≥3 days), consider preventive therapy 2
4. For chronic tension headaches, start amitriptyline at a low dose (10-25 mg) at bedtime, gradually increase to an effective dose (typically 50-100 mg) 2, 5
5. Monitor for anticholinergic side effects and adjust dosing accordingly 1, 2
6. Incorporate non-pharmacological approaches such as physical therapy, aerobic exercise, and stress management techniques 1, 2

Cautions and Monitoring

• Avoid opioids for tension-type headache due to risk of dependence and medication overuse headache 2, 8
• Botulinum toxin injections are not recommended for chronic tension-type headache prevention 6
• Gabapentin is not recommended based on lack of efficacy evidence 6
• Regularly assess treatment effectiveness and adjust therapy as needed 1, 2