What are the treatment options for tension headaches?

Treatment Options for Tension Headaches

For tension headaches, first-line treatment is ibuprofen 400 mg or acetaminophen 1000 mg for acute episodes, with amitriptyline recommended for prevention of chronic tension-type headache. 1, 2

Acute Treatment

• Ibuprofen 400 mg is recommended as first-line treatment for acute tension headaches, showing significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is an equally effective alternative for acute treatment 1, 2
• 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
• Limit use of acute headache medications to no more than 2 days per week to prevent medication overuse headache 1
• For inadequate response to initial treatment, consider combination therapy with caffeine-containing preparations or try alternative NSAIDs, such as naproxen sodium 2, 3

Preventive Treatment

• Amitriptyline is the drug of first choice for prevention of chronic tension-type headache 1, 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 1, 5
• Be aware of anticholinergic adverse effects with amitriptyline, especially in older patients and those with cardiac comorbidities 2, 5
• Alternative preventive medications with some evidence include mirtazapine and venlafaxine for patients who cannot tolerate amitriptyline 4, 6

Non-Pharmacological Approaches

• Physical therapy is recommended for management of tension-type headache 7, 1
• Aerobic exercise or progressive strength training can help prevent tension-type headache 7, 1
• Lifestyle modifications should include regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 7, 1
• Electromyographic (EMG) biofeedback has documented effectiveness for tension-type headache 4, 8
• Cognitive-behavioral therapy and relaxation training are likely effective options 4, 8

Treatment Algorithm

1. For acute episodes:

   • Start with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
   • If inadequate relief, consider combination analgesics with caffeine 2, 3
   • Avoid opioids due to risk of dependence and medication overuse headache 7, 2

2. For chronic tension headaches (≥15 days/month):

   • Start amitriptyline at low dose (10-25 mg) at bedtime 1, 5
   • Gradually increase to effective dose (typically 50-100 mg) 1, 5
   • Monitor for anticholinergic side effects 2, 5
   • Consider non-pharmacological approaches as adjunctive therapy 1, 4

Cautions and Monitoring

• Avoid opioids for tension-type headache due to risk of dependence and medication overuse headache 7, 1
• NSAIDs like ibuprofen carry risks of gastrointestinal, cardiovascular, and renal adverse effects with prolonged use 9
• If medication overuse is present, gradual withdrawal of the overused medication is necessary 7, 1
• Regular assessment of treatment effectiveness and adjustment of therapy as needed is recommended 1, 2
• Be aware of potential cardiovascular risks with NSAIDs, especially in patients with cardiovascular disease or risk factors 9