What medications are used to treat tension headaches?

Medications for Tension Headaches

For tension headaches, ibuprofen 400 mg and acetaminophen 1000 mg are the first-line treatments for acute episodes, while amitriptyline is recommended for prevention of chronic tension-type headache. 1, 2

Acute Treatment Options

First-Line Medications

• Ibuprofen 400 mg: Recommended by the American College of Physicians for short-term treatment of tension-type headache, showing statistically significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg: Equally effective option for acute treatment, with significant improvement in pain-free response at 2 hours 1, 2
• Ibuprofen shows slightly faster onset of action, with a significantly larger mean pain intensity difference from baseline at one hour compared to naproxen 3

Second-Line Options

• For inadequate response to initial treatment, consider combination therapy with caffeine-containing preparations or alternative NSAIDs such as naproxen sodium 550 mg 1, 2
• Naproxen 375 mg has demonstrated similar efficacy to acetaminophen 1000 mg in treating moderate-to-severe tension headaches 3

Important Considerations for Acute Treatment

• 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
• Limit use of acute headache medications to no more than 2 days per week to prevent medication overuse headache 2
• Opioids should be avoided due to risk of dependence and medication overuse headache 1, 2

Preventive Treatment

First-Line Preventive Medication

• Amitriptyline: Recommended by both the American College of Physicians and American Academy of Neurology for prevention of chronic tension-type headache 1, 2
• Starting doses typically range from 10-25 mg at bedtime, with gradual titration up to 50-100 mg as needed and tolerated 2
• Significantly reduces monthly headache days in patients with chronic tension-type headache 1

Amitriptyline Precautions

• Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 4
• Monitor for potential overdose signs including cardiac dysrhythmias, hypotension, convulsions, and CNS depression 4
• Regular assessment of treatment effectiveness and adjustment of therapy as needed is recommended 2

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 1, 2
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques can be beneficial 2
• Relaxation therapies with EMG biofeedback have shown efficacy rates of 40-50% in chronic tension-type headache 5

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 or alternative NSAIDs 2
   • Avoid using acute medications more than 2 days per week 1, 2

2. For chronic tension-type headache (≥15 headache days/month):

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

Common Pitfalls and Caveats

• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 1, 2
• If medication overuse is present, gradual withdrawal of the overused medication is necessary 2
• Lower doses of acetaminophen (500-650 mg) may not be superior to placebo for tension headaches 6
• Opioids and medications containing butalbital should be avoided due to risk of dependence and medication overuse headache 1, 2