What is the treatment for tension headaches?

Treatment of Tension Headache

For acute tension headaches, start with ibuprofen 400 mg or acetaminophen 1000 mg at the onset of symptoms, and for chronic tension headaches requiring prevention, use amitriptyline starting at 10-25 mg at bedtime and titrate to 50-100 mg as needed. 1, 2

Acute Treatment

First-Line Options

• Ibuprofen 400 mg is the recommended first-line treatment, demonstrating statistically significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is an equally effective alternative, showing comparable efficacy to ibuprofen for acute episodes 1, 2, 3
• Medications must be taken early in the headache episode for maximum effectiveness 1

Second-Line and Adjunctive Options

• If initial treatment provides inadequate relief, consider combination therapy with caffeine-containing preparations or switch to an alternative NSAID such as naproxen sodium 550 mg 1
• For severe attacks accompanied by nausea, add an antiemetic medication to improve treatment outcomes 1
• Naproxen 375-550 mg is an effective alternative NSAID option 4, 3

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache, which worsens the overall condition 1, 2
• Overuse of acute medications can lead to chronic daily headache and refractory pain 1, 5
• Avoid opioids and butalbital-containing compounds due to high risk of dependence and medication overuse headache 1, 2, 5

Preventive Treatment for Chronic Tension Headache

Pharmacological Prevention

• Amitriptyline is the first-line preventive agent, significantly reducing monthly headache days in chronic tension-type headache 1, 2, 6
• Start with 10-25 mg at bedtime and gradually titrate to 50-100 mg as needed and tolerated 2, 7
• The typical effective maintenance dose ranges from 50-100 mg daily, though some patients respond to as little as 40 mg per day 7
• Increases should be made preferably in the late afternoon and/or bedtime doses 7

Monitoring for Amitriptyline

• Be vigilant for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2
• A sedative effect may appear before the antidepressant/analgesic effect, and adequate therapeutic effect may take up to 30 days to develop 7
• Elderly patients require careful monitoring with lower doses (10 mg three times daily with 20 mg at bedtime may be sufficient) and potentially quantitative serum levels 7
• Continue maintenance therapy for at least 3 months to lessen the possibility of relapse 7

Alternative Preventive Agents

• Mirtazapine and venlafaxine have documented efficacy as alternative antidepressants 6
• Weaker evidence supports gabapentin, topiramate, and tizanidine 6

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 should be implemented 2
• Relaxation therapies with EMG biofeedback have approximately 40-50% efficacy rates, comparable to tricyclic antidepressants 4
• Acupuncture has documented efficacy as a non-pharmacological preventive method 6
• Note that evidence for non-pharmacological interventions is generally of lower quality than for medications 1

Treatment Algorithm

For Episodic Tension Headaches

1. Use ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
2. If inadequate relief, try combination analgesics with caffeine or alternative NSAIDs 1, 2
3. Add antiemetic if nausea is present 1
4. Assess response and adjust treatment accordingly 1

For Chronic Tension Headaches (Frequent Episodes)

1. Initiate amitriptyline at 10-25 mg at bedtime 2
2. Gradually increase to effective dose (typically 50-100 mg) 2
3. Monitor for anticholinergic side effects and adjust dosing accordingly 1, 2
4. Continue acute treatment as needed, but limit to ≤2 days per week 2
5. Incorporate physical therapy, aerobic exercise, and lifestyle modifications 2

Common Pitfalls to Avoid

• Never use opioids for tension headache due to dependence risk and medication overuse headache 1, 2
• Do not allow patients to use acute medications more than twice weekly without addressing prevention 1, 2
• Avoid butalbital-containing compounds despite their effectiveness, as they carry increased risk of chronic daily headache 5
• Do not delay initiation of preventive therapy in patients with frequent headaches, as this leads to unnecessary suffering and potential chronification 1, 2