What is the recommended treatment for tension headaches in the elderly?

Treatment for Tension Headache in Elderly

For acute tension-type headache in elderly patients, use ibuprofen 400 mg or acetaminophen 1000 mg as first-line treatment, and for prevention of chronic tension-type headache, use amitriptyline 50-100 mg daily, but start at the lowest dose (10 mg three times daily with 20 mg at bedtime) due to increased anticholinergic risks in this population. 1, 2, 3

Acute Treatment Approach

First-line acute therapy:

• Ibuprofen 400 mg demonstrates statistically significant pain-free response at 2 hours 1
• Acetaminophen 1000 mg is equally effective, but lower doses (500-650 mg) do not show significant improvement 1
• Both medications received "weak for" recommendations from the 2023 VA/DoD guidelines 1

Preventive Treatment Strategy

When prevention is needed (frequent or chronic tension-type headache):

First-Line Prevention:

• Amitriptyline 50-100 mg daily significantly reduces monthly headache days 1, 2
• This is supported by multiple double-blind, placebo-controlled studies 4

Critical Dosing Considerations in Elderly:

The standard adult dosing must be modified for elderly patients due to age-related pharmacokinetic changes:

• Start with 10 mg three times daily plus 20 mg at bedtime (total 50 mg/day) 3
• Elderly patients have increased intestinal transit time and decreased hepatic metabolism, resulting in higher plasma levels for any given dose 3
• Increases should be made preferably in late afternoon and/or bedtime doses 3
• Monitor carefully with quantitative serum levels as clinically appropriate 3

Specific Anticholinergic Risks in Elderly:

Amitriptyline poses heightened risks in older patients that require vigilance 1, 3:

• Peripheral effects: tachycardia, urinary retention, constipation, dry mouth, blurred vision, narrow-angle glaucoma exacerbation 3
• Central nervous system effects: cognitive impairment, psychomotor slowing, confusion, sedation, delirium 3
• Increased fall risk 3
• Cardiac concerns: particularly in patients with multiple cardiac comorbidities 1
• Overdose potential must be considered 1

Second-Line Prevention Options:

If amitriptyline is ineffective or not tolerated:

• Mirtazapine 2, 4
• Venlafaxine 2, 4
• Intensify non-pharmacological interventions 2

Non-Pharmacological Interventions

Aerobic exercise or progressive strength training is suggested for prevention 2

Physiotherapy is suggested for management 2

Insufficient evidence exists for biofeedback, cognitive-behavioral therapy, mindfulness-based therapies, progressive muscle relaxation, acupuncture, dry needling, or yoga 1, 2

Critical Diagnostic Caveat

Before treating as primary tension-type headache, exclude secondary causes 1, 5, 6, 7:

• The prevalence of secondary headache disorders increases significantly with age 1, 5, 6
• New-onset headache after age 50 should arouse suspicion of underlying pathology 1, 5
• Secondary causes to consider: temporal arteritis, trigeminal neuralgia, cervical spondylosis, intracranial pathology, post-herpetic neuralgia 8
• Vigilance for organic disease is mandatory before confirming tension-type headache diagnosis 7

What NOT to Use

OnabotulinumtoxinA injections are NOT recommended for chronic tension-type headache—they showed no statistically significant improvement in critical outcomes across 12 RCTs 1, 2

Common Pitfalls to Avoid

• Do not use standard adult doses of amitriptyline in elderly patients without downward adjustment 3
• Do not overlook cardiovascular and cognitive comorbidities when prescribing tricyclic antidepressants 1, 3
• Do not assume primary headache without excluding secondary causes, especially in new-onset or changed headache patterns 1, 5, 6, 7
• Do not use acetaminophen doses below 1000 mg expecting therapeutic benefit 1